Tue, Nov 29, 2022 5:04PM • 1:00:14
SUMMARY KEYWORDS
patients, addiction, pain, opioids, osteopathic, substance, chronic pain, lead, treatment, substance abuse, neurotransmitters, week, techniques, prescribing, mirza, alcohol, addiction medicine, physical, gaba, body
SPEAKERS
Bill Clearfield
00:12
There’s an admit right there welcome back
Bill Clearfield 00:35
sorry everybody. I don’t know what happened it was kept saying I was on on a different meeting which I wasn’t I don’t know where I don’t know what happened.
00:47
Hey, Bill, I can that’s really the last one you were on. Open. And you don’t end it. Because nothing had happened the other day where my meeting? Everybody else was in the meeting, but I wasn’t because I kept saying, you know, so I can’t I cancelled everybody by accident. And when I did steps,
Bill Clearfield 01:06
I don’t I don’t know what happened. I apologize. I hope we didn’t lose too many.
01:13
Doctor I do Abdul I apologize
Bill Clearfield 01:14
to you Dr. Mirza, I I apologize to you. Sorry about the
01:19
No, no worries. No worries. detectable. Okay. I completely understand.
Bill Clearfield 01:25
Yeah, we’re all here. Most of us are old here. You know, we don’t have it now. This stuff works. Well, we’re here every week and it’s, you know, they always do the same thing, but
01:35
it’s unpredictable. No worries.
Bill Clearfield 01:39
Well, it looks like we’re getting most of our crowd and you get naughty, naughty later. Oh, okay. So give it another couple of minutes and then we’ll we’ll we’ll send you on your way is Dave around to is that Dr. Lefkowitz around too or is it just going to be you
02:06
Yeah, I’m expecting him here as well.
02:14
So Alright, looks like
Bill Clearfield 02:19
those of our those are those who are trying to get in are now in so
02:32
one more minute.
Bill Clearfield 02:33
I get a bunch of text messages from folks. So So I apologize. I don’t know what what went wrong.
02:44
Why this happened, but
Bill Clearfield 02:47
we look like we’re fairly good shape now.
02:53
Okay, so everybody here. Okay,
Bill Clearfield 02:58
so thank you all for coming up. Y’all had a good holiday. And sorry about the technical issues. Today we’re going to be here discussing substance abuse. Dr. David Lefkowitz who’s one of our one of our regulars, as you know, and talks quite quite often for us has as a new program, Dr. Mirza is some sort of new program. It’s it’s a relatively new program. Yeah. So So So Dr. Abdul Mirza is a you’re a resident evil resident addiction. Addiction fellow. Yeah, these are fellow and he’s going to I look like Oh, Mmm Oh, mmm you know osteopathic manipulation on the on the on the flyer but I wrote you know, that was not a typo, right that I think that I get the letters right, because I’m not exactly sure sure what they were what they
03:53
do, cause you’re missing one, but it still does the work. Alright, so
Bill Clearfield 03:57
so I’m gonna let you introduce yourself. And since we’re starting a little bit late, I’ll let anybody in was a straggler. I’m gonna let you introduce yourself and you take it away. So this is Dr. Abdul Mirza he’s a substance abuse fellow.
04:13
Yes, thank you so much. Dr. Clearfield, thank you so much everybody for having me. Yes. My name is Abdul Mirza. I am did a residency in osteopathic neuro musculoskeletal medicine. We’re here in Florida. At Larkin Community Hospital. And then from there, I’m currently doing my fellowship in addiction medicine, also at Morgan community hospital in Florida.
Bill Clearfield 04:44
So we usually record these and put them on our website if that’s okay with you.
04:50
Yeah, that’s totally fine. Okay.
Bill Clearfield 04:52
And if you have slides and all you know how to run this thing, right, the shared screen and
04:56
yeah.
04:58
Do you want to give it a few more minutes for anyone else?
Bill Clearfield 05:01
I think I think we’re okay for now. You can why don’t we get started? Okay.
05:06
Okay. Sounds good. Give me one second here. Okay. Can you guys see my screen? Yes. Okay. Okay. I’d also like to mention I have Dr Brainiac who’s, who’s always one of the participants. She’s our program director. So she’s here as well.
06:11
Alright, so um, yeah, so older men, so it’s osteopathic stands for osteopathic neuro musculoskeletal medicine, pain and addiction. And I kind of wanted to bring these three fields and our specialties together. Because, you know, me being board certified in omm you know we I had the experience of doing a lot of pain medicine in my residency as well. And now that I’m currently doing addiction medicine, I kind of see that, you know, I found a way to kind of put them all together and I kind of use them you know, all three specialties together to kind of do the best for my patients. And so I just wanted to share a little bit about you know what I do kind of day to day, and, you know, everybody here is probably more experienced than me. So I’m here to learn and maybe I can spread a little bit more about what I’m doing and maybe, you know, you guys can learn something from me that you know, and that that’s basically my main goal here today. So just starting up, I want to dive right into it. So what what really is addiction. And so, you know, there’s a lot of definitions out there. You know, there’s addictions for different things. But one way that you can kind of bring it together is this if you go to the American Society of Addiction Medicine, the Board of Directors adopted this definition in September 2019. So they say that addiction is a treatable chronic medical disease involving a complex interactions among brain circuits genetics the environment and an individual’s life experiences. People with addiction use substances. They use substances or engage in behaviors that become compulsive, and often continue despite harmful consequences. And then prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. So a few key points are here that I want us to just keep in mind is that addiction is as per the definition it is a treatable as a chronicle medical disease. And there’s there’s a lot of factors that contribute to one’s addiction. And so, you know, just like it’s incorporated in definition, you know, patients who have mental health disorders, who have environmental factors, and that can be beliefs and attitudes of one’s family interactions, you know, between certain peer groups and then genetics, you know, we see that you know, someone who is, for example, corroded alcoholic may have an uncle who was an alcoholic, we kind of see that a lot. And then another risk factor is you know, somebody who starts using drugs at a very young age. So, these are all different. You know, factors that can help basically help us that tell us that define the define the addiction of that of that patient. And, you know, just just a few things to keep in mind here. And so, you know, on this diagram on the right, you know, this I want to kind of go into each little aspect of it. So, there’s the, there’s the initial use, and then there’s the there’s the abuse when you you know when you use the substance, the way it’s not recommended. And then I really want to get into like the tolerance because tolerance can be confused with the dependence. And so tolerance is basically it refers to the body getting used to a substance and whenever required is hot and and it requires higher doses. So, basically, you need you need more of that substance, to make you feel this the same way. So that’s your body telling you it is tolerant, and then and then independence, we need to make a very clear distinctions from tolerance. It basically refers to the physical or psychological symptoms that occur that make someone feel like they must continue taking that substance and so basically, that person is dependent on that substance. Otherwise, they get symptoms if they don’t have that substance. So that’s kind of the distinction between dependence and tolerance. And then and then that kind of feeds its way into addiction. So addiction is basically it’s a behavior in a nutshell, and it’s basically when a person is unable to stop using a substance even though he or she knows the negative consequences or the risk associated with it, but they just have to use it and it becomes a behavior and lifestyle. So that’s kind of what the difference between addiction and dependence is. And then addiction can lead to relapse. And then from there, the cycle kind of starts all over again.
11:06
Okay. And so, if I, if you wanted to talk about what addiction is an interesting way that I found out about that someone explained to me was during one of the conference at the American College of Addiction Medicine that we went to a few weeks ago and the presenter kind of said that if you look at the synaptic cleft, that’s that pretty much is where all the addiction takes place. You know, there’s addiction has to do a lot with the neurotransmitters, and a lot of the activity of the neurotransmitters takes place in the synaptic cleft. For example, the one of the major neurotransmitters in addiction is dopamine, serotonin, glutamate, endorphins, GABA, just to name a few among the many different ones. And so, basically, addiction can be described as, you know, a balance of the neurotransmitters. We have inhibitory transmitters, and then we have excitatory transmitter so the inhibitory are usually like the GABA, and then the excitatory usually like the good and glutamate. And so if there’s an imbalance in these neurotransmitters that can lead to you know, certain changes in physiology, either in the brain or in the body. And, you know, there could be things that happen, for example, such as seizures, epilepsy, you know, this is usually due to an imbalance in these neurotransmitters. And so, just want to talk a little bit about the community transmitters that I’ve listed. And so like dopamine, is one of the biggest neurotransmitters in addiction. It plays a huge role in our bodies. It influences learning concentration memory, and it’s mostly known for our body, our body’s reward system. And so you know, having adequate amounts of dopamine is essential for physical, mental, and emotional well being a good balance of it is good for the body. And then and then cocaine for example, I want to list some substances that affect the neurotransmitter so cocaine disrupts the imbalance in the dopamine largely, and then, and serotonin is basically known as the happy chemical. It contributes to feelings of like well being it helps. It also helps regulate the mood and sleep wake cycle and you know, hallucinate. hallucinogens play a key role in the serotonin neurotransmitters. A lot of patients that we see with who use herbs in regions, they’re usually you know, very happy and, you know, already like calm and, and kind of cool. That’s kind of the personality we see in patients who use this in journals. And then glutamate. Glutamate is one of the most important neurotransmitter out of the for normal brain function. Like I said, it’s an excitatory neurotransmitter so it plays a huge role in the excitatory part of our brain, and so, you know, it’s involved with it’s also involved with learning fine and gross motor skills. And that’s why we see you know, kids with ADHD, they lacked these these functions. And so that’s why, you know, we give Adderall and amphetamines are kind of like the drug over here that affected me. And then, I just want to talk a little bit about GABA. So GABA is really important because it’s very it’s really affected by alcohol. And we see a lot of alcohol use disorder in our program and our patients almost on a daily basis. And you know, GABA is basically a neurotransmitter that causes sedation. It’s inhibitory neurotransmitter. And so you know, it’s good for you know, everything has a role in the body. So GABA can be good for to help, you know, with sleep and people who have insomnia. So you know, we can, you know, if you give them some GABA, they’ll be able to relax and help their sleep. It helps with anxiety, and it helps reduce overall excitability. Again, that balance that we talked about. However, if you drink too much alcohol it can overstimulate the gala pathways, and that causes the extreme sedation of the central nervous system and in turn, can cause alcohol toxicity and overdose and so in patients that have continued exposure to alcohol over time, it can desensitize the GABA receptors, and then to a point they become so desensitized that people they feel like they they have increased stress and anxiety. Which makes them want to drink even more. And it comes becomes a cycle because they that receptor is so desensitized that if you take away the alcohol, it just causes a severe imbalance in the excitatory and inhibitory pathways of the brain. And so, I want to dive a little bit into what osteoporotic is So, you know, I’m sure this is osteopathic board so we all know as you’re standing by Andrew Taylor still in the late 1880s. And and we often hear that in osteopathic medicine is a holistic approach to medicine. And so that’s what it is. It’s a whole person approach to hands on care. We are the highest professionals that provide hands on treatment and management. And so, some general concepts you know with osteopathy is that it is the medicine that sees you know, different systems of the body and how they relate to each other. You know, and how and how you can use different modalities, different techniques to allow the body to heal itself. So that’s one of the main points of osteopathy is that the body is able to heal itself. And so we must remove the restrictions to allow the body to do just a, you know, an example that, you know, I thought about was that if we if we get a cut on our bodies, the body heals the cut. So, if if there’s imbalances in our brain, or changes in our brain, we have to allow the brain to heal itself. So it kind of falls under the realm of possibility that we could we could allow the body to heal itself whether it’s a physical manifestation or even a you know psychological or from addiction standpoint I’m gonna get into this in a little bit. Just first want to talk about what what pain is. And so pain is also one of those definitions that you know there’s there’s different ways it could be defined but different sources, but just generally speaking, and I want to I just want to keep things very general is that pain is usually when we think about pain, it’s usually has to do something with a physical impact. You know, like, if so if a patient a lot of time patients are in a car accident, as a physical trauma to the body, and now they have pain and they develop chronic pain. Or, you know, if you stub your toe, you know there’s we know that there’s chemicals going back to the brain and then synapses that that make you feel the pain from a physical cause. But what I want to get more at in this lecture is that pain can also be mental and it could be emotional. And and in those terms pain a lot of times what it is, is suffering. And in our patients we see a lot of suffering on that his patients have been through. They’ve been through a lot of trauma, emotional, mental verbal trauma in their early lives, and they carry that with them over time. And and it causes chronic suffering, we can which leads leads to substance use addiction. And so I kind of want to want us to focus more about the mental and emotional aspects of pain and so, you know, acute pain versus chronic pain, so usually acute pain and depending on what resource you look at it could be anything that’s less than three months, or less than six months, because some sources say chronic pain is anything that pain that lasts anywhere from three to six or more months. And so one of the ways we can look at the differences is by looking at the symptoms, and so, in patients with chronic pain, a lot of times we see very tense and stiff muscles and in osteopathy we can we kind of say tar changes, tissue texture changes, so someone with chronic changes will have really tight, stiff changes in the body. They have limited ability to move around once again due to the stiffness over a long period of time. A lack of energy and changes in appetite you know, and then emotional wise, chronic pain can lead to depression, anger, anxiety, fear of the reinjury itself. Usually this is seen in you know athletes, veterans and it can really limit the patient’s ability to to return to work or do something that they enjoyed doing. I got injured while doing doing it. And so I want to go back to this chart that I need. Basically here I’m leading, leading a pathway towards addiction. And so I started I started listing the different ways that we manage pain. So pain as we know, can be managed by prescription drugs, you know, like opioids, we can it can be manage, but over the counter drugs like Tylenol, and said it can be patients use illicit substances to manage their pain. And then there’s also non pharmacological methods some of the novel form well, it makes you morning Can you guys hear me
Bill Clearfield 22:23
sorry about that. We’re good. Good.
22:27
Perfect. Yeah, so um, I want to focus on OMT because that falls into the non pharmacological methods. Well, one of the non pharmacological methods to treat pain and then the other ones that we know about, that are common are like nerve blocks physical therapy, neuro stimulation, comfort therapy, psychosocial therapy, and that kind of falls back into, you know, like the risk factors that patients can have, you know, coming from poverty, or different you get in mind and so you know, that’s why that kind of falls into the non pharmacological method. And then we have an AI characterized substance use as, as those methods where pain usually isn’t controlled. So, if if pain isn’t controlled by opioids, from prescription drug, it can lead to substance use. If your pain if a patient’s pain is controlled by Tylenol and an Advil, they can leave, they can look at other avenues to control the pain. And so once you do have use of any substance, your pain can be either controlled or not controlled. And usually when the pain is controlled, you you know you allow the body body to heal itself, and then you go towards recovery. But if there’s inadequate control, most of it can easily lead to substance abuse. So you can go from using a substance that is not controlling your pain, which can lead you to abuse that substance because you’re just in so much pain and you just need something to make you feel better. And as you can look in if you look in the green box, we have the different risk factors that we talked about. There’s genetic factors, psychiatric, you know, there’s a huge overlap of Psychiatry in this field. And so we always have to keep that in mind that patients who do have a psychiatric illness or psychiatric component, they’re higher risk of developing substance abuse, and then socio socio economic risk. These are all things that can lead to substance abuse. And then once you’re abusing something, you can that can lead you down the road to addiction.
25:00
So a little bit about chronic pain. There was a study done in 2016 and estimated that about 1/5 of the US adults had chronic pain. And so this is a pretty big deal, first of all, because it’s 2016 and now we’re a little over six years past that time, so it only went up, but that’s basically saying that every one in one of the five people that you meet is dealing with chronic pain and that means that they do they’re dealing with either physical, emotional or, or mental pain that they’ve been dealing with for at least three to six months. And so like you mentioned earlier, chronic pain. You know, it leads to so many different things down the road not immediately but usually down the road. It affects relationships. It affects families that can break down found as we see a lot of our patients who not only are homeless but they’ve lost contact with their, with their siblings and their parents and their other family members and and you know, they don’t have contact with them. And usually this is a this is a chronic thing. You know, if you’re, and then chronic pain can lead to anger frustration. So just imagine if your pain is controlled by something that your physician is prescribing. It can lead to anger over time. And that can lead to you know, hopelessness and disturbances in your career. And if you’re, you know, fatigued because you have this pain that you can’t do anything it’s you know, making you incapable of performing, you know, your day to day activities, you’re just going to feel hopeless and depressed. And then you have insomnia because you have so much anxiety and you don’t know what to do. And so it really has a domino effect in terms of you know, psychological issues and mental and emotional suffering that these patients exhibit. And so, this is just a general summary that we talked about that, you know, you always want to make an assessment. You know, you want to always prescribed you’ll want we want to keep non opioid options in mind first, and then opioid options and the you always want to assess, you know, at each step, you know, in in this field, like you have to weigh the risks and benefits you have to keep in mind that, okay, if I want to prescribe X amount of medicine to this patient, I have to keep in mind that it may benefit him, even though it’s a opioid agonist, for example, methadone, but it’s going to prevent them from overdosing on the drug and, and killing themselves. So there’s always risk and benefit at each step and we always have to weigh our options in terms of management of the pain. And so, you know, we come back to the question can only really help with pain? There’s a lot of research that I found, you know, and, you know, it’s not it’s not it’s not one sided at all. There’s a lot of studies that, you know, support voluntee in terms of, you know, pain management, there’s a lot of research on on T and low back pain. So there’s research for that supports, that the thesis of warranty does help reduce pain, but there’s also a lot of research against it. And so, you know, we, if anything that that tells me that OMT is not really going to, it’s an option to have because you can help a lot of patients and the worst thing that can happen is you don’t help them. But if you do help even just one more person, that’s a really big deal because that could be one more person that you delayed in prescribing the opioids and then overdosing on it. And so, there was a systematic study in 2005 that show the systematic review of low back pain and it was treated with a warranty and it found the OMD significantly reduces lower back pain. And this is something and in the study they they had consistent on T implemented it was several times a week over the span of several months. There was another study in 2021 that looked at 23 different articles. And same thing, the old chief reduce the pain levels, improve functional status, a decrease in medication usage. And so, you know, it just shows there’s there’s a lot of articles there that do support this thesis. And you know, there’s definitely you know, you know, good that’s been done with Auntie not just diving into a few techniques that I want us to keep in mind is that a lot a lot of patients in addiction medicine have a lot of mental illness or psychological illnesses. And one of the direct ways you can approach that an auntie is cranial, cranial aunty or current cranial sacral. And so you know in osteopathy you believe we believe that, you know, the cranial bones have movement, there’s sutures and they move with the sutures. And so these patients a lot of times have a lot of cranial restrictions. And so doing cranial is one of the best ways that I’ve seen. You know me, I’ve seen improvement in terms of anxiety and stress in my patients. There’s also myofascial release, specifically in the head and neck. Once again, these patients are very stressed and when you’re just when you’re stressed, you kind of tighten up your traps and your shoulders come up. And so that’s why you know, focusing on the head and neck can kind of dissipate that stress can cause relief in the tightness in those muscles. And I’m sure everybody knows that if you get a neck massage really does make a big difference in your day. There’s also suboccipital release and I have some images of these into the next few slides but suboccipital release is basically taking your fingers and putting holding it in the suboccipital area and kind of just applying some pressure. So purely an end with some traction towards you. As the patient is laying on their back facing up. It creates gapping within the occiput and that’s one of the areas where by doing so you can relieve a lot of stress in the tissues and so there was actually a study done about cranial sacral treatment. And you know, they use the treatment routinely with with follow ups and the best way they found symptoms to be relieved in patients was continuously doing it and the symptoms lasts and the relief lasted for up to six months. And so these are just some images of how you can incorporate Oriente and so if you look all the way on the bottom, you can see some cranial techniques. You know, the hands around both ears, fingers underneath the neck. You can put your hands on top of the head and OMT is a very gentle, gentle technique on generally speaking on T techniques are very gentle. And so if you just think about it, placing placing your hand on somebody for let’s say about just 60 seconds, right without moving without inducing much movement. It’s a pretty it’s pretty good amount of time. You know, and so your patient is just lying there and you have your hands on them for a couple of minutes. It To them it seems like the world has slowed down and things are okay. And you know, they can even like feel themselves calming down and like I said it only takes a few minutes, but just having that physical touch on these patients who are usually always in a fight or flight mode or are very anxious and are paranoid, you know, just slowing them down. It just really giving them this physical touch really does make a big difference.
34:04
So this is myofascial release, there was a study done that showed using myofascial release improved pain, it helps with sleep, and ultimately if you sleep better, your quality of life improves. This is suboccipital reviews. So like I said there’s a lot of small muscles in the neck and really strong muscles, such as the rectus capitis posterior major oblique is Catherine superior rectus capitis posterior minor and oblique establish and fear is a very small, very strong muscles that can really tighten up in these patients and almost every one of these patients are my patients that I do suboccipital release on just extremely tight. And I’ve seen tightness in this area a lot more in my fellowship than in my residency. And that just kind of tells me that you know, this is definitely one of the key areas to focus on in patients with substance use
35:08
and so can only really help with addiction. You know, it really comes down to you know, the philosophy you know, you want to maintain homeostasis in, in a neural in the synaptic cleft. And osteopathy is all about maintaining homeostasis. It’s a key tenant of Osteopathic philosophy. And so if we address the disruption in homeostasis and dopamine homeostasis, for example, in patients who use cocaine, you know, it could, it could really play an important role in in better understanding and ultimately treating these patients with their complex clinical phenotype. And so, you know, osteopathic care, osteopathic primary care physicians, we can identify patients in the practice in our practices that may have substance use disorder. And we can initiate treatment grounded in core osteopathic principles of treating the whole patient, not just some specific symptoms or behaviors. And so some of the clinical goals with using ology is for using is using non pharmacological options and our patients. And during my residency, I was very fortunate that it was it was a it was we had a lot of options to do pain medicine as well. And so, although we were occasionally prescribing opioids to patients who really needed it, we were always supplementing OMT. And that was, that was like a standard so if a patient came in, he was always getting on to you unless it was contraindicated and they refused. But even the patients who were on opioid medications for years and years from due to, you know, in for veterans who we had a lot of veterans who had injuries during war overseas and patients with you know, crushing, crushing injuries and severe low back issues that couldn’t even get surgery. So we always use on T to supplement the opioids. And a lot of patients patient would always tell me that, you know, on T is one of the main reasons why they haven’t went gone up into doses of the opioids. And then I’ve heard a lot of times they told me that I’m only on this low dose, because I come every week or every other week and get on T. And so you know, that’s that’s a big deal because we all know the long term effects, the chronic effects of opioids and how they can affect, you know, daily life and the quality of life. And so the fact that you can just use hands on treatment for a few minutes, you know, a few times a month can really help delay the progression of opioid use delay, delay the progression of pain, which has that domino effect of, you know, depression, anxiety and worsening quality of life. There’s, like I said, there’s a lot of research that says there really wasn’t that didn’t doesn’t attribute on Qi to relieving pain. And in that research, a lot of time, what I found was that there just weren’t enough participants. It wasn’t a big enough study. So there’s a lot more research that’s needed with addiction, and OMT. And so I think that’s only going to come at time, but we have to start somewhere. And so, in the hospitals what I’m starting to do now is I’m actually starting to consult you know, I asked my osteopathic on a meme colleagues, and I tell them just do cranial you know, if if they don’t have a physical complaint if their knees and hurting back because they’re hurting just do some cranial sacral therapy on them, because just that amount of just a little bit of cranial sacral makes them a much better patient and easier to handle easier to attack their anxiety, psychological diseases, you know, and it’s, it’s a great supplement treatment to have. And it all it all comes back to this chart because if you can, if you can delay, the time that substance use goes into substance abuse, and if we can go from inadequate pain control dyadic adequate pain control with non pharmacological methods, you know, we’re just delaying and pushing off addiction as much as possible. And that’s, that’s it. Thank you so much, everybody.
39:56
Thank you.
39:59
Excellent. That was that was very nice. I don’t know. If I get a list of participants, hopefully I can give every I can get a CME credits for the deals for this lecture. Thanks, Doctor. Mizdow. That was excellent. Thank you. You’re welcome.
Bill Clearfield 40:21
Some way to get a list. This list. Yeah,
40:25
just give me the list of the deals. Thanks.
Bill Clearfield 40:31
Okay, anybody know how to do that?
40:37
Well, I took a picture of the participants so we work on it. I can handle it.
Bill Clearfield 40:46
Okay, great. Okay. Dave, do you have anything to add?
40:50
No, I just just the combination of, you know, have us the apathy and family medicine and nasty apathy in substance abuse. It’s just so ideal. I almost feel like it still is looking down upon us and saying I told you so. You know, I told you there was going to be an opioid epidemic. So he just fits right into addiction fellowship, and I’m really proud of the progression that fellows are making. So
Bill Clearfield 41:24
so how many how many leads and types of patients? Are you feeling? Well, we have addiction
41:32
consults, service, so there’s three hospitals. So these kinds of work and I don’t know sometimes we get up to 2010 to 15 Hospital consults, most of the issues, you know, so there’s a lot of modalities we can use. Sometimes it’s harder to we’re trying to have our efforts on retaining them when they, you know, leave, but at least in the hospital there, you know, hospitalizations can be a little shorter and, and there’s other modalities that we can, you know, use to treat other than medication. So, it’s a good thing. It’s a great combination.
Bill Clearfield 42:10
What, what what are you doing to sort of document the you know, that this is a legitimate way to go?
42:20
Well, you know, someone’s a lot of our patients as you heard, you know, have addiction and pain right. So, you know, we consult Oh nm on some of the pain patients and, and they do some manipulation and, and document just like they do on, you know, any type of consult. So,
42:45
okay, yeah, also looking at the length of stay, and you know, documenting it and like the notes, we ask them a pain scale. And we basically just get their feedback, you know, after a few minutes and, and see what know what kind of what they’re thinking if they’ve ever, you know, experienced such a treatment before. And so all these smaller things, you know, we’re just starting to but I want to continue this for the remainder of the fellowship, and kind of see what patterns it leads to. So it’s a work in progress.
Bill Clearfield 43:21
What kind of what kind of response are you getting from your non do folks or those that are you know, kind of skeptical?
43:35
got abs, Dr. Mister you have anything to answer there. We seem to be well accepted. You know, maybe because I’m gonna do and Dr. miseries. So I just, yeah, I think I think Go ahead. Yeah, the
43:53
old the old meme consoles have been around for several years at our hospital. But this is like the first time that we’re using it to supplement addiction patients. So all the other residents and fellows they’re, you know quite familiar with the osteopathic manipulative treatment. We get, they get consulted for for any type of patient you know if a patient has any GI disturbances, any other MSK pain on them is always being done in the hospital, but it never really was directed towards addiction, addiction patients. And so now we’re using it in our detox unit a lot more.
Bill Clearfield 44:36
Okay, there’s a question in the chat that’s a little bit off topic, but what kind of manipulation can help patients with neck stiffness and dizziness as a result of Vestibular neuritis?
44:51
Yeah, so, you know, for Vestibular neuritis, I would certainly focus on the cervical upper thoracic areas. And then and then the sacrum for sure the sacrum and the cranium. They’re connected. And so, the way I the way I start off the treatment is I balanced the cranium and the sacrum. One hand underneath the occipital one hand I didn’t need the sacral base and I kind of just look at the pattern, the the rhythm that the patient has, and try to balance that that rhythm and then that kind of tells me which one is more stuck because if the sacrum is stuck, that can affect the aux input and vice versa. So it ends up leading to you know working on the sacrum a little bit and then the cranium, but ultimately, also the cervical area. So a lot of myofascial suboccipital release, all these soft techniques are very helpful, balanced ligamentous tension just balancing the different planes of motion of the cervical spine is also a very good indirect technique. It’s a lot softer and a lot more, I guess convenient for for patients. Because myofascial can you know if you apply some pressure BLT doesn’t have involved as much pressure. And so you can use a combination of direct and indirect but I would stay away from the hvla which is a high velocity low amplitude, which involves a trust that that could worsen the Vestibular neuritis. So I would I would mostly focus on the indirect techniques and cranial sacral technique.
Bill Clearfield 46:37
Okay, I hope Dr. Fishbein that answers your question. Back to the your addiction service. Is there a Have you developed a protocol or prescribed sort of way to go for different types of substance abuses, so, you know, uppers versus downers perhaps or you just look at the individual and see they got a you know, subscapular T T three, tightness and go go for that. Is there anything specific for addictions and specifically for different different types of substances?
47:25
question that comes into play with you know, some, like certainly some medications we use so, you know, the osteopathic is in conjunction with our medication. So, let’s just start out by saying all, all medications that are indicated for alcohol and substance use disorder are indicated for alcohol and substance use disorder with therapy, both, you know, physical therapy and mental health therapy. So it just depends. So if someone’s with opioids, we we tend to use buprenorphine a lot Vivitrol. But as far as as far as specific body parts, that’s separate. It just depends what like if they’re addicted to cocaine, we may we may use some cross tolerance like Wellbutrin if that you know, or I tried Adderall sometimes. But alcohol is standard, you know, so, not really, as if I’m trying to get to your question, as far as body part that’s on T. And as far as what their, what their substances is, is, is usually kind of how we go with what medication we use. But we both get a combination, because most of our patients with substance use disorder complain of pain, or at least it started with pain, or they think they have pain, and they really don’t so that’s the story there. Okay.
Bill Clearfield 48:55
So what kind of what kind of it’s a general OMT training or is there anything specific you know, for with your, in your program? Good.
49:06
Yeah, so, I mean, are you talking about the residency that I did?
Bill Clearfield 49:12
Yeah. Well, I mean, you know, you did your addiction residency, right, but is there anything is there any specific OMT techniques, you know, for what you’re, you know, you know, we’re gonna use it exclusively for you know, first for for what you’re doing.
49:29
Yeah. So, I would say that just in general with OMT. You know, you’re always wanting to diagnose first. So, depending on what area you’re you’re trying to feed in terms of what I usually do with them on the addiction Console service, is that I usually start off the arm and the head and neck and the sacrum those are kind of like my three areas. Three, go to areas. And then you know, so I diagnose and then I treat those areas. And that’s kind of that’s kind of the way that you know, we were taught in my residency, and that’s how I implemented it into my fellowship. And so there’s not really a particular protocol that I follow, but you know, I think just generally speaking, you know, I, for me, I it makes sense for me to attack this area first. And then why No, whenever attack when I work on the neck, I have to on the head I have to work on the sacrum as well. So you know, that’s kind of kind of my mindset is mostly about balancing and finding you know, good movement in the body. It is a patient by everyone is different. So some patients require more work than others. But ultimately, there’s no there’s no so probably, it’s kind of how I was taught in residency.
Bill Clearfield 50:55
Okay, great. Okay. Anybody else have have any comments or questions or anything?
51:05
Yes, I have one. Um, Deborah. In my practice, I was near a army day base and I also had a number of veterans in my practice. And I found number one, the patients that I found that had a lot of addiction problems. I always did a fairly complex family history and I would see Depression, depression, alcohol, alcoholism, alcoholism, suicide, depression, depression, in their theories, that was the number one thing I saw a lot of P PTSD. And in all of those patients and in addiction patients, I’ve found that om te was so helpful. It not only did it help them relaxed, and not only did it help them, feel that someone else was on their side and that in and help them deal with their pain. It also would frequently bring up issues that they had the emotional or mental issues, PTSD issues that they had, and hadn’t realized that they had. And so I think that that’s a wonderful idea to implement OMT with treatment for addiction.
52:33
Well, well said well said they, I think you put your hands on a patient, as opposed to just, you know, just prescribing medications is, you know, it’s what I’ve heard, and it’s just so true.
52:48
And you bring up a very good point. This is Dell is that, you know, a lot of times when you’re doing cranial osteopathy in these patients, you do tend to bring out you know, past emotions, hidden emotions, hidden traumas that the patient is suppressing. So those do come out quite often, if not to the full, you know, capability but like a portion of that trauma. I see it all the time. And so it does help them you know if to them it’s like a wow factor, like they’ve never seen a treatment or hands on treatment that can induce emotional, you know, release in a way. So that’s definitely a good point.
Bill Clearfield 53:38
Um, so a long time ago, I went through the UCLA acupuncture program and they had some ear acupuncture techniques. Do you ever use any of those? Is that ever part of your protocols it was also used for calming and you know, sort of bringing, you know, sort of bring the patients into a state of
54:06
we’re open to that the addiction ship right now is just one year. I feel that, you know, soon it’ll be two years as we add pediatric addiction, ob addiction, and I certainly alternative, you know, we’re very open to anything other than opioids. So acupuncture would be you know, we have an elective. Nobody’s chosen that yet, but I would certainly approve and certainly look to you or, Hey, take one.
Bill Clearfield 54:39
I mean, it was 1985. Dr. Michael Smith in New York City, came up with this it was called the NADA protocol nada, and it was auricular acupuncture for addiction and then modified slightly over time, but we use it all the time for all sorts of things here you know, in our allowance.
54:58
Well, that you’ll be you’ll be getting you’ll be get you’ll be glad to hopefully get a resident or an addiction fellow I hope doctor to spend a couple weeks with you then you know,
Bill Clearfield 55:11
anytime day if you have
55:14
a pro we plus we like your neck of the woods out there in Las Vegas. So yeah, that’d be great. There you go. Dr. Misaki. You’re welcome.
Bill Clearfield 55:24
I will let him fool you Dr. Misery. On 400 miles from Las Vegas. All right. Okay, anybody else have any comments or questions? That was very informative. It was great succinct. We’re gonna let everybody get out of here at a decent hour for once. And next week, we have a Mr. John FIDIC. Who work he’s a psychologist in Reno here in Reno, Nevada here and at Lake Tahoe. And he does some integrative psychiatric work with biofeedback and some other other techniques. So he’s going to give us a little bit of insight on that in a day, Dave, maybe there’s something that you guys could use also. Oh, for sure. Well, so. So that’s, you know, next week, same time, same station. I don’t know what happened with the you know what, why we had trouble signing on the night I did the same thing I always do. And you’re getting also so sorry. We got started a little bit late. I hope we didn’t lose hardly anybody. We had an average crowd for us. And so, again, we’re gonna monitor you. Anybody who’s new, please leave us your email address there in the chat so I can add you to our email list. We’re here every Tuesday at this time. 5pm Pacific 8pm Eastern and wherever you are in between. When you get our emails, they’re still Stephen Hardman is and Mr. Gonzales are still working on the prostate program that they had presented. And there’s you know, there’s another there’s another program on there too, and I forget what that was for diabetes type one that we had keto diet, study also. So all if you’re interested in that the links are there on our email every week. Dave, thank you. Great as always, Dr. miseria thank you so much.
57:26
Thank you for having me.
Bill Clearfield 57:27
I really appreciate it. Please, please come back sometime. Aos or d.org/webinars. This is where all of our programs are. You can find the videos on a lot of them have transcripts also. And some of them have slides. But you can get all of the programs that we’ve had. We’ve been doing this for over two years. We’ve had quite a variety of speakers. And we we’ve sort of built a tradition here so thank you again, everybody. I know it’s you know, holiday time. And please be you know, be well be safe out there. Anybody who wants to present anything, please let me know. And always like I always ask you every week please bring one friend so we can we can double our you know, double our census here every week. So and again, take care Dave, thanks as always, I will be bothering him again in the future. Mirza you’re always welcome. Please don’t be a stranger. John. You got anything for us? I can’t hear you.
58:46
All is good and very beautiful talk.
58:49
We’re doing another convention this year bill before I work. I’m kind of on hold.
Bill Clearfield 58:55
As you know, we had a bit of a setback and unfortunately I’ve taken it rather hard and I need a little I need a little space. So maybe by the end of the year, you know, middle to the end of the year I’ll have it together. I mean, if you want to if you want to get it together, that’s that’s fine. We’ll talk but I’m a little bit burned out at the moment and every time the subject comes up, I start seeing red and my blood goes up. So I want to try it. I’m trying to put it put it to rest. So we’ll do something maybe maybe there’s just an online thing or something we’ll do surfing. Okay.
59:37
Thank you very much.
Bill Clearfield 59:38
Thank you, everybody. Thanks for being here. We’ll have this up as soon as we can. Usually we have it up within 24 hours on our website. Next week, John Finnick, again, with some integrative psych psychiatric techniques, so we’ll see you then and if you know anybody who wants to give us a talk, is afraid to give a talk. We don’t wait. Only on Thursdays. Please let us know. So Good night, everybody. Thanks. Thank you again, Dave. Thank you, Dr. Misora. Thank you so much. Take care. Thank you