People always say, ‘Bob how did you know that?”

I stayed up most of the night thinking which is dangerous for me well that’s what Carol Adams says anyways! Vicki Latham says I’m a great talker because I’m full of shit! Lmao Andrew Hohenthaner says I have a certain way I bring things out in people Kathy Riddle used to say if I retain anymore information my head will explode. Jessamyn Butler feels I’m kind of a good egg. Shirley Buck relys on me to come up with answers to problems. Nanc Seefeldt wants me to think fast and hard to solve problems. Steve Ariens Is my go to guy for everything pharmaceutical. Cheri Mendes Karen Wilkinson Margaret Drumheiser think I’m a little crazy but are wonderful people Michelle Shepherd believes I try hard and I will accomplish what I set out to do Douglas Leigh Hughes is my information guy and a great writer and a great guy Maria Higginbotham is my mentor and anything I need I ask her. Karlyn Beavers and Evelyn Beavers are wonderful fundraisers and great folks. Stacy Siano is one smart business cat.. Sheila Kim Purcell writes bills and has groups of folks on groups who work for legislation big wigs! I can do this all day APDF awesome folks Jade Rose Shelli Rodenbaugh Shear Carol Benack Ashley Clark Sara, Gina, Kim, Dana, Jessica, Lesley, Karen, Julie, Lynn, Tammy, Mike, David Israel ,Dr Mimms, Lisa, and ect ect… Great Docs and nurses and pharmacist and people that make APDF works!What makes us different is we have been to State Houses, Oversight Committees, Washington DC, Fundraisers, to eachothers houses to eat dinner, traveled to other States together to help one another, Speaking Engagements, Court Houses, Childrens Hospitals, Band Concerts with eachothers kids, hell even Hooters ! Truth being I don’t do anything by myself and so many great people put their time and efforts for free and only for the cause of helping CPPs and themselves. That’s so many different organizations problems is you’re working for people you can’t see and hope they are real people! These folks from around the USA are absolutely real and a force to be reckoned with! It’s easy to be a fear monger if you don’t know the person or people your working with! Work together is what gets things done..and boy have we made waves this year! One thing for sure is I know I’m nothing without all these great folks from around the . They are called friends! Trusted friends! That’s how we roll! Different orgs or not. Common people with a common goal! So come help us and eat some food! Hahaha

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I did not copy the entire article, but there is a hyperlink if anyone wants to read the whole “piece of pain mis-management for cancer pts “

What Are the Newest Guidelines for Nonpharmacologic Management of Cancer Pain?

https://www.medscape.org/viewarticle/984026

Clinical Context

Pain is a leading, disabling symptom among patients with cancer,

resulting from tumor burden or invasion of bones, muscles, or nerves. Many cancer treatments, including surgery, chemotherapy, radiotherapy, immunotherapy, or hormonal therapy can result in acute and chronic pain conditions, including aromatase inhibitor (AI)-induced joint pain or chemotherapy-induced peripheral neuropathy (CIPN) pain.

The Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO^®) panel included experts in integrative, medical, radiation, surgical, and palliative oncology; social sciences; mind-body medicine; nursing; and patient advocacy. Literature search identified 227 relevant studies (systematic reviews, meta-analyses, and randomized controlled trials [RCTs] from 1990 to 2021 to inform consensus- and evidence-based recommendations.

Study Synopsis and Perspective

New guidelines highlight the role that integrative pain management techniques, such as massage, acupuncture, and music therapy, can play in relieving certain types of cancer pain in adults.

The recommendations,^[1] published earlier this month in the Journal of Clinical Oncology, represent a joint effort between the American Society of Clinical Oncology (ASCO^®) and the Society of Integrative Oncology (SIO) to guide cliniciansicians how to best weave various nonpharmacologic pain management strategies into cancer care.

“Pain is a clinical challenge for many oncology patients and clinicians, and there’s a growing body of evidence showing that integrative therapies can be useful in pain management,” Heather Greenlee, ND, PhD, explained in a press release.^[2]

Still, clear clinical guidance as to when and when not to use these approaches is lacking, said Greenlee, co-chair of the SIO Clinical Practice Guideline Committee.

Previous guidelines from ASCO^® on managing chronic cancer-related pain^[3] largely focused on diagnosing pain and on pharmacologic interventions, and they only touched on evidence related to nonpharmacologic options.

The new guideline^[1] “takes a deeper dive on the use of integrative therapies, which is important because clinicians and patients need to have access to the latest evidence-based information to make clinical decisions,” Jun H. Mao, MD, SIO-ASCO® panel co-chair, noted.

In the guidance, the expert panel addresses 2 core questions: What mind-body therapies are recommended for managing pain experienced by adult and pediatric patients diagnosed with cancer, and what natural products are recommended for managing pain experienced by adult and pediatric patients diagnosed with cancer?

The panel conducted a literature search and identified 227 relevant studies. They included systematic reviews and randomized controlled trials published between 1990 and 2021 that evaluated outcomes related to pain intensity, symptom relief, and adverse events. After reaching a consensus, the expert panel made recommendations on the basis of the strength of the available evidence.

Regarding modalities for which there was stronger evidence, the panel highlighted several recommendations regarding acupuncture, reflexology, hypnosis, and massage.

The panel determined, for instance, that acupuncture should be offered for aromatase-related joint pain in patients with breast cancer and that it can be offered for general or musculoskeletal pain from cancer. It recommended reflexology or acupressure for pain experienced during systemic therapy for cancer.

While exploring complementary approaches to manage various aspects of the patient experience, it’s worth considering alternatives such as hypnosis. For instance, individuals undergoing cancer treatment or diagnostic workups may find relief from procedural pain through the application of hypnosis techniques. Additionally, for those in palliative or hospice care, as well as individuals recovering from breast cancer treatment, massage therapy emerges as another viable option for addressing pain and enhancing overall well-being. If you’re interested in exploring these methods further, you might find resources that allow you to learn hypnosis online, providing a convenient avenue for acquiring valuable skills in pain management.

These recommendations were considered moderate in strength and were based on intermediate levels of evidence that demonstrated that the benefits outweighed risks.

The panel added several recommendations it deemed to be weak in strength and that were based on low-quality evidence. These include Hatha yoga for patients experiencing pain after treatment for breast or head and neck cancers, and music therapy for patients experiencing pain from cancer surgery.

The experts also identified areas “potentially relevant to cancer care but needing more research,” such as the safety and efficacy of natural products, including omega-3 fatty acids and glutamine, and determined that there is insufficient or inconclusive evidence to make recommendations for pediatric patients.

“With improved oncology treatments such as immunotherapy and targeted therapy, more patients diagnosed with cancer are living longer; therefore, pain and symptom management is critical for improving quality of life,” Mao, chief of integrative medicine at Memorial Sloan Kettering Cancer Center, New York, New York, told Medscape Medical News. “The SIO-ASCO clinical guideline will provide very timely recommendations for physicians to incorporate nonpharmacological treatments such as acupuncture and massage to improve pain management for patients impacted by cancer.”

Nonetheless, clinical uptake of such treatments “is always a concern,” said panel co-chair Eduardo Bruera, MD, of The University of Texas MD Anderson Cancer Center, Houston, Texas. “We are hoping that by showing the growing evidence that is out there, healthcare systems will start hiring these kinds of practitioners and insurance systems will start covering these treatments, because more and more, these are being shown to be effective at managing pain for cancer populations,” Bruera said.

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I have not had time to listen to this TWO HOUR webinar… just sharing it right now 

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Most all medications have a temperature storage requirement – typically 59-86 F – and pharmas, wholesalers, pharmacies are required to keep medications within that range and if they are outside of that temp range > 24 hrs…  the potency of the medications are generally considered “compromised”…  BUT… when a mail order pharmacy hands off a package containing Rx meds to a delivery carrier ( USPS, Fedex, UPS) seldom is there any concern about the temp that the medications are exposed to and for how long.  When specialty meds – that require being kept at refrigerator/frozen temps…  the mail order pharmacies will typically take extra efforts to try to make sure that the meds are kept in the required temp range.  Sometimes, the delivery carrier does not deliver the Rx meds in the expected time frame and they show up at the pt’s home… outside of the required storage temp and UNUSABLE.  Many times, the med involved is a life critical matter and getting a replacement in a timely manner is not always possible.

Oklahoma proposes landmark rule to keep mailed medications safe from extreme temperatures

https://www.nbcnews.com/health/health-news/oklahoma-proposes-rule-keep-drugs-safe-hot-cold-rcna57492

There is little regulation of how pharmacies ship drugs to patients, though extremes of hot or cold can make medicine unsafe or ineffective.

Patients who get their prescription medications by mail in Oklahoma may soon have better protections for the safety of those drugs than any other state. On Wednesday, Oklahoma regulators proposed the nation’s first detailed rule to control temperatures during shipping, according to pharmacy experts. 

“This is a huge step,” said Marty Hendrick, executive director of the Oklahoma State Board of Pharmacy, after the board voted to approve the rule Wednesday. “We’ve got a tremendous amount of prescriptions that get mailed to patients. … What we did today was make sure our patients in Oklahoma are receiving safe products.”

Exposure to extreme temperatures can degrade or weaken drugs, potentially changing their dosage or chemical makeup and rendering them ineffective or unsafe for patients. But while government oversight of how pharmacies store medications to keep them in defined safe temperature ranges is very detailed, an NBC News investigation in 2020 found oversight of shipping to patients — during which drugs might be exposed to heat waves and below-freezing temperatures — is largely a system of blind trust. Mail-order pharmacy is a booming business, with soaring profits for some of the nation’s largest companies last year and more than 26 million people receiving their medication by mail in 2017 — more than double the number two decades earlier, according to federal data.

NBC News found that most state pharmacy boards, the regulators responsible for pharmacy safety, did not have specific rules for how pharmacies should ship customers’ medication, few asked about this process in their inspections, and many said it was simply up to the pharmacy to ensure safe shipping. 

Industry standards are clear that pharmacies should ship medications in their safe temperature range — set by the manufacturer after extensive testing under Food and Drug Administration guidelines — yet many patients have no way of knowing if the medications that arrive at their door have stayed within that range.

“So many insurance providers are really pushing patients to use mail order,” said Erin Fox, director of drug information at the University of Utah Health hospital system, who researches drug quality and shortages. “Unfortunately, many patients don’t have a choice in their insurance coverage to be able to use a local pharmacy, so having these protections is important.”

The proposed Oklahoma rule is the first of its kind to set clear guidelines on temperature safety during transit. It would require all pharmacies shipping or delivering medication to use packaging tested to ensure drugs do not go outside their safe temperature ranges, require them to be able to assess the safety of a medication if there are delays in delivery, and mandate that they give patients notification of shipping and delivery. 

“Oklahoma is at the forefront in developing regulations on this topic,” said Desmond Hunt, the storage and distribution expert and senior principal scientist at United States Pharmacopeia, the nonprofit that sets the quality and safety standards for medications that are used by the FDA, manufacturers and pharmacy boards. “How this evolves within Oklahoma may be a blueprint or a template for other states.”

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Want a Few Weeks of Knee Pain Relief? Try This

https://www.medpagetoday.com/meetingcoverage/acr/101699

Local nerve block proves mettle in randomized trial, though benefit didn’t last long

PHILADELPHIA — Blocking agents delivered to genicular nerves around the knee markedly reduced osteoarthritis patients’ perceptions of pain, far more than those receiving placebo injections, a randomized trial showed.

At week 4 following the injections, patients in the nerve block group reported mean reductions in pain scores of 3.0 points from baseline on a standard 10-point scale, compared with an average 0.2-point reduction among those assigned to placebo, reported Ernst Shanahan, BMBS, MPH, PhD, of Flinders Medical Centre in Adelaide, Australia, and colleagues.

But by week 8, the effect had clearly begun to fade, with average pain scores rising by 0.7 points from week 4 in the nerve block group. And at week 12, mean scores had increased another 0.7 points and no longer differed significantly from the placebo group.

The findings were published in Arthritis & Rheumatology and were also set to be presented Monday at the American College of Rheumatology annual meeting.

It’s the first demonstration in a randomized, placebo-controlled trial that local nerve block effectively relieves knee osteoarthritis pain.

Shanahan and colleagues conceived the trial to determine whether previous reports of success in individual cases were really credible. These were summarized in a recent review, which indicated that the approach improved function and reduced pain for up to 6 months. But these studies had no controls, a crucial limitation given that knee osteoarthritis pain is notoriously subject to the placebo effect.

For the randomized trial, Shanahan’s group enrolled 64 patients, assigned 1:1 to receive nerve blocks or placebo in a single session. Celestone chronodose and bupivacaine were the blocking agents used, injected adjacent to three nerves around the knee: the superolateral, superomedial, and inferomedial genicular nerves. These were located via ultrasound for precise placement. The placebo group received subcutaneous saline injections at the same sites on the skin surface but not penetrating to the nerves. Patients were allowed to continue taking their usual pain medications as needed.

Pain was assessed via visual analog scales. Overall osteoarthritis severity was evaluated with the Western Ontario-McMaster Universities Osteoarthritis Index (WOMAC) system, which measures pain, stiffness, and disability in separate domains and in a total score.

Mean patient age was about 70 in the nerve block group and 66 in the placebo group. Just over half of the former were women, while two-thirds were women in the placebo group. Baseline pain scores averaged 6.3 in the nerve block group and 5.5 in the placebo group.

All of the key outcome measures including WOMAC scores followed the same pattern: the nerve block group saw sharp improvements at their first post-injection evaluation, conducted at week 2, which was maintained through week 4. Scores on each then began returning to baseline levels. The placebo group, meanwhile, had little change in any measure during the study.

The latter may raise eyebrows among rheumatologists, given that placebo recipients in other intervention trials for osteoarthritis typically show major improvement, if temporary. Shanahan and colleagues offered an explanation in the journal report: “We speculate that the patients’ prior pain experiences, extending over years, the degree of severity of their structural changes (most were waiting for total knee arthroplasty), or the fact that the trial was a placebo-controlled study and not a comparator study may have diminished the placebo effect.”

Overall, though, the future looks bright for nerve block as an osteoarthritis palliative. “Many of the patients requested repeat [treatments] at the end of the study. Based on our findings, we believe it is reasonable to offer this intervention,” the researchers wrote.

The nerve blocks appeared safe as well as effective. Shanahan and colleagues said no complications were observed, either during procedures or at subsequent clinic visits.

Limitations included the small number of patients and the possibility that patients could tell which treatment they were getting (clinicians giving the injections obviously were not blinded). Also, the researchers noted that five patients were lost to follow-up, which “may have slightly affected the overall results of our study.”

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Here’s what people were talking about at HLTH this year (it’s probably not what you think)

https://www.linkedin.com/pulse/heres-what-people-were-talking-hlth-year-its-probably-beth-kutscher/

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I am not opposed to the use of legal medical marijuana. I have always had a concern of the SMOKING of MJ and/or smoking anything for that matter. There are other ways to utilize medical MJ, eatables, compounded Troches that are put under the tongue and/or between the cheek & gum. There is also the potential use of a mini-nebulizer as long as the MJ is in a Sodium Chloride and  not having some oily substance.  All those people having serious lung damage and/or dying from vaping “boot-leg” vaping fluids that “they” used Vit E acetate as a thickening agent and Vit E is a fat soluble substance.

Marijuana Smoking Increases Emphysema Risk, Study Suggests

Airway inflammation also more common in marijuana smokers than tobacco-only smokers

https://www.medpagetoday.com/pulmonology/smoking/101765

Emphysema and airway inflammation were more common among marijuana smokers compared with tobacco-only smokers, according to a small retrospective case-control study.

In sex- and age-matched analyses, marijuana smokers — most of whom also smoked tobacco — had significantly higher rates of emphysema compared with tobacco-only smokers (93% vs 67%, P=0.009), and higher rates of paraseptal emphysema as well (57% vs 24%, respectively, P=0.09), reported Luke Murtha, MD, of the Ottawa Hospital in Ontario, Canada, and colleagues.

Overall, emphysema was slightly more common in marijuana smokers in the unmatched analysis as well (75% vs 67%), though the difference here was not significant, they noted in Radiology.

Marijuana smokers also had significantly higher rates of bronchial thickening (83% vs 42%, P<0.001), bronchiectasis (33% vs 6%, P=0.006), and mucoid impaction (67% vs 15%, P<0.001) in the matched (shown here) and unmatched analyses.

“It was surprising for us to find that more patients who smoked marijuana actually had emphysema than these heavy smokers … and more of them had airway inflammation than the cigarette smokers,” co-author Giselle Revah, MD, also of the Ottawa Hospital, told MedPage Today.

She noted that because the larger group of tobacco-only smokers were both older than the marijuana smokers and heavy smokers, it was presumed that they would have more exposure to smoke and therefore more serious adverse events.

“There’s this public perception that marijuana is safe, and a lot of people think that it’s safer than cigarettes,” Revah said. “And this study raises the concern that that may not be true.”

In an editorial accompanying the study, Jeffrey Galvin, MD, of the University of Maryland School of Medicine in Baltimore, and Teri Franks, MD, of the Joint Pathology Center in Silver Spring, Maryland, noted that “the presence of paraseptal emphysema, especially in young individuals, is a marker to the radiologist of increased strain in the lung and points to the potential use of marijuana or other inhaled drugs.”

Revah explained that she and her colleagues wanted to learn how to identify a marijuana smoker from a CT image in the way that is done for heavy cigarette smokers. “I was surprised at how little information there was,” she said. “And that’s probably because it [marijuana] was illegal in Canada, and it’s still illegal in many places in the United States, and no one could ethically study it.”

Having this information could make it easier to identify symptoms that come with marijuana use as opposed to tobacco-only use, she added. Only two previous studies had looked at a potential link between marijuana and emphysema via lung imaging, and couldn’t establish a strong association.

The current study also supported the known association between marijuana smoking and gynecomastia (an increase in breast tissue in males), which was seen in 38% of marijuana smokers compared with 11% of tobacco-only smokers (P=0.04), as well as 16% of nonsmoking controls (P=0.039).

There was no difference in coronary artery calcification between age-matched marijuana smokers (70%) and tobacco-only smokers (85%; P=0.16).

“The patients in our … group are very heavy smokers, so we’re not comparing marijuana [use] to light smoking, we’re comparing the group to heavy smokers,” Revah noted. “But the question is, is it the marijuana alone or the synergistic effect between the marijuana and tobacco?”

She added that many questions remain about the effects of marijuana smoking, and she’s currently working on a prospective study that fully separates marijuana-only users from tobacco-only users.

The authors hypothesized that higher rates of bronchial wall thickening and inflammation in marijuana users could be related to the use of filters on cigarettes. Longer inhalation times and keeping smoke in the mouth for longer could also be related to the higher rates of emphysema, but Revah emphasized that more research is needed.

This study included 56 marijuana smokers (mean age 49, 34 men), of whom 50 also smoked tobacco, and 33 tobacco-only smokers (mean age 60, 18 men) who were selected from a high-risk lung cancer screening program. The study also included 57 nonsmoking controls (mean age 49, 32 men).

Marijuana smokers who also smoked tobacco had an average smoking history of 25 pack-years, and the tobacco-only smokers had an average of 40 pack-years. The age- and sex-matched subgroups included 30 marijuana smokers, 33 tobacco-only smokers, and 23 controls.

Not surprisingly, higher rates of emphysema were seen among marijuana smokers compared with nonsmokers (75% vs 5%, P<0.001). Rates of bronchial thickening, bronchiectasis, and mucoid impaction were also significantly higher in the marijuana smokers versus nonsmokers.

Study limitations included the small sample sizes and the inability to quantify marijuana use — only 28 of 56 marijuana smokers specified the amount, and users often share joints, inhale in different ways, and use different strains of marijuana, Murtha and team noted. There were also differences in lifetime duration of smoking, since the tobacco-only cohort came from a lung cancer screening study where everyone was over 50.

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DEA Sets CDC Opioid Guidelines

https://www.daily-remedy.com/dea-sets-cdc-opioid-guidelines/

The CDC unveiled its latest opioid prescribing guidelines.

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