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.