MANAGING THE MONSTER PART 3: The PHC Response

Part 1 and 2 of this series on Managing the Monster have outlined the evidence that supports the extreme risk posed by co-prescribing benzodiazepines and opioids. This blog outlines the initiative that Partnership HealthPlan of California is undertaking to reduce this risk, starting with provider education.

Where are we going?

As Partnership dives in to our last phase of the Managing Pain Safely initiative, we are expanding its focus to include co-prescribing of benzodiazepines (BZD).  For the last two and a half years, Partnership has been actively working to reduce the number of members prescribed high dose opioids.  Since the start of the project in January 2014, we have seen a 74% reduction in the proportion of members on high dose opioids (>120 mg MED), PMPM, plan-wide.  This is only 1% away from our initial goal of 75% reduction!    As the project begins to accomplish the goals we initially set out to tackle, it is apparent that there is one crucial area that we have yet to focus on- co-prescribing BZD and opioids.

Why is it important?

As detailed in the last two blogs, the risks of severe complications, including overdose and death, are significantly higher when a patient uses a combination of opioids and benzodiazepines.  While the dangers of opioids alone are significant, they drastically increase when combined with BZD. It has been shown that as much as 80% of unintentional opioid overdoses deaths also involve BZD 1.  In the past five years, the U.S. has seen a fivefold increase in the number of unintentional BZD associated deaths1.  Studies have shown that the adjusted hazard ratio for risk from drug overdose for patients currently taking both opioids and BZD for is 3.86.3 This is especially concerning when keeping in mind that compared with opioid abusers, those taking both opioids and BZD are more likely to take the medications for longer periods of time and at higher doses.2

What are we doing?

Given the evidence of the dangers of co-prescribing, PHC leadership has designated this as a priority within this next year.  The MPS team has convened to determine a new goal for the initiative- to reduce the number of members with co-prescriptions of both opioids and benzodiazepines, PMPM.  While final plans and anticipated targets are still being defined, the top strategy of the health plan as of now is to provide education for our providers and our members.  The Plan intends on creating educational material for both providers and members, host a webinar to discuss how to manage patients taking both opioids and BZD, and share provider-site level data detailing who in the practice has prescriptions for both.  PHC is also promoting the CDC guidelines which recommend avoiding co-prescribing. PHC will also be working with community coalitions currently developing and implementing county-wide safe prescribing guidelines acknowledge the dangers of co-prescribing and recommend against the practice.

How will it impact you?

As mentioned, as of now the primary strategy to address co-prescribing will be to create educational materials for the provider and member, share best practices, share provider-site level data, and have 1:1 provider level academic detailing sessions with select provider sites.   PHC is dedicated to support our providers in continuing to grow a knowledge base and develop and utilize tools on safe prescribing.  Throughout the fall of 2016, expect to see more material and discussions on the use of BZD in conjunction of opioids.

Webinar on Co-Prescribing

Managing the Monster: Strategies in Managing Opioid and Benzodiazepine Co-Prescribing

Tuesday October 25, 2016

Noon-1pm

Registration: https://attendee.gotowebinar.com/register/8210921216123819778

References

  • Gudin JA; Mogal S; Jones JD; Comer SD. “Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use”. Post Graduate Medicine, 2013, 125 (4) 0032-5481
  • Jann M; Kennedy WK; Lopez G. “Benzodiazepines: A Major Component in Unintentional Prescription Drug Overdoses with Opioid Analgesics”. Journal of Pharmacy Practice, 2014, 27(1) 5-16
  • Park TW; Saitz R; Ganoczy D; Ilgen MA; Bohnert ASB. “Benzodiazepine prescribing patters and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study”. BMJ Open Access, 2015, 350:h2698

 

MANAGING THE MONSTER PART 2: Starting, Managing, Tapering Benzodiazepines

This is part 2 of a 3 part series on the dual headed monster of opioids and benzodiazepines. This blog describes strategies for managing and tapering benzodiazepines.

. However, when combined with opioids, benzodiazepines have proven to be very dangerous. In the past five years the U.S. has seen a fivefold increase in the number of unintentional benzodiazepine-associated deaths.  Reviewing data from multiple states, it has been shown that benzodiazepines are a leading cause of fatal drug overdoses, second only to opioid analgesics.2 The increase in benzodiazepine and opioid related Emergency Room visits and unintentional deaths has been attributed to the concomitant use of both medications, either illicitly or prescribed.

Despite the data showing the drastic increase in deaths for patients concomitantly using benzodiazepines and opioids, co-prescribing continues to be an alarming trend. It has been shown that taking benzodiazepines is a greater indicator of future long term opioid use than chronic or musculoskeletal pain, with as many as 40% of opioid users also taking benzodiazepines. When compared with opioid abusers, patients who take both opioids and benzodiazepiines are more likely to take the medications for longer periods of time and at higher doses. Concomitant users are also more likely to use or abuse other drugs and have a comorbid psychiatric disorder. This fatal combination has contributed to as much as 80% of unintentional overdose deaths involving opioids.1  In a study detailing the association between benzodiazepine prescribing and opioid use in US veterans, it was shown that the adjusted hazard ratio for risk from drug overdose for patients currently taking opioids who had a history of taking benzodiazepines was 2.33 (95% confidence interval 2.05- 2.64), and for those who are currently taking both opioids and benzodiazepines the adjusted hazard ratio for risk from drug overdose was 3.864.

Risks in Medication Assisted Therapy. The rates of benzodiazepine use among those who are also taking an opioid agonist, such as methadone or buprenorphine, have been regularly noted in literature.   Individuals may be abusing opioids and benzodiazepines in order to amplify the euphoric effect of opioids.  It has been noted that for individuals participating in methadone maintenance programs, rates of concomitant benzodiazepine use have been as high as 70%.3 For individuals participating in medication assisted treatment for opioid use disorder, it is important to note that there has been evidence that benzodiazepine use can remove the protective ceiling effect of buprenorphine on respiration depression.  Caution is recommended with patients on opioid replacement therapy- ensure that proper regular screening for alternative drugs/ medications is occurring, and consider using an alternative medication for anxiety relief, such as SSRIs. 3

Managing Benzodiazepines.  Benzodiazepines are most often prescribed for their anxiolytic effects, as well as their adjunctive treatment for several neurological and psychiatric disorders such as seizures and alcohol withdrawal, as well as for their muscle relaxant effects.  Opioids and benzodiazepines are often prescribed by different physicians, who may or may not be in communication with one another regarding the patient’s medication regimen. 1 While assessing risk of co-prescribing, physicians should be aware that benzodiazepines pharmokinetic interactions can be incredibly variable, dependent on multiple factors such as patient age, ethnicity, poly-drug use, and certain medical conditions (such as renal failure). Prior to initiation of a benzodiazepines or opioid analgesics, it is important to complete a comprehensive review of patient history, including checking of your state’s prescription drug monitoring system (CURES in CA), and a standardized risk stratification tool.   It is important to note that in addition to the increasing rates of medically prescribed benzodiazepines, the rates of illicitly used B benzodiazepines, especially in conjunction with opioids, has also been increasing2.

In starting to prescribe benzodiazepines, consider the above factors and remember that the benzodiazepines are Beer List drugs that should be avoided if possible in the elderly and frail.

  • Start at the lowest possible dose for the shortest period of time.
  • Use the formulation best suited to the indication. For instance, use the short acting benzodiazepines for sleep induction. Use the longer acting formulations for chronic daily management of anxiety.
  • If anxiety is the indication, use short-term (< 6 weeks) as a bridge to more effective anti-depressant therapy (SNRIs, SSRIs, Buproprion)
  • Use in conjunction with other modalities such as cognitive behavioral therapy, and stress reduction strategies.
  • Do not stop abruptly but establish a taper schedule.

Equivalent Doses of Benzodiazepines

  • Alprazolam         -0.5mg
  • Chloradizepoxide 25mg
  • Clonazepam0.5mg
  • Diazepam   10mg
  • Lorazepam1mg
  • Temazepam –       20mg

Tapering Benzodiazepines.  Given the dramatically increased risk of overdose and death with co-prescribing of benzodiazepines and opioids, consider tapering to the lowest possible dose or off, of one or both of these high risk medications. Tapering of benzodiazepines is fraught with obstacles. Rebound symptoms with heighted anxiety and insomnia is common so longer tapers may be required. CDC recommends tapering opioids first due to the difficulty with benzodiazepine tapering. If the patient has memory difficulties that might impair their ability to remember and stay on the opioid taper or the benzodiazepine dose is low, consider starting with the benzodiazepine taper. Some considerations:

  • Go slow (3-6 months)
  • Expect anxiety, insomnia, and resistance. Provide supportive psychotherapy
  • One prescriber, one pharmacy
  • Switch from short acting agents such as lorazepam to longer acting agents such as diazepam or clonazepam
  • Reduce the daily dose by 5-10% per week
  • Early follow-up – 1 week after starting and adjust tapering dose if needed
  • Slow taper after ½ of original dose achieved
  • Add adjunctive therapy if withdrawal/rebound symptoms are problematic. Drugs to consider are buspirone, clonidine, Vistaril, Inderal

Resources

Gudin JA; Mogal S; Jones JD; Comer SD. “Risks, Management, and Monitoring of Combination Opioid, Benzodiazepines, and/or Alcohol Use”. Post Graduate Medicine, 2013, 125 (4) 0032-5481

Jann M; Kennedy WK; Lopez G. “Benzodiazepines: A Major Component in Unintentional Prescription Drug Overdoses with Opioid Analgesics”. Journal of Pharmacy Practice, 2014, 27(1) 5-16

Jones JD; Mogali S; Comer SD. “Polydrug Abuse: A Review of Opioid and Benzodiazepine Combination Use.” Drug and Alcohol Dependence, 2012, 125(1-2) 8-18

Park TW; Saitz R; Ganoczy D; Ilgen MA; Bohnert ASB.  “Benzodiazepine prescribing patters and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study”. BMJ Open Access, 2015, 350:h2698

written by: Scott Endsley MD and Danielle Carter

NEXT: Part 3: the PHC Reducing Benzodiazepine Initiative

Protect the Newborn from Pertussis – Vaccinate in Pregnancy

In 2014, there were over 32,000 cases of pertussis in the United States. This represented a whooping 15% increase in incidence over the prior year (pun intended). The incidence rates for pertussis among babies exceeds all other age groups. The majority of pertussis deaths are in babies less than 3 months of age.

In California in 2015, there were over 10,000 cases of pertussis. Of the counties reporting pertussis, the six top counties with “rates substantially higher than statewide average” were all Partnership counties. These are Marin, Sonoma, Napa, Yolo, Humboldt and Modoc counties. Of worrisome note, only 16% of mothers of infants diagnosed with pertussis in 2015 had been vaccinated during pregnancy with Tdap. A CDC study in 2014 found that only 14% of pregnant women had been vaccinated during the pregnancy.

For many years, the American College of Obstetrics and the Advisory Committee on Immunization Practice recommended an approach to pertussis prevention in neonates called “cocooning”. This consisted of administering Tdap vaccine to all women in the post-partum period, and all other family members and caregivers who are in the infants environs to provide a “cocoon” of protection. This strategy has proved insufficient and ineffective as the epidemic of pertussis continues to grow. One key gap was that cocooning left a minimum of a two month gap of exposure between birth and receiving their first immunization.

Confronted with the inadequacy of the cocooning approach, the recommendations were revised by ACIP in 2013 to recommend the following:

  • All pregnant women regardless of prior immunization history should receive the Tdap vaccine during pregnancy.
  • Tdap should be given between 27 and 36 weeks of gestation to maximize the maternal antibody response, although it can be given at any point during pregnancy.
  • If not given during pregnancy, a Tdap should be given in the post-partum period.
  • If a tetanus immunization is needed for wound management during the pregnancy, Tdap is the preferred vaccine.

TAKE HOME: if you care for pregnant women in your practice, ensure that ALL women are offered Tdap during pregnancy, optimally during weeks 27-36.

http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html

http://www.cdc.gov/pertussis/pregnant/index.html

https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co566.pdf?dmc=1&ts=20160714T1327084446

 

Cognitive Behavioral Therapy (CBT) for Pain Management in Primary Care: Fun and Laughter

10-Minute Mini Lesson Four:  Scheduling Fun, Enjoyment, and Achievement

10-Minute Mini Lesson Four is designed to provide a basic understanding of how to help members set schedule fun, enjoyment, and achievement as part of their pain management treatment.

IS LAUGHTER THE BEST MEDICINE?

For years, humor has been used in medicine. Surgeons used humor to distract patients from pain as early as the 13th century. Later, in the 20th century, came the scientific study of the effect of humor on physical wellness. Many credit this to Norman Cousins. After years of prolonged pain from a serious illness, Cousins claims to have cured himself with a self-invented regimen of laughter and vitamins. In his 1979 book Anatomy of an Illness, Cousins describes how watching comedic movies helped him recover.

Over the years, researchers have conducted studies to explore the impact of laughter on health. According to some studies, laughter therapy may provide physical benefits, such as helping to:

  • Boost the immune system and circulatory system
  • Enhance oxygen intake
  • Stimulate the heart and lungs
  • Relax muscles throughout the body
  • Trigger the release of endorphins (the body’s natural painkillers)
  • Ease digestion/soothes stomach aches
  • Relieve pain
  • Balance blood pressure
  • Improve mental functions (i.e., alertness, memory, creativity)

Laughter therapy may also help to:

  • Improve overall attitude
  • Reduce stress/tension
  • Promote relaxation
  • Improve sleep
  • Enhance quality of life
  • Strengthen social bonds and relationships
  • Produce a general sense of well-being

Today more than ever before, people are turning to humor for therapy and healing.

FIVE EXERCISES FOR LAUGHTER THERAPY:

  1. Humming Laughter Sounds: Laugh as you hum, mouth closed. Play with the pitch, up and down the scale, feeling the vibrations resonate through your body. As you get more adapt at feeling the resonation, try and move it deliberately, through your chest, your jaw, your nose, your sinus cavities, your forehead, the top of your head, then back down again.
  2. Laughter Breath: Inhale deeply, and then exhale in a combination of first quick bursts of air coming out and finishing with vocal laughter. Repeat 5-7 times.
  3. Laughter Vowels: Laugh the sound of the following laughter vowels. Let’s start with: “A” as in “papa”: Aaaaa ha ha ha ha ha. Then “E” as in “free”: Eeeee he he he he he. Next is “I” as in “pie”: iiiii hi hi hi hi hi. Next is “O” as in “Bingo”: Ooooo ho ho ho ho ho. Last is “U” as in “soup”: Uuuuu hu hu hu hu hu. Excellent! Now repeat, but backwards.
  4. Happy Memories Chuckle: Go back in time and find a truly happy memory, typically of a time when you felt safe, loved, surrounded by people you loved, and when you all laughed. Take time to connect with this memory, laughing now as if you were back then. It normally takes 90-120 seconds to start to recreate the associated emotions.
  5. Hearty Laughter: Make an elongated “aeeee” sound as you slowly lift both arms all the way up, and then laugh heartily with your hands pointed to the sky. Imagine that your laughter is coming straight from your heart.

HOW TO ENJOY LIFE IN SPITE OF PAIN:

Suggestions from real patients at HOW TO COPE WITH PAIN:

I know the pain was going to be there but if I could get out and go places and do things I could still have some kind of life. My husband got me a mobility scooter. I am still restricted as to when I can get out but I do get out.

It is very difficult to maintain a positive attitude when all you feel is pain. Continue everyday being positive and keep going your family and friends need you. Breathe. Exercise. Pray. Diversions. Win your pain battle every hour.

I have a couple hours of the day when I can do a little bit and try to take advantage of cramming fun stuff into those few minutes here and there.
SUGGESTIONS FOR FINDING NEW WAYS TO MEASURE ACHIEVEMENT:

Tell your patients to treasure their big life achievements like graduating from school, getting that promotion, or finding the perfect life partner BUT when battling pain suggest that they DO NOT set that level of accomplishment as a goal.

Instead, they can consider each and every daily life activity as an accomplishment. Here are ten they can start with:

  1. Waking up
  2. Brushing my teeth
  3. Preparing one food item and eating it
  4. Patting the dog
  5. Calling a friend
  6. Typing my own shoes
  7. Remembering to fill a prescription
  8. Sitting outside for 15 minutes
  9. Enjoying a TV program
  10. Being grateful for the first nine!

*************************************************************************

AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

  1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
  2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
  3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

  1. PCP is best qualified to understand Member’s medical history and current needs.
  2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
  3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
  4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
  5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

  1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
  2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
  3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
  4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
  5. Improved self-management—Reliance on self rather than others to provide solutions
  6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

 

Cognitive Behavioral Therapy (CBT) for Pain Management in Primary Care

10-Minute Mini Lesson Three:  Goal Setting

10-Minute Mini Lesson Three is designed to provide a basic understanding of how to help members set achievable goals as part of their pain management treatment.

WHAT MAKES GOAL-SETTING DIFFICULT?

Most of us are good at identifying changes we would like to see in our lives. However, effecting these changes is often more difficult than identifying what they are — easier said than done, as they say!

Sometimes we feel overwhelmed by the size of the goal before us, and we simply do not know where to start. Other times we try to achieve a goal, but it just doesn’t work out. In these situations, it’s easy to feel discouraged and give up.

USING THE ACRONYM “SMART”:

The acronym SMART can be an important part of identifying appropriate goals and steps. This stands for:

Specific. Suggest patients be as specific as possible so they can tell when they have completed a goal or step. “Get more exercise” is vague, but “Walk around the block on Monday, Wednesday, and Friday” can be easily checked off.

Measurable. Suggest they make goals and steps measurable. Then they can track their progress over time. In the example above, specifying the “3 days” gives them a way to measure any change in their exercise habits.

Achievable. Make sure they pick a goal they can actually be attained. If it is NOT achievable then suggest they select a smaller step. For example, “Walk to the corner and back on Monday and Friday”

THE PRIMARY LAW OF CHANGE: If they are NOT achieving their goal, they haven’t selected a SMALL ENOUGH step.

Relevant. Make sure the goal they have chosen is in line with what they want to accomplish overall. Learning to be a better public speaker is a great goal, but perhaps not the most relevant if your greater aim is to make more friends.

Timely. Make sure that now is a good time to work toward their goal. For example, are they physically able to walk to the corner or around the block? This may have to wait until they have a walker or more strength in their legs.

HERE IS AN EXAMPLE OF GOAL SETTING:

Tom has been very athletic in the past and is very depressed about being relegated to his recliner because of his pain. He comes in with the goal of being able to take his usual five-mile run in the morning.

  1. ACKNOWLEDGE HIS OVERALL GOAL of returning to his usual exercise regime.
  2. Help him IDENTIFY A START POINT. He needs to be honest and ask himself, “Where do things stand now?” His answer: I can walk to the bathroom or kitchen. I need to rest after 5 minutes of walking or the pain is too much.
  3. Help him break down his “goal” by IDENTIFYING ALL OF THE STEPS it would take to get from his start point to his goal. Suggestions that could be made to Tom:
  4. Track how many times you walk to the bathroom or kitchen. Increase that by 2-3 more trips each day. Remember that EACH trip matters as a step toward your goal. These early steps are important. Congratulate yourself.
  5. Add walking outside (e.g., to the backyard, front yard, or outdoor hallway) but limit it to 5 minutes. Do this with a partner if it seems scary to you.
  6. Time your trips and add ONE minute each day. This means you would more than double your stamina in less than a week.
  7. Track all your trips and times. This is your training schedule and will help you reach your goal.
  8. Once a day, do more than what you think you can do. Then you can feel proud of yourself for going above and beyond.
  9. Help him CONSIDER POTENTIAL OBSTACLES and how to work through or around them:
  10. He says, “I can’t imagine going outside.” Suggestion: Suit up, put on your walking shoes, and just stand outside your front door. This is the trick: Almost everyone goes for the walk once they are outside their front door.
  11. He says, “But it hurts too much.” Suggestion: Remind him that the pain could lessen once he gets his body more active or that he can hurt on a walk as easily as he can hurt in his recliner and it will be more fun and more distracting from the pain. Ask what he’d like to see on his walk—a good way to encourage getting outside.
  12. He says, “I’m afraid I’ll fall.” Suggestion: This is a realistic concern. Offer to help him obtain whatever walking aid would decrease his fears.

CAN GOAL SETTING HELP IN ADDRESSING EMOTIONAL OR BEHAVIORAL DIFFICULTIES?

Goal setting can also be helpful when addressing emotional or behavioral difficulties. For example, someone who is depressed and isolated may work toward a goal of increasing the number and strength of his friendships. Someone experiencing anxiety related to her job may work toward exploring a career change or making time more often for relaxation and leisure. Because goal setting strategies are often used in CBT, this therapeutic approach is particularly helpful for those struggling to meet their goals, regardless of what those goals may be.

*************************************************************************

AS A REMINDER (from the Introduction to this series on CBT for pain management in the primary care office):

CBT is the “gold standard” psychological treatment for individuals with a wide range of pain problems. It can reduce pain, distress, pain interference with activities, and disability. And it may well have positive benefits for common comorbid conditions such as depression, diabetes, and cardiovascular disease. It has been shown to be effective regardless of the particular licensing or background of the provider, as long as they have an understanding of basic CBT concepts and skills, and can even be effective in web-based applications. Brief in-office CBT is not designed to replace referral to a professional mental health provider with his/her diagnostic skills and therapy and/or medication options when this seems more appropriate.

CBT is not just for the licensed behaviorist! These CBT Mini Lessons can be used by:

  1. The PCP him/herself (using appropriate billing codes to cover the extra 5-10 minutes),
  2. Office staff such as nurses, medical assistants, behavioral health providers (using Health & Behavior codes billed to PHC)
  3. A co-located Beacon-credentialed behavioral health provider (billed to Beacon)

Having practiced as a cognitive behavioral therapist for 40 years, I’ve seen CBT techniques used effectively in individual and group settings, in both clinical and psycho-educational venues, and provided by both professional and para-professional providers.

What are the advantages of bringing CBT into the primary care office?

  1. PCP is best qualified to understand Member’s medical history and current needs.
  2. Interventions are made when the Member is most motivated for change, i.e., the very moment when they are asking for help
  3. Providing behavioral alternatives allows the PCP to manage the Member’s pain more safely
  4. CBT interventions with home practice recommendations and handouts are quite effective in the primary care setting
  5. Avoid the stigma and wait time sometimes associated with referral to a behavioral health specialist

What are the basic goals for using CBT for pain management?

  1. Improved relationship with health professional—Member not shuffled off elsewhere, workable alternatives to medication changes
  2. Increased functional activities—Focus changes from Member saying, “I can’t…” to Member asking, “How can I…?”
  3. Improved mood and quality of life—Decreased depression, more optimism and self-confidence, less risk of side effects from medication
  4. Improved symptom control—Better awareness of pain cycles, reducing use of unworkable strategies for managing pain
  5. Improved self-management—Reliance on self rather than others to provide solutions
  6. Reduction in unnecessary visits—Reliable self-management options rather than unnecessary appointments when pain increases

FUTURE BLOGS on CBT for Chronic Pain in the PRIMARY CARE OFFICE:

10 Minute Mini Lesson Four – Scheduling Fun, Enjoyment, and Achievement

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

More on Mosquitoes

My last blog was about the life of a mosquito and Zika concerns.  Now how to avoid mosquito bites

“He told many remarkable things about those lawless insects. Among others, said he had seen them try to vote.” – Mark Twain, Life on the Mississippi

According to the Travel site of the CDC here is some advice.

General avoidance and protection.

Don’t go there.  No really, don’t go there.  – avoid travel to outbreak areas.  The CDC traveler’s website has information.   An unfortunate intersection for the Brazil Summer Olympics.

Avoid peak traffic hours – some mosquitos are dawn and dusk feeders, crepuscular.  But others, including the concerning Aedes albopictus (Asian tiger mosquito), a possible vector for Zika is a daytime feeder.

Protective clothing – obvious enough.  There are also available topically applied clothing (tent, shoes, camping gear) repellants and manufacturer infused insect repellant clothing.  These repellants contain permethrin and the manufacturer infused brands can remain active through several washings.   The topical permethrins have shorter activity.

Spatial protection

Spatial repellants and insecticides have been available and new products are available.  Spatial preventive measures intercept mosquitos prior to human approach.  Closing the doors and windows are an example as are mosquito netting in malarial environs.  Fans discourage the weak flying mosquito and disperse the chemical into which they home.

Spatial repellants and insecticides have been available and new products are available.  Devices that envelop an area or individual in repellent clouds.  Big clouds, small clouds, walking, wind, bug density …  These include coils, candles, foggers and personal devices that vaporize repellants such as metofluthrin.  These devices have not been fully reviewed but under the right conditions likely are helpful.

There are also electronic insect repellent devices which produce sounds that were developed to keep away mosquitos. No EPA or other scientific research has ever sought evidence that these are effective.

Topical Repellants

“I am rather like a mosquito in a nudist camp; I know what I ought to do, but I don’t know where to begin.” – Stephen Bayne

These are the familiar agents.  Off, Cutter, Sawyer, Ultrathon, Skin So Soft, and the like.  Protection time varies by agent, form, ambient temperature, activity level, exposure to sweat and water and abrasion.

The best known repellant is DEET (N,N-diethy-m-tolua-mide).  The CDC recommends using products with > 20% DEET, with effectives that plateaus at about 50%.  Micronized formulations may last longer.  Other products registered with the EPA include those is picaridin, IR3535 and some oil of lemon eucalyptus (formulated as a repellant) and para-methane-diol (artificial OLE) products. Researchers at New Mexico State University tested ten commercially available products for their effectiveness at repelling mosquitoes.  On the mosquito Aedes aegypti, the vector of Zika virus, only one repellent that did not contain DEET had a strong effect for the duration of the 240 minutes test: a lemon eucalyptus oil repellent. All DEET-containing mosquito repellents were active.

The CDC recommendations for repellants

  • Apply only to exposed skin and clothing (not under clothing)
  • Never to open, irritated skin
  • Never to eyes, mouth and sparingly to the ears (for the face apply to hands then transfer to face). The same transfer to apply to kid
  • Have kids wash their hands afterwards
  • Just enough to cover –thick application does not last longer
  • Wash when protection is no longer needed or in case of an allergic reaction

EPA registered products can be used by kids and pregnant or nursing women according to labelling.  DEET should not be used in children under 2 months of age and OLE products on kids less than 3 years old.

You can use both sunscreen (first applied) and repellant at the same time although the reapplication times may make this tricky and the same applies to combination products where the sunscreen may wear off first.

Ironically, the high pitched whine of the mosquito (The Mosquito) has been used as deterrent to human loitering and in high crime areas.  High pitched emissions target a younger, and presumably more delinquent, group with more acute hearing. The Council of Europe considers the device degrading and discriminatory to youngsters and has targeted the U.K. having more that 3,500 such devices in the country.  So that’s why the Brexit!

“Even a mosquito doesn’t get a slap on the back until it starts to work.”

The World’s Deadliest Insect – The Mosquito

Anyone who thinks that they are too small to make a difference has never tried to fall asleep with a mosquito in the room  – Christine Todd Whitman

Not to confuse, or perhaps to confuse etymology and entomology when you put together the Spanish for fly – mosca and the diminutive suffix –ito together you get mosquito.  A topic, an insect, of great interest in this, the possible summer of Zika.

The mosquito species of interest are the Aedes species – aegypti and albopictus (Asian tiger mosquito).  The former as a known vector of arboviruses in the United States with a limited geographic range and albopictus as a possible, unquantified vector but with a wider range.

The range of the mosquito is limited by winter temperatures – isotherms – but exceptions exist, particularly in urban areas where species can winter in protected environments.

In the vector map below by Gardner, et. al., the solid circles represent the suitable habitat and relative risk for Aedes aegypti and clear circles Aedes albopictus with larger concentric circles representing higher total estimated relative risk.  If you want to be mosquito free, move to Iceland, where both the cold temperatures and weather unpredictability are hostile to establishing a mosquito population.

The life-cycle of the mosquito runs the typical egg-larvae-pupae- adult stages.  The Aedes species can breed in casual puddles such as artificial water containers, cupped leaves, bromeliad axils or notoriously in abandoned spare tires (with the curious physics that have them become upright in marshes).  The eggs are also resistant to drying out and can enter diapause for several months if they dry out.  The male of the species is a nectar feeding insect as is the female, until it is time to breed.  A blood meal is needed to produce eggs.  Different species prefer different hosts such as animals, birds, cold-blooded animals, insects, even fish.

Female mosquitos hunt their hosts by detecting CO2, visual recognition and body chemicals, in particular octenol produced by the host.  Some unfortunate people are just genetically predetermined targets for mosquitos (we all know these people if you are not one of them).  Preferred targets include type O blood, heavy breathers, those with a lot of skin bacteria, body heat and the pregnant.   The antennae of mosquitos have 72 types of odor receptors, 27 are represented by chemicals in sweat.  The male mosquito has bushy auditory receptors to hear the whine of the female (this paraphrase is from Wikipedia- really).

Most mosquitoes are crepuscular hunters – dawn and dusk – ominously the Asian tiger mosquito (a potential Zika vector) is a daytime feeder.   Upon feeding the mosquito injects saliva as an anticoagulant.  This serves as the transmission fluid for arboviruses such as Zika.  The irritating and itchy bite is the result of histamine release in response to the bite.

Next Blog – How to protect yourself from mosquitos