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Osteoporosis affects millions of people in the US, leading to a little under one million compression fractures a year. It also is a cause in many patients with chronic pain condition. Osteoporosis is a disease of the bone that results in bone fractures and deterioration of bone strength. In osteoporosis there is an imbalance with increased bone loss and a decrease in new bone formation. Although anybody can develop osteoporosis, known risk factors include: advanced age, female gender especially with estrogen deficiency such as postmenopausal, European or Asian ancestry, thin and small body frames, excess alcohol, nicotine use, malnutrition such as vitamin D or calcium deficiency, high protein diet, lack of weight bearing exercises, phosphoric acid from soda, heavy metals such as cadmium, as well as excessive physical activity such as in intensive training without proper compensatory increase in nutrition. Caffeine is not known risk factor for osteoporosis. First important steps in prevention of osteoporosis or to minimize the effects of the disease is to get appropriate screening. Also make sure you have a balanced diet and appropriate amount of exercise. Access your environment to help prevent falls which will help decrease osteoporosis related complications. There are also many medications used in the prevention and treatment of osteoporosis. Consult with your doctor to discuss how you can take steps to prevent or address osteoporosis. Addressing osteoporosis will make a big difference in your overall management of your chronic pain condition.

Prolonged sitting and forward bending at your work station can aggravate disc pain, so take a load off your disc by taking breaks and lying down. When sitting have your feet supported by the floor and not dangling. Sit on a chair with a mild wedged cushion (thick edge at the back against the seat) that is sloped downward thus forcing a more natural arch in your lower back. Chairs with proper lumbar supports and arm rests can also be helpful. Try to maintain yourself aligned while sitting so that your shoulders line up squarely over your hips and your ears line up with your shoulders. From the side it should look like you are sitting up straight and you are well aligned from head to hip.

You may not believe it but the way you stand can put unnecessary strain on your back. Lets get into an ideal standing position: Start by placing your feet about 5 inches apart, next align the pelvis over the ankles to create a natural lordosis in your lower back (your body weight should be equally disturbed on the heels and toes), now align your shoulders over your pelvis, and your ears over your shoulders. It may feel awkward at first as most of us are used to our old slumping position. With a little retraining you will come to find this stance more natural and your back will thank you for it. If you have to stand for a long period of time consider resting your foot on a prop or footstool (about 5 inches high) and alternate between feet, one at a time.

We spent more than 30% of our lives in bed, so invest in the right orthopedically designed bed for your back sooner than later. The best bed is one that when you lie down it keeps your spine aligned correctly (head to hips forming a straight line), which is usually a medium-firm bed. Sleep on your back or side, and avoid sleeping on your stomach. When sleeping on your back make sure the pillow supports your head and neck instead of supporting your neck and shoulder. Also consider a pillow under your knees & thighs. When sleeping on your side use enough head support so your upper spine is straight (your nose lines up with your breastbone), and use a pillow length wise under your knees. A third pillow in front of your chest and abdomen is optional but can provide added support. Avoid sleeping in the fetal position as this puts pressure on your disc. Be mindful how you get in and out of bed to avoid unnecessary twisting or flopping onto the bed. The “logroll” method is often recommended. Also consider stretching when you wake up before getting out of bed. Again the goal of proper body ergonomics is try to keep your spine, from head to toe, as aligned as possible. Also stay active and avoid prolonged sitting or standing positions. Remember in your daily activities use your legs and engage your abdominal muscles instead of forcing the workload onto your back or neck. Take the time to evaluate your day to day activities and see how you can improve your posture from simple things as getting out of your car to brushing your teeth.

Ergonomics is the often defined as “the scientific study and analysis of the human, the machine, and/or working environment interface and an investigation of those elements in the system that affect optimum human performance on a given task or set of tasks”. However, ergonomists have attempted to define postures which minimize unnecessary static work and reduce the forces acting on the body. Goal of proper body ergonomics is try to keep your spine, from head to toe, as aligned as possible. Also stay active and avoid prolonged sitting or standing positions. Remember in your daily activities use your legs and engage your abdominal muscles instead of forcing the workload onto your back or neck. Take the time to evaluate your day to day activities and see how you can improve your posture from simple things as getting out of your car to brushing your teeth. The section on ergonomics can be endless, here we will focus on only a few important areas of proper ergonomics such as lifting, sitting, standing and sleeping. By being mindful to the ergonomic principles when it comes to lifting, sitting, standing and sleeping one can significantly aid in the management of their chronic pain condition.

The following sections review some of the principles of physical therapy. Physical therapy can be a very important part of your pain management regimen. Physical therapy itself involves multiple different treatment options, which we will not cover here. We will review a few general stretches and exercises for the lower back and neck. These general recommendations do not apply to everyone, so please consult with your physical therapist to determine a specific program for your particular chronic condition. Although stretching may be beneficial for many conditions, core strengthening may not be appropriate for some pain conditions. Core strengthening may be difficult for the elder population who may find more benefit from a combination of stretching and aerobic exercises. Please consult with your doctor and physical therapist before beginning any physical therapy program. IMPORTANT MUSCLES FOR THE LOW BACK Primary Core Stabilizers Transverse Abdominus Multifidus Pelvic Floor/Diaphragm Muscles Other Muscles Quadriceps Gastrocnemius Soleus Hamstrings Gluteus Medius Gluteus Maximus Rectus Abdominus Abdominal Obliques Piriformis Iliopsoas Latissimus Dorsi Quadratus Lumborum IMPORTANT MUSCLES FOR THE NECK Primary Neck Muscles Splenius Muscle Semispinalis Muscle Multifidi Muscles Other Muscles Levator Scapula Rhomboids Sternocleidomastoid Trapezius Scalene Muscles

SUSPECTED OPIOID OVERDOSE TREATMENT With the rise in concern for opioid deaths due to overdose and rise in opioid prescriptions over the years, the CDC has recommend that physicians prescribe take-home emergency treatments such as Naloxone for opioid overdose to patients and family members. Any person can request these Naloxone devices regardless of whether they are taking opioid medications or not and usually do not require a prescription (i.e. you can walk up to any pharmacy and request it). TAKE THE FOLLOWING STEPS IF YOU SUSPECT AN OPIOID OVERDOSE STEP 1: CALL FOR HELP and DIAL 911. AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL ATTENTION. STEP 2: CHECK FOR SIGNS OF OPIOID OVERDOSE Signs of OVERDOSE and/or OVERMEDICATION, which often results in death if not treated, include: 1) Mental confusion, slurred speech, intoxicated behavior 2) Nodding off during conversation or activity 3) Unusual or Extreme sleepiness, inability to awaken verbally or upon sternal rub 4) Breathing problems or respiratory distress 5) Slow to shallow breathing in a patient that cannot be awakened 6) Fingernails or lips turning blue/purple. 7) Small “pinpoint” pupils 8) Slow heartbeat and/or low blood pressure 9) Hearing the “death rattle”: an exhaled breath with a very distinct, labored sound coming from the throat STEP 3: SUPPORT THE PERSON’S BREATHING: Start rescue breathing which can be very effective in supporting respiration. Start full CPR is needed. (Rescue breathing for adults involves the following steps: Be sure the person’s airway is clear, check that nothing inside the person’s mouth or throat is blocking the airway. Place one hand on the person’s chin, tilt the head back and pinch the nose closed. Place your mouth over the person’s mouth to make a seal and give 2 slow breaths. The person’s chest should rise (but not the stomach). Follow up with one breath every 5 seconds.) STEP 4: ADMINISTER NALOXONE: If available Naloxone injection is approved by the FDA and has been used for decades by EMS personnel to reverse opioid overdose and resuscitate individuals who have overdosed on opioids. Naloxone can be given intranasal with the NARCAN Nasal Spray or intramuscular (into the muscle) injection with EVZIO. Once patient starts breathing independently, put them in the “recovery position” on the side and always stay with the patient and keep them warm. Do not put in cold bath due to risk of drowning and do not try to make the patient vomit the drugs due to risk of chocking or aspiration. The NARCAN Nasal Spray: is a pre-filled, needle-free device that requires no assembly. To use remove from package and deliver a single dose into one nostril. If needed you can Re-administer NARCAN Nasal Spray using a new NARCAN nasal spray in alternative nostrils 2 to 3 minutes after first dose if the patient does not respond or responds and then relapses into respiratory depression. The EVZIO Auto-Injector is injected into to the muscle. Remove from package. Pull EVZIO out of the outer case and remove safety guard. Once turned on, the device provides verbal instruction to the user describing how to deliver the medication, similar to automated defibrillators. Place black end against the middle of the patient’s outer thigh, through clothing if necessary, then press firmly and hold for 5 seconds, Can inject a second dose of EVZIO 2to 3 minuted after first dose if if the patient does not respond or responds and then relapses into respiratory depression. EVZIO comes with a trainer device that all family members should practice with prior to a real emergency. Both NARCAN Nasal Spray and EVZIO are packaged in a carton containing two doses, to allow for repeat dosing if needed. Always call 911 after administration of Naloxone products. NOTE: It is important to seek medical care or call 911 after the administration of Naloxone, even if the patient fully awakens, as the patient can become unconscious again once the Naloxone wears off. NOTE: All naloxone products have an expiration date, so it is important to check the expiration date and obtain replacement naloxone as needed. SIDE EFFECTS: Note Naloxone products are contraindicated in patients with known allergies to naloxone hydrochloride or any other ingredient in naloxone. Use with caution in patients with cardiac disease or history of seizures. Note naloxone is category C in pregnancy. In each of these cases always call 911 and the benefit of saving a life may still outweigh the risk of death and adverse side effects. Patients who are physically dependent on opioid therapy will experience opioid withdrawal with the administration of naloxone, in these individuals although unpleasant opioid withdrawal is not considered to be life threatening. In each of these cases always call 911 and the benefit of saving a life may still outweigh the risk of death and adverse side effects. (If you do not have a Naloxone nasal spray or the EVZIO auto-injector device, please ask your provider or your pharmacist for one.)

Although the term opiate is often used as a synonym for opioid, the term opiate is properly limited to the natural alkaloids found in the resin of the opium poppy (Papaver somniferum). The opium poppy was cultivated as early as 3400 BC in Mesopotamia. The term opium refers to a mixture of alkaloids from the poppy seed. Opiates are naturally occurring alkaloids such as morphine or codeine. Opioid is the term used broadly to describe all compounds that work at the opioid receptors. The term narcotic (from the Greek word for stupor) originally was used to describe medications for sleep, then was used to describe opioids, but now is a legal term for drugs that are abused as well. OPIOID CLASSIFICATIONS Most opioid medications are in the oral formulation but some of the opioids do come in a patch option. The two most common used opioid patches currently include the fentanyl patch and the buprenorphine patch, also known as the Butrans® Patch. Extra caution should be taken with thOccurringe use of the Fentanyl patch in the elderly and is contraindicated in the opioid-naïve patient (patients who are taking less than 60mg of morphine equivalence daily). Fentanyl patches are advantageous in patients who are unable to swallow pills. The disadvantage with fentanyl patches is their delayed onset of action and being highly proteinbound they increase the risk of overdose in frail patients (decreased plasma protein resulting in higher free fentanyl levels combined with the reduced ability to metabolize fentanyl). As body temperature increases, the absorption of the drug can increase, and therefore may be problematic with febrile patients or those who use heating pads, etc. Once the patch is removed, the time to drug elimination is significantly longer (>24hours) in the elderly patient. These patches also have a higher risk of skin rashes which can be very uncomfortable for the patient who have sensitive skin. An alternative to the Fentanyl patch is the Butrans® Patch, which contains the medication buprenorphine. These patches have the advantage of being better tolerated in elderly patients and a decrease risk of over sedation and other side effects. They also can be used in opioid naive patients. They are good options when strong opioids are undesirable. They also have lower abuse potential and milder withdrawal symptoms. In elderly patients, buprenorphine patches may have altered pharmacokinetics due to poor fat stores, muscle wasting or altered clearance; therefore they should be used with caution with skinny patients. Patients on high doses of morphine and/or strong opioids should NOT be switched to transdermal buprenorphine due to its potential to precipitate opioid withdrawal. The Butrans® patch also has similar concerns of a skin rash and increased absorption of the drug with higher body temperature as does the fentanyl patch.

Opioid related deaths have been a hot topic recently as well as in the past. Their safety and role in the treatment of chronic diseases such as pain as come into question. However, studies over the past 20 years have repeatedly shown opioids to be safe when they are used correctly. Multiple studies in the United States and around the world have shown opioids to be a safe and effective treatment option. Risk of opioid therapy also includes physical dependence, tolerance, opioid induced hyperalgesia, and addiction. Often the adverse events related with the use of opioid medications involve over use and often are due to the combination of other “sedative” agents such as alcohol, benzodiazepines, sleep medications and/or other sedative medications. The key point is that yes opioids are safe when USED CORRECTLY but they can be deadly if ABUSED. Please note like any medication, significant side effects such as death have been reported in individuals who take their medications correctly. The KEY to being SAFE is understanding the medications you take. This is why this course is a necessary part for anyone taking these or similar medications. It is important that patients speak to their doctor if they have any questions or safety concerns before starting opioid therapy. Please note there is limited evidence as to the benefits of long-term opioid therapy. It is impossible to tell which patients need low doses and which need high doses, so we recommend that all patients start on low doses, especially those who are new to these medications. Over time if needed your doctor can titrate the dose of the opioid medication to provide more effective pain relief, while minimizing adverse side effects. It is important to understand that the lowest dose needed for effective pain control is recommended. Higher doses do not translate into better pain relief in many cases. Rather than adding high doses of opioids to your treatment plan talk to your doctor about the addition of other treatment options, which are discussed later in this course. Opioid analgesics themselves for the most part do not cause any specific organ toxicity, unlike many other drugs, such as NSAIDs, aspirin and acetaminophen. They are not associated with upper gastrointestinal bleeding and renal toxicity like long term NSAID use. However, we do still recommend annual liver and renal function test from your primary care doctor for patients who are on long term chronic opioid therapy. The metabolism and excretion of these medications are affected greatly by the liver and kidneys. We will discuss more about the side effects of these medications and issues in patients with liver and renal disease later in this course. When using combination opioid products containing acetaminophen, aspirin, or ibuprofen (such as Norco®, Vicodin® or Percocet®), the dose limiting toxicity is generally attributable to acetaminophen, aspirin, or ibuprofen respectively. The maximum amount of acetaminophen should be no more than 4 grams/day considering all combined acetaminophen in 24 hours. Using more than 4 g/day of acetaminophen can cause acute hepatic failure. Aspirin and ibuprofen have their own inherent toxicities, including but not limited to possible gastrointestinal bleeding, kidney dysfunction, hypertension, etc. Maximum daily dose of aspirin is 4grams/day. The maximum daily dose of ibuprofen is 3.2grams/day. For chronic daily use of combination medications I recommend you use the least amount needed and I do not recommend more than 50% of the daily maximum dose of these medications when used chronically (i.e. acetaminophen no more than 2 grams a day). Also if used on a chronic basis routine and annual blood work by your primary care physician is recommended which includes liver and renal function tests. It is important that you report any abnormal lab results to the doctor who prescribes you your opioid medications. It is important for us to note here, regarding senior citizens, opioid use is associated with increased adverse effects such as "sedation, nausea, vomiting, constipation, urinary retention, and falls. As a result older adults taking opioids are at greater risk for injury. We will also revisit this topic at the end of the course. Opioids are well accepted for the treatment of acute pain, such as post-operative pain. They have been extremely valuable in the treatment of terminal disease such as cancer as well as severe degenerative conditions such as rheumatoid arthritis. When used properly they have also found to be an important modality in the treatment of chronic pain. The field of pain management itself also evolved over the decades and now patients with chronic pain are often treated by board certified pain medicine specialists. Current opioids such as methadone should only be prescribed after trying other opioids first due to the higher risk of adverse side effects. Safety concerns with methadone are due to its sometimes unpredictable pharmacodynamics and pharmacokinetics. Methadone is difficult to titrate due to its half-life variability. It may take a long time to reach a stable level in the body. Never ever take more than prescribed when it comes to Methadone, as it can seriously lead to overdose and death. To improve safety always inform your doctor of any change in your health. Inform your doctor if you have or develop COPD, Pneumonia, CHF, sleep apnea, alcohol or substance abuse, are over 65 years of age, have history of or develop renal or hepatic dysfunction. These conditions may potentiate opioid adverse effects and require close monitoring. Even low doses of opioids can lead to more risks than benefits with these conditions. The Basic DOs and DON’Ts of Opioid Safety Call 911 Or Your Local Emergency Service Right Away If: You take too much medicine You have trouble breathing, or shortness of breath A child has taken your medicine Tell Your Healthcare Provider: Your complete medical and family history, including any history of substance abuse or mental illness The cause, severity, and nature of your pain If the dose you are taking does not control your pain • About any side effects you may be having About all the medicines you take, including over-the-counter medicines, vitamins, and dietary supplements Your treatment goals If you have underlying respiratory disease Certain medical conditions such as sleep apnea, pneumonia, COPD, etc. can increase your risk of overdose and respiratory arrest when combined with opioid therapy. If you develop pneumonia you should inform your provider as you may need to consider a reduction of your dose. If you suspect you snore heavily or have day time sleepiness, it is important you discuss with your provider the option of a sleep study to evaluate for sleep apnea and possible use of a CPAP machine.