The PM&R Podcast

2016 was a watershed year in the United States in the attempt to reverse the epidemic of opioid overdose deaths and addiction. Perhaps no event crystallized this intention more than a set of guidelines released by the Centers for Disease Control and Prevention offering evidence-based prescriptions for responsible opioid prescription. This influential document did have the net effect of reducing opioid prescriptions for pain, but also had unintended effects in the process.  Dr. Roger Chou is here to discuss the intended and unintended effects three years out. Dr. Chou is a unique authority in the pain medicine field because of his influential scientific publications and, more uniquely, his participation as a member of the CDC consensus panel that created the 2016 guidelines. He is a recent co-author of a New England Journal of Medicine editorial that discusses his reservations about how the guidelines have been misunderstood and misapplied. 

Dr. Joshua Schrecker is a member of the clinical team at Aegis Sciences Corporation. He received his Doctor of Pharmacy from the University of Tennessee College of Pharmacy. He has expertise in developing leadership skills within a corporate environment and has received certifications through completion of advanced cardiac life support courses. On this episode, Dr. Schrecker discusses the clinical utility and role of urine drug screens. 

Dysautonomia is the most important nervous system problem you have probably never heard about. It is a vast grouping of diseases that affects the body's most basic functions that occurs below the level of direct conscious control--temperature control, digestion, and regulation of blood pressure are some of the critical functions of this unheralded system. When things go wrong with the system, it is obvious to patients. The problem is the cultural awareness and conventional medical system has been slow to recognize and effectively treat this dysautonomia. Enter: Kelly Freeman. A survivor turned patient advocate, Kelly is the founder of The Dysautonomia Project dedicated to educating patients and clinical providers alike to close this big gap. Having survived dysautonomia herself, she has founded The Dysautonomia Project to provide patient advocacy and education. She is the co-author of a book of the same name and her website can be found at thedysautonomiaproject.org.

Dr. Christina Hayhurst is an assistant professor of Anesthesiology and Critical Care medicine at Vanderbilt University Medical Center. She trained at the University of Virginia, where she first began to explore opioid-sparing anesthetics and the effects of high-dose opioids on post-operative outcomes. At Vanderbilt, in addition to critical care, she is a member of the Perioperative Anesthesia service, which designs and implements enhanced recovery protocols for a variety of surgical services, with an emphasis on opioid reduction. Her research interests include the clinical implications of opioid-induced hyperalgesia in the perioperative and critically ill patient populations.

Mast cell activation syndrome is a condition that most doctors have never heard about, yet it is an important cause of illness that is underrecognized and, as a result, misdiagnosed. It belongs in the category of chronic inflammatory illnesses with symptoms including fatigue, allergy-like symptoms and problems with virtually every organ system in the body. Dr. Lawrence Afrin is a leading scientist and clinician on mast cell activation syndrome. Dr. Afrin is based out of the University of Minnesota and the author of the book Never Bet Against Occam, a book detailing his clinical experiences and knowledge of this mysterious disease.  

Dr. Jack Berger discusses his experiences as a medical consultant to the California Medical Board and a regular expert witness in cases in which doctors are accused of mis-prescribing opioids. Dr. Berger has served as the director of residency training in regional anesthesia and acute pain medicine since 2000 and holds the academic rank of Professor of Clinical Anesthesiology at the Keck School of Medicine of the University of Southern California. He has been practicing pain medicine since 1982. 

Metabolic medicine is a fascinating paradigm to treat the individual patient. The individualization of care, everyone agrees, is the future of medicine, but the assessment and use of readily available patient parameters--things easily obtainable today--is still rare. Dr. Michael Rothman joins us today to discuss metabolic medicine and how he uses it in his clinical practice MD Wellness in New Jersey. Board-certified in internal medicine and emergency medicine, Dr. Rothman employs a unique approach that tracks dynamic clinical and laboratory measures, such as urinary pH, to determine the underlying imbalances in his patients. The identification and correction of dualities is one of the core principles of this approach. These dualities are familiar to most physicians, but not usually thought of as directly treatable entities. Distinctions like sympathetic and parasympathetic, anabolic and catabolic, acid and alkaline comprise some of the foundational categories. Dr. Rothman proposes specific life-style changes and the judicious use of lipid compounds to correct these measures with the goal of restoring health rather than masking symptoms. He also discusses one of his greatest influences, Dr. Emanuel Revici, a legendary physician in his time whose reputation and prescient work has largely been forgotten. Learn more about Dr. Rothman from his website at mdwellnessmd.com and his Amazon five-star rated book Edibolic Stress. 

Dr. Ritchie Shoemaker returns to discuss the diagnosis and management of a condition he discovered as a physician-researcher, chronic inflammatory inflammatory syndrome (CIRS). CIRS is important because it is a scientifically-validated condition that affects millions of Americans, most often in the form of chronic illness after mold exposure. (One out of every two buildings in the United States is water-damaged.) Genetically vulnerable patients develop a wide range of symptoms including fatigue, depression, muscle soreness and other symptoms and are often misdiagnosed by the medical establishment as having fibromyalgia, chronic fatigue syndrome or a psychiatric condition. In our first conversation, Dr. Shoemaker discussed how he came to discover this mysterious illness as a family medicine doctor in Maryland. In this second part, we turn our attention toward all things clinical including the case definition of CIRS, the main symptoms, biomarkers, genetic susceptibility, visual contrast sensitivity testing and the treatment protocol. To learn more, we highly recommend his books Mold Warriors and Surviving Mold and his website survivingmold.com. 

Ritchie Shoemaker, M.D. is a recognized leader in the field of biotoxin-related illness. Dr. Shoemaker was a primary care physician in Pocomoke, Maryland who began treating a mysterious illness in 1996 related to a Pfiesteria outbreak in the Chesapeake Bay. His subsequent journey in patient care, advocacy and scientific research led him to identify a common underlying pathway called the Chronic Inflammatory Response Syndrome (CIRS). CIRS is the end-result illness that occurs after exposure to biotoxins in genetically susceptible individuals. Dr. Shoemaker identified the same clinical symptoms, vision problems and alterations in blood work reflecting underlying inflammatory and immune irregularity in patients who became chronically ill after exposure to a wide range of biotoxins from Pfiesteria, blue-green algal blooms in Florida, tick bites and, most prevalent, mold from water-damaged buildings. He is the author of Mold Warriors and Surviving Mold. Dr. Shoemaker is joining us for a two-part interview. In this first segment, he discusses the events that led to his discovery of CIRS. The second segment will focus on the clinical work-up of CIRS. Learn more at Dr. Shoemaker's website survivingmold.com

Our guest today is Stuart McGill, PhD. Professor McGill is a Professor of Spine Biomechanics at the University of Waterloo. He has over 400 scientific publications including three text books: Low Back Disorders, Back Mechanic and Ultimate Back Fitness and Performance. Professor McGill will be discussing low back pain evaluation and management with us today. You can learn more at his website backfitpro.com.

Our guest today is Dr. Fadel Zeidan. Dr. Zeidan is an assistant professor of neurobiology and anatomy at Wake Forest School of Medicine and associate director of neuroscience at the Center for Integrative Medicine. His programmatic line of research is focused on determining the neural mechanisms that mediate the relationship between self-regulatory practices and health.  He is especially interested in determining if and how mindfulness-based mental training regimens affect pain and health.  Dr. Zeidan will be discussing the effects of mindfulness meditation on a spectrum of pain outcomes.

We welcome Dr. Lani Simpon. Dr. Lani is a certified clinical densitometrist and has a doctorate in chiropractic care. She is the author of the highly-regarded book Dr. Lani’s No-Nonsense Bone Health Guide and will be discussing osteoporosis with us today. You can learn more about Dr. Lani and find more educational resources at her website lanisimpson.com.

Our guest today is Anna Maria Aloisi, MD, PhD. Professor Aloisi studied at and now teaches at the University of Siena. Her research activity focuses on pain and hormonal-induced effects in pain mechanisms. She will be discussing opioid-induced hypogonadism with us today.

We welcome return guest Roger Chou, MD. Among his many titles and distinctions, Dr. Chou is a Professor in the Departments of Medicine and Medical Informatics & Clinical Epidemiology at Oregon Health & Science University (OHSU) School of Medicine. He will discuss his recent article Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis A Systematic Review and Meta-analysis published in the Annals of Internal Medicine.

On today’s episode we welcome Salim Hayek, MD, PhD. Dr. Hayek is currently the chief of the Division of Pain Medicine at University Hospitals and Professor in the Department of Anesthesiology at Case Western Reserve University. He obtained a Bachelor of Science degree in Biology with Distinction at the American University of Beirut in 1987 and a medical degree in 1991. Following a residency in Anesthesiology training at University Hospitals of Cleveland, he completed a PhD in Cellular Physiology at Case Western Reserve University in 2000 and subsequently obtained fellowship training in Pain Medicine at the Cleveland Clinic Foundation. He is well-published and serves on the editorial board of most pain journals. Dr. Hayek has had a number of service accomplishments at the local and national levels and is an editor of a textbook entitled Pain Medicine. Published in 2015, it is the first textbook to bring together the four main disciplines in managing pain: anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry.  

On today’s episode we welcome Jane Liebschutz, MD MPH. Dr. Liebschutz has been the Program Director of the Family Medicine­General Internal Medicine­-General Pediatrics Fellowship at the Boston University Medical Center since 2010. She is board certified in internal medicine and preventive medicine, and is an experienced researcher and educator, working across disciplines and with trainees pursuing diverse career goals. Her research agenda focuses on the intersection of violence, mental health and substance abuse withgeneral medical care, including active NIH grants in implementation research. She has been Principal Investigator or co-Investigator on over 12 training grants aimed at post­doctoral fellows. Dr. Liebschutz will be discussing her article “Managing chronic pain in patients with opioid dependence” published in a June 2014 issue of Clinical Treatment Options in Psychiatry.  

We welcome Roger Chou, MD. Dr. Chou is a Professor in the Departments of Medicine and Medical Informatics & Clinical Epidemiology at Oregon Health & Science University (OHSU) School of Medicine. He is Staff Physician in the Internal Medicine Clinic at OHSU and has served as Director of the Pacific Northwest Evidence-based Practice Center since 2012. Dr. Chou's research interests are systematic review methodology, meta-analysis, screening and preventive services, guideline development, and drug effectiveness. He has conducted systematic reviews in a number of areas, including chronic pain and musculoskeletal conditions, screening and prevention, diagnostic testing, and prognosis. Dr. Chou has served as Director of the American Pain Society clinical guidelines program, the GRADE methodologist for the World Health Organization’s Division of Reproductive Health, is a member of the Cochrane Back Review Editorial Board, and co-chair of the National Quality Forum Musculoskeletal Standing Committee. Dr. Chou is on several journal editorial boards and is an author on numerous scientific articles published in peer-reviewed journals. He will discuss his systematic review from a February 2015 issue of Annals of Internal Medicine entitled “The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop.”  

We welcome Sabrina Paganoni, MD, PhD. Dr. Paganoni is a physician at Spaulding Rehabilitation Hospital and Massachusetts General Hospital’s Physical Medicine and Rehabilitation Service. She is board certified in physical medicine and rehabilitation and neuromuscular medicine and her clinical interests include amyotrophic lateral sclerosis, electrodiagnostic medicine and neuromuscular disorders. We will be discussing her article “Rehabilitation in Amyotrophic Lateral Sclerosis: Why It Matters” published in 2014 in the journal Muscle and Nerve.

We welcome guest Tenley Fukui, MA, LPC. Ms. Fukui will be discussing her recent study entitled A Randomized Control Trial of Hypnosis Compared with Biofeedback for Adults with Chronic Low Back Pain published in the European Journal of Pain. Ms. Fukui is certified in clinical hypnosis by The American Society of Clinical Hypnosis. She has been in private practice for eight years in Houston specializing in chronic pain management, anxiety disorders, clinical hypnosis and biofeedback. Her extensive training and experience include interning at the Michael E. DeBakey VA Medicine Center in the Chronic Pain Clinic and Trauma Recovery Program; conducting research at the VA for 12 years; and serving as past president of the Biofeedback Society of Texas.

We welcome guest Jamil Bashir, MD, a regenerative medicine and interventional orthopedics fellow at the Centeno Schulz clinic. He will be discussing his article The Emerging Use of Platelet-Rich Plasma in Musculoskeletal Medicine published in the January 2015 issue of The Journal of the American Osteopathic Association. Dr. Bashir is a native of Rockville, Maryland and a graduate of the University of Maryland School of Medicine. After medical school he completed residency in Physical Medicine and Rehabilitation at The University of Miami Miller School of Medicine. Dr. Bashir worked closely with the Interdisciplinary Stem Cell Institute at the University of Miami, publishing a literature review on stem cell use in musculoskeletal diseases as well as helping to develop a pilot study investigating expanded stem cell use in the treatment of facet joint arthropathy.