In this episode we talk with Ryan Garbalosa, DO, FACC, a cardiologist practicing in the Carolina East Health System in New Bern, North Carolina.

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Interview transcript below:

Steve Legault: Hello and welcome to the ACOFP.DO FM Clinical Podcast. I'm, Steve Legault, the Director of Knowledge, Learning and Assessment and host for this episode. Today, we're going to be talking about cardiovascular disease and type 2 diabetes. We're welcoming Ryan Garbalosa, DO, FACC to the podcast. He practices as a cardiologist in the Carolina East Health System in New Bern, North Carolina. He's an alum of Nova Southeastern University College of Osteopathic Medicine, completed his residency at Palmetto General Hospital, followed by a Fellowship at the Deborah Heart and Lung Center in New Jersey. Welcome to the Podcast Dr. Garbalosa.

Ryan Garbalosa: Thank you for having me.

Steve Legault: Excellent, well for today's conversation. I thought it would be great to discuss type 2 diabetes and cardiovascular disease in a few different sections, beginning with risk and prevention. So what are the most important cardiovascular risk factors to monitor in patients with diabetes.

Ryan Garbalosa: A large portion of our knowledge of cardiovascular risk comes from the Framingham Heart Study something that's been going on for 70 years, and the risk factors for diabetics are just about the same as the risk factors for all the rest of us things like smoking, high blood pressure, high cholesterol, you know, our old favorites things that we're all familiar with.

Steve Legault: How aggressively should blood pressure be managed in patients with diabetes to reduce cardiovascular events.

Ryan Garbalosa: Blood pressure is pretty important, and it's a modifiable risk factor. The most recent Acc Aha guidelines came out in about 2017. They changed the definition of blood pressure as well as stage one hypertension to anything over 130 over 80. It's a class, one recommendation to start pharmacologic therapy, and any diabetic with stage one hypertension. In addition to your usual lifestyle modifications, diet exercise, particularly the dash diet. Our goal is to keep blood pressures under 130 over 80, which will in turn reduce their cardiovascular risk, reduce, stroke, reduce heart attack, and that's kind of based off what we saw in the Sprint Trial. Blood pressure is pretty important. They recently changed the guidelines. In 2017 we had an Acc. Aha update to hypertension, and they changed the definition of stage one hypertension to anything that was over 130 over 80, and this made a lot more people hypertensive, including diabetics and diabetics being that they are a. They have a specific, they have a risk factor themselves for being diabetic, for hypertension. They recommend that you aggressively treat their blood pressure with a goal of less than 130 over 80. It's a class, one recommendation, in addition to lifestyle, modification, like the dash, diet and exercise, and the more aggressive you are with treating their blood pressure, the more heart attacks and strokes you prevent, and that comes from data from the sprint trial.

Steve Legault: Excellent. Well, thank you, and kind of getting into medication management for this. How do the newer diabetes, medications, the SGLT2 inhibitors and GLP-1 receptor agonists. How do they impact cardiovascular risk?

Ryan Garbalosa: They're all pretty favorable. Ever since the black box labeling of TZD medications for heart failure several years back there's been a lot of scrutiny over the development of new diabetic medications, and even though GLP-1s were around at that time with exenatide, which is no longer produced, the newer ones, like Semaglutide and Tirzepatide. They're like all over the news. You got patients asking for them, and they've been shown to be beneficial. They have a decrease in morbidity, mortality in certain patients and the new SGLT2 inhibitors as well, have been making waves in the community, especially in the cardiovascular community, with their benefit in heart failure, both heart failure with reduced ejection, fraction, and heart failure with preserved ejection, fraction.

Steve Legault: Excellent. Are there any specific antihypertensive or lipid lowering agents that provide the best cardiovascular protection for patients with diabetes.

Ryan Garbalosa: As far as lipid lowering agents, the 2018 ACC Guidelines and a 2022 consensus statement said that all diabetics should be taking a statin. The evidence is a little hazy for patients who are younger than 40 or over 75, so you'll have to have a little more discussion with those groups of patients the research kind of trends towards using the medication, especially in the older patients. You definitely shouldn't be stopping statins in patients over 75. If they're already on it, it's shown to be harmful. But if you have a patient who's 78, 79, starting a statin might not have a huge benefit for them, and it's kind of outside of the research and guidelines. So you can again discuss with the patient the guidelines recommend a moderate intensity statin, and that encompasses most statins. But there's no real reason not to use the high potency statins Atorvastatin and Rosuvastatin. They're the ones that are recommended for anyone with cardiovascular disease. They're all readily available. They're all generic. They're cheap. And the only reason I don't use them is if there's any kind of tolerability issue. Then I'll start looking at other medications to use as far as blood pressure medications go. Like we all know most you should be starting these patients on things like ARBs. There is a class 2 B indication for all diabetic patients that have albuminuria because of adrenal protective effects. And honestly, even if they don't have albuminuria. ARBs are still a class one medication. They're basically all generic. They're readily available. They're very well tolerated. So that's another very important medication to be using in diabetics. Now, you notice I didn't say ACE inhibitors, and I want to say this with the caveat that the ACC and AHA Guidelines do not make this distinction. This is from my own practice, my own experience, and my own interpretation of the data that's available. ACE inhibitors to me are kind of an antiquated medication. ARBs, ow they're generic, they're well tolerated, they do not have the side effect of cough. They have a much lower incidence of Angioedema. There's some research data trial 2019 in the British Medical Journal, showing that long-term ACE inhibitor use might actually have an increased risk of things like lung cancer. Even in my practice, treating heart failure. The number one class one recommended treatment for heart failure. ARB-wise is sacubitril valsartan, you know, an ARB combination. So in my practice, ACE inhibitors are kind of phased out, and I stick with ARBs.

Steve Legault: That's great insight, thank you for that. When should switching a patient from Metformin to medication with proven cardiovascular benefits, be considered.

Ryan Garbalosa: Whenever they can afford it. And all joking aside, I'll admit I'm not completely up to date on the family practice side of diabetics without heart disease, and how to start and initiate medications. But I do know that when they come to see me there's some heart things that we need to take care of, and all heart failure patients with both reduced and preserved ejection fraction should be on SGLT2 inhibitors like Mpagliflozin or Dapagliflozin. In addition to this. There's more data emerging with the GLP-1 inhibitors like Semaglutide. There's some research like the select trial that's giving them the patients with cardiovascular disease, even if they don't have diabetes, and it's showing some morbidity, mortality benefits. Data is still emerging with the GLP1s. But you know, from what we have, if you can get on these medications, it's probably a good idea to be on them. They're backed by some good data.

Steve Legault: Awesome. Thank you. All right. So, jumping into complications and co-morbidities, how should family physicians approach the prevention and early detection of heart failure in patients with diabetes.

Ryan Garbalosa: Prevention is as simple as risk factor modification. Make sure the blood pressure. Cholesterol is treated, avoid smoking, encourage diet, and exercise. If the patient's overweight, encourage weight loss. As far as early detection, you want to pay very close attention to the symptoms that the patient is having. There are no screening recommendations for cardiovascular disease, with diabetics for asymptomatic, diabetic patients. But the symptoms might be pretty insidious. You want to make sure that they're not having any. You know strange symptoms or not, outside of the typical symptoms of chest pain, and shortness of breath. They may be just feeling tired. They might have reduced exercise tolerance. You just want to keep a high index of suspicion for those things.

Steve Legault: Thanks. And you just mentioned some different lifestyle kind of choices that can be made. Are there any modifications that have the strongest evidence for reducing cardiovascular risk and diabetes.

Ryan Garbalosa: I don't think there's any trials comparing the effectiveness of each modification head-to-head, but we can look to data showing that tobacco is the number one cause of preventable death, preventable death for everyone, diabetics, non-diabetics alike. I doubt there's anything we can do better than just not smoking. There's robust data, also showing the benefits of the DASH diet which was developed for hypertension, but it's just an all around good diet. The Acc has a recommendation that you should do 30 min of exercise 5 days a week, and you can kind of play with that on your own. They give you some leeway. If you want to bunch it up, let's say 3 days do 1 hour of exercise. Let's say you're a weekend warrior, you want to do Friday, Saturday, Sunday, that's okay, too, and the moderate activity they define as just anything that gets you breathing harder than normal. You can be lifting weights. You can be running, jogging. Anything is fine.

Steve Legault: Excellent. Thank you. And so, for the final portion of the conversation, I'd like to talk about interdisciplinary care. So when should a family physician refer a patient with diabetes to a cardiologist.

Ryan Garbalosa: This varies dramatically based on where you practice and the availability of both your primary care, docs and cardiology. Anytime a diabetic patient has heart failure, any atherosclerotic cardiovascular disease, or any kind of concerning symptoms, a lot of chest pain, a lot of shortness of breath with activities, they probably should be seeing cardiology. Sometimes the things like difficult to control, hypertension and hyperlipidemia might take over treatment on those patients. Some insurance companies will require them to be seeing a specialist or a cardiologist if they want a newer fancy medication like a PCSK9  inhibitor. But I understand there's a lot of specialist shortages in a lot of areas and your threshold for referring someone is going to vary based on how soon you can actually get someone in.

Steve Legault: Yeah, you touched on something important there. So my next question was going to be around what are the best ways to coordinate that care between primary care and cardiology for those patients.

Ryan Garbalosa: It can be either really easy or really hard, depending on the EMR system you use. Unfortunately, you know, if you're all in the same EMR, you have something like epic or something, you can communicate with each other, send people messages, you get your notes right away, your lab tests right away. It's very difficult if everyone's on a different electronic medical record system, you just have to make sure that you get your notes, your information to your refer your specialist and to the referring physician, either by some kind of electronic fax, or even sometimes patients, come in with a packet of notes from their from their doctor, so they make sure I can see it. So, whatever you can do. But it is important to have that communication back and forth.

Steve Legault: Excellent. Well, just want to thank you for being on the podcast today and sharing some of this insight with us in our audience.

Ryan Garbalosa: Thank you. Thank you for having me pleasure to be here.

Steve Legault: And thank you for listening to the ACOFP DO.FM Clinical, podcast a production of the American College of Osteopathic Family Physicians.

This episode we welcome Shirin Doshi, DO to the Clinical Podcast to talk about nutrition and how it relates to diabetes technology. We cover providing advice on eating habits and eating patterns, team-based approaches to nutrition, and how CGMs can influence eating and behavior.

• CGM and Nutrition
• Continuous Glucose Monitoring and Diabetes Distress

This transcript was created with the aid of automatic speech recognition technology.

Stephen Legault: Hello and welcome to the ACOFP DO.FM Clinical podcast. I'm Steve Legault, the director of Knowledge, learning and assessment and host for this episode. Today we're going to talk about the important intersection of nutrition and diabetes technology. For people with diabetes, food nutrition choices carry even more significance. With advances in technology, patients can see the impact of those choices almost immediately. Today we welcome Shirin Doshi DO. She's the lead physician advisor for Sparrow Hospital, where she supplies provider education, reviews hospital cases for medical necessity, assists with insurance denials, and continues to assist the medical staff with coding and documentation requirements, who's also part of the planning faculty for the American Diabetes Association supporting healthy eating habits through CGM program. Welcome to the podcast, Doctor Doshi.

Shirin Doshi, DO: Hi, Steve, nice to be here.

Stephen Legault: Well, thank you so much again for participating, and let's jump right in. But before we get into diabetes specific technology, let's talk about nutrition. I imagine that giving advice on eating habits and food selection can be a tricky area in some cases. How do you go about discussing those food choices that support overall health goals and targets with patients?

Shirin Doshi, DO: Well, every patient is different in the way that you speak with them because it depends on their level of understanding and their primary language, etcetera. So, it just depends on what they come to the table with, with their understanding. But one of the key points is that many of our patients do not have significant financial resources, and so it can be really difficult for them to buy, you know, the healthiest foods, the organic food, you know, the, the convenience of major fast-food chains. And some of those types of things are definite barriers. So, what I do is I discuss with them just a healthy balance. Foods, you know, including the good fats, protein, complex carbs, foods that are really dense and fiber and vitamins and minerals. And I explained to them that, you know, you don't have to go to a fancy, expensive organic food store, that you can go to your regular local market. And even frozen options of fruit and vegetables can be quite healthy, and they tend to be quite cheap compared to some of the fresher options. The other thing is that we talk about avoiding, you know, significant amounts of simple sugars, which are in, like, highly processed foods, like candy, you know, cakes, cookies, ice cream, stuff like that. And a lot of the white things such as white pasta, white rice and white bread, you know, trying to steer patients towards more the complex carbs. Fresh food, even though it still has sugar in it, it's, it's still balanced with fiber and, you know, vitamins and minerals, et cetera, and so it is a better option than food that is liquidities, that you just slurp up, that your body doesn't have to work super hard to actually absorb all those nutrients. And if we can get them to just even start making small choices, little baby steps in their nutrition, we can get them to a healthier point and have them feel like we're not asking them to completely change their diet within a day. We try to partner with them to make small decisions, small steps. You know, maybe the first step that we have them do is to cut out pop or soda for those of you that are not from the Midwest. So, cutting out pop is a huge source of, you know, unhealthy sugars and chemicals and all of that. And even if they cut out that one thing, and that's the only thing you work on at one time, you know, for a solid month, that's okay if you're moving them in the right direction. So that's kind of how I approach it with patients. It is difficult to really get them to start looking at their diet and figuring out how they could make it a healthy diet, because a lot of them have multiple family members who are eating the same things and who struggle with the same health conditions. And so, you really have to explain, like, this is for the whole family, this can't just be for you, because when you are eating healthier, but the rest of your family is not, then it's going to be tough for them to just slide back into that same mode.

Stephen Legault: Excellent. That's great. Appreciate that. And kind of thinking about the care team, are there some ways that collaborative care models or team-based approaches can be used to reinforce that communication you're having with your patients around nutrition?

Shirin Doshi, DO: I believe there are. I mean, a lot of the primary care offices now are trying to have multi discipline teams, like present in the office. I'm not as familiar with most of them having a registered dietitian as part of their team in the office. But when a lot of the offices are part of a big health system, it's easier to partner with a registered dietitian. And, you know, if you could get an RD in every PCP's office across the country, we would probably make great strides in helping to teach our patients whose multiple chronic medical conditions are greatly affected by their eating habits. So, I think that would be a great goal for us to do that. But in the reality, we have to reach out to resources that are local to us. And so, it tends to be that nutrition consult or we are referring people to the local diabetes education classes that often are put together by the endocrinology, you know, services that are in the community. So, every and some of the states have, you know, with their department of health, they have some resources there that can be used. You know, even though those providers may not specifically be in the same. Housed in the same office, they're still part of that collaboration to actually come together and to be that multidisciplinary approach to take care of these patients, because patients need to hear, most patients need to hear the same message multiple times and from multiple people in order for it to make sense and to sink in. That's great. That's great advice on how to use some of those local resources.

Stephen Legault: Thank you for that. Digging a little bit more into nutrition, what can you tell me about evidence-based eating patterns and how those can be used to treat prediabetes and type two diabetes?

Shirin Doshi, DO: So, for patients to avoid unhealthy dips and spikes of their glucose levels, we're really trying to encourage people to eat well balanced meals and snacks throughout the day. What this does is it supplies a steady amount of energy for the body and it helps with the metabolism and just overall, I mean, overall energy and sense of well-being. Like, whenever you go throughout the day and you're starving yourself, which is what a lot of our patients do, they don't feel good. Part of that is because of their eating pattern and their choice to just, you know, fast throughout the day and then just eat something huge at night. So, when people skip meals, what we know is that they often are so hungry that their ability to make good, healthy choices is hampered. And what they'll do often is they'll overeat. They'll overeat, and then after a large meal, especially if you are a diabetic, you will have a significant spike in your sugar. And the more your sugar spikes, spikes in either direction. That's why we are interested in this continuous glucose monitoring. The more that it spikes in either direction, the worse the outcome. So that's why we really are trying to get people to think more along the lines of steady, sustained nutrition throughout the day. If you eat a few meals a day, if you eat the right combination of meals, it will sustain you for the time in between to when you get to your next meal. And that's part of the education that, you know, goes along with. It's not even just for diabetics, it's for everybody, you know, getting a good amount of protein, a mix with the complex carbs and the healthy fats. And a good amount of fiber, whole grains, those types of things really do help to reduce the acceleration of the blood glucose as you eat. It kind of reduces that spike because your body is working harder to really digest all of those foods. And so that helps to kind of limit the major spike with your eating. And obviously, it depends on what you're eating. So, you know, if some meals are more carb heavy versus others, then you can have more of a spike. But it's really trying to look at that sustained, healthy eating pattern throughout the day that is going to be the most beneficial for most patients. Awesome. And when you're having those conversations or you're educating them on nutrition, how do you go about addressing any misconceptions around nutrition and the treatment of diabetes? If those come up? I think a lot of patients feel that if they're diabetic, they can never have sugar, they can never have a treat, they can never have fruit. So, a lot of that is, it is a misconception because you can, even a diabetic can have, can go to a birthday party and have a little bit of a treat. You don't want to do that every day, multiple times a day. You know, an occasional treat is not, is not looked down upon, but it's making sure that you're looking at your feeding, you know, your food pattern throughout the day, to make sure that the amount of good nutrients is there and to accommodate, especially if you're on insulin, to accommodate for that extra burst of sugar that you may get from having a treat. So, there's a lot of education when you're using insulin to cover for the meals that you're eating. And, you know, you do need to think about the carb counting and trying to figure out, like, oh, you know, I'm going to a party tonight. I normally use this much insulin. I'm probably going to need to monitor it a little bit more closely, and I might need to adjust. I might need to give myself some more. What I try to teach patients is that it's okay to treat yourself. You just don't want to do it all the time. And it is okay for a diabetic to eat fruit. Fruit is good, healthy, natural source of sugar, complex sugars. There are simple sugars there, too, but fruit is healthy. It's healthy for you to eat. Now, do you only eat fruit all day? No, that would not be good. That's not a balanced way to eat. So, there's a, there's a lot of those types of misconceptions and again, like, well, my favorite food is pizza. Well, it doesn't mean you can never have pizza. And there's healthier ways to make pizza. So, it's trying to explain to them that, number one, we want you to eat healthier, but number two, we're not going to ask you to make all of those drastic changes overnight. And number three, there are delicious alternatives to a lot of your most favorite foods that will still make you feel satisfied as if you were eating the thing that you really love and think you're going to miss. So that's sort of how I approach it with my patients.

Stephen Legault: Excellent, thanks. And that kind of segues nicely into the technology side of things. So how could the use of a CGM in the treatment plan both inform food choices and also aid in the behavior modification aspects?

Shirin Doshi, DO: So that's a really good question. Continuous glucose monitoring has now been in use for a little while, and we really were looking at how can we use this to our advantage in our diabetics and even patients who are pre diabetic to really help them kind of look at their eating pattern and to make adjustments in either choices for future eating or, you know, for how they're covering their sugars for their meals. It definitely can be used as a guide to help with lifestyle decisions. You know, you need to know what your targets are for your glucose levels, and it helps patients to kind of monitor their trends. And specific foods that are eaten can affect patients differently. And so, knowing how a specific food or a combination of foods affects them individually and what it does to their sugar, that's very useful information. So, we, you know, work together in this group, and the bulk of the work was done by the nutrition team and the staff side on these American Diabetes association. They were just wonderful to work with and very, very knowledgeable. So, they created an infographic that they basically really explain how to monitor your sugars and why it's important and why it's helpful.

Stephen Legault: Excellent and that kind of segues into the next piece here. So, when you're talking about CGM as an aid for nutritional decisions, what resources are you using to inform the conversation provider?

Shirin Doshi, DO: So, I think for the purpose of CGM, something I'm going to be using is the infographic that we just talked about is on the diabetes.org website. Really, it just explains, you know, in a very easy way, how to look at your sugars and why it's important to do that. It also shows how you want to split your plate up, you know, to make sure that it's the healthiest ratio of foods. So, you know, half of the plate is vegetables, a quarter of the plate might be carbohydrates, and then a quarter of the plate is protein. And so. And that may vary like meal to meal, but it gives an example of how sugars kind of are lower. And then there's a meal, there's a meal with vegetables and how it shows that the sugar doesn't rise as much, but then the meal without vegetables is rising a lot higher. And it also explains that, in general, some people can get very overwhelmed with the idea of continuous glucose monitoring. That was something that we discussed at length because we were worried about patients getting information overload with having their monitor on and constantly getting alerts on their phone or their computer, however they look at it. And so, they're really trying to, you know, explain, like, you don't have to worry about every single reading. You obviously need to worry about those that are extremes, those that are super low or super high. But in general, if your numbers are sort of in an average range, just check that average every couple of weeks. We want to try to get patients into the target range. You know, if you're in the target range more than 70% of the time, then that's associated with better outcomes. And every 5% increase in the being in that target range is clinically beneficial. And so, it kind of helps to show that. And the target range typically is between, like 70 to 180. And so, again, people are going to go below or higher than that, depending on their medication regimen and their nutritional intake. But the graphic that we created, I think, is very helpful. And again, going to the other resources would be the diabetes education classes. The Department of Health for each county or state usually has good resources, and as well as the CDC has some really good diabetes resources as well. And obviously, if you have, again, you're in a system or you're lucky enough to have a nutritionist, then that nutritionist or the registered dietitian is a very good resource as well.

Stephen Legault: Excellent. So, it sounds like there's quite a few places where both providers and patients can go to get this information. Excellent. Well, I think that's it for the questions today. Doctor Doshi, thank you so much for being part of the podcast.

Shirin Doshi, DO: Thank you very much. I appreciate your time. Thank you.

Stephen Legault: And thank you for listening to the ACOFP DO.FM podcast, a production of the American College of osteopathic family physicians.

Mentioned in this episode:

De-stress Pain Management

This month we welcome Robert Agnello, DO, FACOFP to the Clinical Podcast to talk about pain management and opioid use disorder. We cover integrating opioid analgesics into treatment plans along with patient education, handling patient opioid use outside of prescribed use and how to talk to patients about incorporating OMT into their treatment plan.

This transcript was created with the aid of automatic speech recognition technology.

Steve Legault: Welcome to the ACOFP DO.FM Clinical Podcast, I'm your host, Stephen Legault, the Director of Knowledge, Learning and Assessment at ACOFP.

Steve Legault: On today's episode. We're going to be talking about pain management with a specific focus on opioids. Opioid use disorder affects about 2.1 million people in the United States.

Steve Legault: We're glad to be joined for this episode by Robert Agnello, DO, FACOFP.

Steve Legault: He's an Assistant Professor of Family Medicine and Pain Medicine at Campbell University.

Steve Legault: He also serves as the Faculty Senate chair at QSOM for the University and is the NBOME Clinical Family Chair.

Steve Legault: Dr. Agnello serves on the Board of the American Academy of Osteopathy, and on a number of education focused committees here at ACOFP, including the Substance Use Disorder Task Force.

Steve Legault: welcome the Podcast Dr. Nolan. Anything I missed in your background that'd be helpful.

Robert Agnello: Oh, that sounds great, Steve, I think you covered it completely.

Steve Legault: Excellent. Well, thank you. And again, glad to have you here.

Steve Legault: you know you were one of the subject matter experts who created our de-stress pain management, rethinking opioid non opioid therapy, and we cover a lot in that course, and I encourage anyone listening to go and take a look at it and complete it. It will satisfy your DEA requirements, and it's also just a great in-depth resource for anyone looking to learn more about pain management.

Steve Legault: And it's also free. So any anybody who is in healthcare is welcome to do that regardless of ACOFP membership. So we encourage everyone to participate. But I wanted to ask your thoughts on a few specific aspects we cover in the course.

Steve Legault: When looking to safely integrate opioid analgesics into treatment plans, what considerations need to be made around patient education?

Robert Agnello: Oh, thank you so much, Steve, for that question. I think it's very important that all clinicians, physicians all provider types that are involved in chronic pain management. Consider the opportunities for opioid medications, you know, regarding analgesic management.

Robert Agnello: They are an option, you know. We are recovering from some very significant limiting recommendations that were out in the round 2016, and finally was recognized and loosened up upon in 2022 by the CDC.

Robert Agnello: There are patients that benefit from analgesic medications, including opioids. And there are tools that we have to help us select. You know the correct patients that could do well on opioid medications. First, we always want to make sure we have a wonderful history physical exam, and then come up with a complete his treatment plan.

Robert Agnello: And in that treatment plan we should be very integrative about our approach, very osteopathic about our approach, considering optimizing non-pharmacologic strategies, interventional procedures, and different adjunctive pain medications. There's a whole host to choose from.

Robert Agnello: But every now and then I like to give this example. You're going to get that patient. I won't say any specific age, but they have very extensive degenerative change, maybe in their spine, their hips, their knees, their quality of life is impacted, their functional status impacted and their pain levels are high and maybe they have a little bit of renal insufficiency.

Robert Agnello: Maybe they've had a bleed, a Gi. Bleed in the past. Maybe they aren't the ideal patient for typical types of medications like non-steroidal anti inflammatories that we use with patients. It. Perhaps they've already maxed out the amount of acetaminophen that they use per day.

Robert Agnello: It's possible that they're not great candidates for some of those adjunct adjunctive medications like duloxetine or amitriptyline or maybe a nerve stabilizing medication like a Gabapentin.

Robert Agnello: So where are you? What do you have to offer that patient?

Robert Agnello: Probably an Opioid, and I would suggest, you know, that you consider adding to your toolkit a medication like buprenorphine. And you're going to hear more about that.

Robert Agnello: Maybe you already heard about it. In our course that we we've helped to provide. But buprenorphine is a wonderful medication that has both some opioid agonist activity on the opioid mu receptor, just like the common opioids we're used to. But in addition, it has an impact on a receptor called opioid Kappa receptor. And what's great about that is it helps to keep things awake right? So you don't get the respiratory, depressing effects that you get from medications like oxycodone, hydromorphone, oxycontin, etc. So I think that there is a great place for utilizing these medications. Now, education is key and we typically recommend thinking about an opioid consent. Form not not the medication agreement, but this is how you can keep things safe. You use an opioid consent form just like you would for a procedure.

Robert Agnello: And you go over all of the possible positive and negative outcomes that this met type of medication may cause or contribute to so that's how we go ahead. We also want to screen patients typically before we start them on an opioid for depression, anxiety, and for risk of developing a problem with an opioid and there's a wonderful tool for that called the opioid risk tool that you can utilize to help determine if there's like no risk mild, moderate, or severe risk for your patient utilizing that medication in developing, and an addiction or an opioid use disorder.

Steve Legault: Excellent. Thank you. And kind of keeping in line with that, another thing covered in the course is the tapering of opioids in line with evidence-based practices. So do you have any pearls in this area you'd like to share with our listeners.

Robert Agnello: Oh, Steve, this is a tough one, you know. There are a lot of wonderful guides and tools out there. First of all, when it comes to tapering, there could be a variety of reasons. Number one, maybe your patients just ready.

Robert Agnello: Guess what it is possible that your patient could just be ready and they want to try to be off of opioids.

Robert Agnello: And that could be because you provided other complementary integrative strategies that have been successful. And they've seen the light.

Robert Agnello: Perhaps you are running into a problem with the way they're using opioids.

Robert Agnello: And there is an opioid use disorder, or they're not really getting the benefits anticipated for the opioid. They're not improving in their function or their quality of life.

Robert Agnello: So tapering is interesting. There are a lot of guides.

Robert Agnello: There's plenty of great recommendations out there. My biggest pearl. What I've really learned over the course of time is to go slow.

Robert Agnello: and and you may see recommendations out there that recommend or say, you can reduce by 10 or 15 or 20 per month for people that have been on their opioid for 10 to 15 years that might not work, and it might really scare them. So I've learned that reducing by maybe 2 and a half percent or 5% of their morphine equivalents daily okay, or their morphine milli equivalents used in a daily basis. There's a lot of different ways that that's being looked at now, but knowing what that number is, will help you to slowly titrate that medication down over the course of time. Yes, some people can do it quicker. Some people are slower, some people you might get down to just that very last little nighttime dose right? And they can't. They just can't. They can't. It helps them sleep, maybe find out the reason why. Ask them the questions. But you might have reduced them 50, 75, even 90% on their total Opioid milli equivalents daily. That's fantastic.

Robert Agnello: Be happy, you know. Maybe you stop until they're like coming back to you and saying I did it all on my own and that's some of the tips. I think that work best for me in regard to tapering, which may lead into thinking about buprenorphine as well so some people maybe they convert at least to a safer opioid. You've got them down solo now, maybe below. What if you look in most of your guides if you look in Buprenorphine's information, getting them below 30 morphine milli equivalents of whatever opioid they're taking, could open up the doorway to do that pretty safely without inducing any kind of withdrawal symptoms. And so that could be at least an alternate safer opportunity.

Steve Legault: Excellent. Thank you for that. Something we get in follow up questions when we have courses on pain management around clinical presentations of patients at risk for opioid use disorder, or who may be inappropriately, inappropriately using opioids. So what advice do you have for it for physicians that suspect a patient of theirs might be using opioids outside of their prescribed use.

Robert Agnello: Yeah, in regard to this, you know, I think, that it's very important that you have tools to help identify this. You know, we already spoke about a tool to identify starting a patient on an opioid. There are tools that we should at least probably do once a year on continuing opioids. There is a tool called the continuing opioids misuse measurement scale, otherwise known as the COM. There's another tool known as Dyer, and there's several other tools as well. And and those might indicate to you, okay, we need to have a new conversation or an updated conversation about the safety with you and the opioid medication.

Robert Agnello: I I think that if you do suspect a problem, let's say the dates are coming sooner and sooner. When your patients, requesting a refill or you go into the registry. The State registry, which is almost like a national registry now, but the registry, and there seems to be medications filled from other providers. You do a urine test and there's another substance that you don't expect. Right. What do you do you? You talk to the patient? Did you expect that that was going to be there and find out? Why? Why is Tetrahydro cannabinoid there? Why is cocaine there? And you have a conversation, and maybe you identify that they don't just have an opioid use disorder, but maybe they have another substance use and that is not grounds any more for discharging a patient from your practice. That's what I just wanted you to walk out with tonight. Don't discharge those patients. Don't send them to another place. Don't pass the buck, as I like to say these people need your help and in these circumstances conversations can go far. Regaining trust can go far I use a lot of different strategies. We might only refill the medications one week at a time instead of 30, 28, or 30 days we might recheck those urines more frequently and if they ever get to a point where I continue to not be able to trust them, then we're going to work on titrating the medication down, and I will take care of them in every other way possible and we will. We'll work out a plan. And so that's kind of the advice that I would pro, you know, provide regarding, you know, if you think a patient is using opioids outside of their prescribed use. One other one, you know it's so interesting, Steve. You should prescribe your opioid very specifically but so on your directions. It should be oxycodone 5 milligrams every 6 h for pain level, greater than 7 over 10 for low back pain. If a patient decides to take that for their elbow, they are inappropriately using the medication. And so again, that would be another thing that would prompt conversation. To make sure that patient uses the Opioid correctly in the future.

Steve Legault: Excellent. Thank you. You know, having conversations like this kind of reminds me of the live case forms that we have that are part of this program. You know, where healthcare providers are coming, and they're bringing their cases to their peers. And then together, they're kind of devising solutions or getting ideas on treatment. Sowith that in mind, what's your favorite aspect of that portion of that program that with that live learning.

Robert Agnello: I think, Steve, that this has been so well received. The idea that we came up with as an organization working with ACOI and formulating a course where 6 h are asynchronous 6 and a half. Whatever we've kind of decided is and and the materials for that are very interactive. By the way, I just want to let you know those of you that haven't taken it, this is interactive material. There are some videos. There's some dragging columns. There's multiple choice. There are timelines. There's a lot of great, interesting, interactive stuff. I even learned stuff from our course from my colleagues. This is something always to learn about pain management. I always say it's the most fun field in medicine, you know, is pain management. So I try to get people as excited as I am about it. But I think the live format and the conversations that come from that live format are really invaluable and you know, I can tell you, I can share that Dr. Farrell and I, when we presented this information in New Orleans at our National ACOFP Conference that we were nervous, that nobody was going to talk, so we even prepared like 20 backup slides and we presented a couple of slides, and then offered it up and said, We want to hear about your patients. How can we help you? Or how can your colleagues that are out there sitting with you, help your patients. And well, once one person got going we heard from many more people. We spoke and went on for that full hour and a half allotted time, and probably could have filled up another hour or 2 based on the conversations we were having. And what does that also lead to. It leads to those sideline conversations after the live talk is over, that you're just not going to get in a virtual environment right? Somebody's pulls their colleague from the residency program. Wow, how did you guys implement opioid management in a family medicine residency buprenorphine opioid use disorder. That's what happened, and we're looking forward, Steve, to do that again this year at OMED, in San Antonio in September.

Steve Legault: Exactly. It's going to be a good time. I encourage anybody who hasn't registered yet. Registration just opened in June, so please do register. ACOI is having their live case form at their conference as well. It's going to be in October. So we're looking forward to that.

Steve Legault: For the final area. I wanted to touch on with pain management around OMT, it's a unique to Osteopathic physicians. So when a patient is, you know, looking for pain, relief, how do you bring up the idea of trying OMT? If they've never done it before.

Robert Agnello: Wow, that's a wonderful question. I offer up basically a menu of integrative opportunities for patients. A lot of the times. A good way, Steve, to get going with this is to have a screening tool to find out where a patient's interests lie. I have a tool that I utilize. That's comes from the integrative medicine and functional medicine world. That is a 14 page intake paperwork. That helps to really identify and figure out what the roots of this might be. How we can really optimize self-care, self-treatment, strategies which are probably the most studied and most important to fortify those routes I always like to mention. You know that if we could get people to eat well, sleep well, stress well, move well and get along with others. Well, the 5 roots alright! Guess what? Regardless of what's going up there in the branches and the leaves, patients are going to start to feel better.

Robert Agnello: So that's where we start. And I make sure that they're interested. So on my screening tool from ill, say, from one to 5, are you interested in changing your food, lifestyle? Are you interested in talking about herbs or supplements for your pain? Are you into and so on? Are you interested in manipulation acupuncture. If I have a patient that's marks that opportunity office 5 out of 5 or 4 out of 5, we're going to go for it now. Many of these patients have tried lots of things. You know, and so sometimes you got to get them a little glimmer of hope somewhere else along the path of where you're when you're treating them, and then they come back, and they might be like, now I would like to try osteopathic manipulation.

Robert Agnello: But you don't want to come in that door on that first visit and be like. I think OMT is going to be the answer, and they've marked one out of 5, their interest in manipulation. You're going to chase them right out the door. They're not going to trust you. You need to meet people where they are. And I talked them all about how osteopathic manipulation can help, just like we would with any other patient. How it impacts their autonomic nervous system, right? So their sympathetics and their parasympathetics, how it affects their biomechanics, and how it affects their circulation, and if we could get things just moving better and less congested that might give them moments where they are like. Wow! I didn't take my oxycodone for 4 extra hours, or I didn't take it for a couple of days and now they might be willing to work on discontinuing opioid medications. So I offer it. And all my patients really pretty much want it. Sometimes it's practicality. It's access it's insurance. So there could be a lot of reasons that could get in the way from certain complementary care strategies that we offer so we do have to meet patients and have to accept their means where they are. Really kind of identifying some of those things makes a big difference. And then, having conversations, you know there are. I've had patients, Steve, that in a million years I would never think they've wanted would want to try acupuncture. And so maybe they just built up trust. Wow! He didn't take my oxy cod on away. I'm still on my 40 morphine equivalents daily and 3 months in. They're like, you know what? I remember you mentioned something. I see this sign about acupuncture. What do you recommend? And we might do a little ear acupuncture needles that they go home with for 5 days, and they come out the next time they come back. And like, Wow! I I didn't need to use my opioids while those were in you know. As soon as they fell out I restarted them, or at least maybe as needed, and so providing opportunities. That's what I think we need to build up our tool kits. So we can really, you know, give our patients the chance to move forward.

Steve Legault: Excellent. Well, thank you so much for coming on the podcast and having this conversation on opioid use, disorder and approaches to pain management. It was a real pleasure getting to talk to you.

Robert Agnello: Steve is a pleasure speaking with you as well. Thank you so much.

Steve Legault: Excellent, and thank you for listening to the ACOFP DO.fm Clinical Podcast, a production of the American College of osteopathic, family physicians.

Mentioned in this episode:

De-stress Pain Management

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