In 2003, the US Department of Veterans Affairs and the Department of Defense recommended the use of long-acting opioid medications to manage chronic pain

"If you find yourself alone, walking in green fields with the sun on your face, 

. . . do not be troubled, for you are in Elysium, and you're already DEAD!"

Courtesy of Ridley Scott, the moving words of David Franzoni from "The Gladiator"

"What we do in life, echoes in eternity!"

Another Veteran gone . . .

My telephone rang this morning, first day of Memorial Weekend. It was about my  good friend USMC gunny-Sergeant SniperChuck. 

His  beloved  "companion of life"  had pulled herself together enough to call and tell me that  Chuck was now in  Elysium.   

Chuck was a cool Bloke (Dude). He and became good friends, constant banter. A bright man. A tough man. A man who loved his kids and his woman without reservation. A gifted musician. In his Forties. A lot to live for. 

A complicated man in constant physical pain. A Veteran with Post Traumatic Stress Disorder. 

He never complained much. He even made jokes about serious events in his life. For example, why his left foot pointed in the direction that he was walking and why his right foot was at a 90 degree tweak:

"Between tours, I was back in California riding my Harley. Out of the darkness came an old Cadillac with an illegal in it. No lights, no insurance. The impact almost tore me in half . . . at the Balboa Hospital, the surgeon told me that I would be better with a prosthetic than a crushed leg . . .

Can you believe I did not know what the word meant?"

When he explained the amputation process I told him 'No, fix my leg' and he put it back on crooked.

I know I annoyed him"

Last week, Chuck emailed me and sounded chipper . . . five days l later and he is no longer with us.

"I don’t think I ever had Lyme disease, but opioid induced endocrynopathy. I determined after reading my HTPA numbers especially my testosterone went from 850 to 250.  But the insurance co.'s tell the doctors what is normal. I looked up what is a normal test level is for my age and it was between 500-800, 250 is normal for a 90 plus yr old.

With the way the VA was administering the opiates started the ball rolling. Since they are happy to get you addicted to them but they suck at managing them. So I would take them on an empty stomach to get the most out of them working and ease the pain. Then I would eat breakfast usually a spinach & broccoli omelets and I would do the same thing at lunch,  starve myself then take the medication and once I felt it kick in I would eat whatever for lunch & dinner. Unbeknownst to me I was burning holes in my digestive tract making it sensitive to everything I ate.

So with this latest revelation I have discovered that chicken breast gluten free corn grits & mild provolone cheese are the only things I can eat., everything else caused a painful reaction gut & brain. As long as I stay on this diet I’m ok. If I cheat even a tiny bit I’m f’d for a week.

That’s the long & short of it. Hope all is well with you!  "

USMC 4h Battalion Memorial May 26. 2012

So, I have shed more than a tear for my Pendleton USMC friend today.  About an hour ago I drove up to the Marine Memorial on the side of the Volcano Haleakala which was collecting Pacific Clouds from California, so rain fell - sort of like the tears of the Ancients. As I stood in front of the three flags, a beam of sunlight lit them up. Chuck and the others in Elysium. 

Chuck was an alert and intelligent man who participated in his own survival.  Read his self-diagnosis again and then read the notes below.  There was no way out for Sniper Chuck. 

Opioid-Induced Endocrinopathy

1. Stephen Colameco, MD, MEd; 
2. Joshua S. Coren, DO, MBA

In 2003, the US Department of Veterans Affairs and the Department of Defense recommended the use of long-acting opioid medications to manage chronic pain.¹ This recommendation was based on data that suggested short-acting opioids (eg, oxycodone, acetaminophen) pose an increased risk of addiction or opioid-induced hyperalgesia and on the assumption that chronic pain requires continuous analgesia.¹ Healthcare providers seemed to agree. As suggested by pharmaceutical sales, opioid therapy is far more common today than it was 10 years ago. One review³ analyzed sales data and determined that opioid sales increased 127% from 1997 to 2006.

However, as opioid use increased, so did the incidence of associated adverse effects. In the present review, we discuss the various symptoms associated with opioid-induced endocrinopathy and outline screening tools physicians can use to diagnose this condition. Treatment options are also described.

Conclusion

Opioids are increasingly used to treat chronic nonmalignant pain. However, long-term opioid treatment can cause endocrinopathy. Therefore, physicians must be aware of the various challenges associated with opioids.

Before initiating daily opioid treatment, physicians should inform patients in writing of all the risks and benefits associated with treatment—as specified in the Model Policy for the Use of Controlled Substances for the Treatment of Pain.⁶⁵ Based on the prevalence of opioid-induced endocrinopathy, physicians should include specific mention of depression, fatigue, hormone deficiency, osteoporosis, sexual dysfunction, vasomotor instability, weight gain, and, in women, menstrual cycle irregularities as possible adverse effects.

After opioid treatment is initiated, patients should be routinely evaluated for signs and symptoms of endocrinopathy. Testosterone supplementation is the primary treatment option for men, while DHEA supplementation may be preferred in women. Because some opioids may result in less endocrine dysfunction than others, rotation to a different opioid may also be an appropriate treatment option, particularly for women.

• Received March 10, 2008.

http://www.jaoa.org/content/109/1/20.long

 Writing this  post for my friend I was struck buy the obvious:

The "System" (VA, etc) let Chuck down in more than one way.

That when we consider the amount of Veterans that we are losing each day, for whatever reason . . . when you close your eyes and can see a face . . . they are not to be regarded as statistics. May that never be so.

"They are only dead when you forget them" Nope, I will not forget my cheeky mate SniperChuck. And his folks will grieve and miss him so badly. My (our) condolences to his wonderful son and daughter and his Sweetheart of 17 years. 

And, by extension, to all of the other survivors of Veterans who are no longer with us. We do feel you pain.

THERE HAS TO BE A BETTER AND FASTER WAY TO HELP THESE VETERANS . . . 

As noted in an earlier post, the most economical way to treat Veterans in pain and with PTSD for the Government, the most convenient way for their physicians is to just zombify them with large amounts of medication.

Time we all looked to other avenues to help these Veterans -- here is one that I advocate and support

GLOBAL STRESS INITIATIVE

http://www.globalstressinitiative.com/

This is why . . . so many of the Veteran's charities are nothing more than "cash-traps" using the Vet's for bait with less than 1o cents in each dollar going to a Veteran. The rest? Parties, cars, big salaries,etc.

Lorraine Cancro

MS. CANCRO ALSO SERVES AS FOUNDER AND EXECUTIVE DIRECTOR OF THE GLOBAL STRESS INITIATIVE, (GSI), A PROGRAM UNDER THE AUSPICES OF ICAMI WHICH IS LED BY DIRECTOR, ROBERT CANCRO, MD, CHAIRMAN EMERITUS OF NYU DEPARTMENT OF PSYCHIATRY. THE GSI HAS 3 TIME EMMY AWARD WINNING ANCHOR AND BEST SELLING AUTHOR, RITA COSBY, AS SPOKESPERSON. AT GSI, THEY ADVOCATE FOR FURTHER RESEARCH AND TREATMENT FOR RETURNING MILITARY MEMBERS, THEIR FAMILIES AND CIVILIANS WHO ARE SURVIVORS OF TRAUMA. 

GLOBAL STRESS INITIATIVE  prides itself that the majority of funds raised goes directly to aiding and assisting actual Veterans.

Bone and Soft Tissue Infections . . .

A second and third opinion are needed before agreeing to surgery . . .

A Happy/Unhappy tale of three Senior Veterans.

First the “OLD” science.

SALVAGE OF INFECTED AND EXPOSED KNEE PROSTHESIS WITH COMBINED TREATMENT OF SPLINT, ANTIBIOTIC AND HYPERBARIC OXYGENATION.

Ramon, Y; Melamed, Y; Katz, M; Reis, D

“As a last resort the patient was referred for HBO treatment. The patient had 55 sessions of 100% oxygen in 2.4 ATA in a multiplace chamber. RESULTS: Under combined treatment of splinting, antibiotics and HBO the infection resolved and the fistula were closed. 

CONCLUSIONS: A combined treatment that includes HBO should be advised for patients with infected prosthesis before removal.”

http://archive.rubicon-foundation.org/xmlui/handle/123456789/6602

Patient #1 – Happy Outcome:  Rear Admiral (USN retired) (female, 52 y.o., extremely fit – tennis player – lean body weight). Vivacious, lively, and attractive -- but limping along with one leg that did not work. Patient underwent knee replacement surgery at Balboa Naval Hospital. Surgical wounding became infected and I.V. antibiotics were ordered. Loosening of the prosthesis, and flexion contractures plagued this normally active patient. Surgeons recommended more surgery. “Hyperbarics are not indicated” was there expert medical opinion to the patient (Balboa and most other USN Hospitals do not have hyperbaric medicine departments for use of non-diving trauma and illness.)

Nonetheless, the Admiral  decided to seek HBOT at a hospital-quality free-standing center, San Diego Gateway Medical Center Hyperbarics (“SDH”.) On presentation, the knee was “hot and angry” and grossly deformed with pitting edema. Twenty-five consecutive daily HBOT Tx at 2.4 ATA later, the patient considered  herself  “cured” with her knee no longer swollen, zero infection and zero pain. The Center’s Medical Director, Brenton Wynne, M.D.   Muscoskeletal Specialist concurred. 

Justin Lyne-Sands, chamber designer and manufacturer, with transportable recompression chamber system  (TRCS) bound for Malaysian Rescue & Fire Department.

Of note was the Admiral’s astonishment “Hyperaric oxygen therapy is astonishing . . . What? The Navy has $60 million worth of transportable recompression chambers (about 70 systems), some of them in San Diego! Why aren’t the being used at Balboa?


Great Question, Admiral! Why not?

Patient #2  -- Happy outcome:  

Practicing San Diego Medical Doctor. - part of the HCI Scientific Advisory Board (male, 64 y.o., extremely fit from professional dancing, 3% body fat).  Patient underwent knee replacement surgery. Complications set in immediately with an MRSA infection. Again (from a different hospital) the orthopedic surgeon ventured the opinion that “hyperbaric oxygen therapy not indicated." The infection created an open fistula and the patient was in extreme pain. Amputation was being considered.

However, the patient was consulting with  the SDH  Medical Director – Dr. Wynne has multiple specialties, including Pain Management --  and was prescribed HBOT at 2.4 ata. In a three week period, the patient went from wheel chair to walker, then walker to crutches, then to driving himself and walking unassisted to the Center. The M.D. patient continues HBOT therapy to close drain from fistula.

TWO OUT OF THREE AINT BAD

Unhappy outcome --The patient that lost his leg. 

Retired U.S.N.Captain – (76 y.o)  Important note here – the information relayed herein is second hand and Sandsie  can only pass it on as relayed to him by one of the SDH physicians.

Patient underwent knee replacement at Balboa Naval Hospital.  Complications (as described above) were immediate – infection, prosthetic loosening. I.V. antibiotics prescribed. When the patient asked for HBOT sessions (his next door neighbors – both Specialist M.D.’s had recommended this), the orthopedic surgeon again commented “Hyperbaric Oxygen Therapy is  not indicated,” 

After some months of misery, the patient changed to another orthopedic specialist who immediately referred him to the UCSD Hyperbaric Medicine Department. After ten sessions in the chamber, the attending wound care physician made the observation that “no progress in the wound is evident’” and the patient’s leg was amputated! The patient now will spend his last years in a wheel chair!

Sandsie’s Comment: 

While not being present to listen to the decision making milestone of the UCSD medical team and the patient’s response – it is difficult to either condemn nor condone this decision to amputate.

However, in many instances the reimbursement levels for the hospital, insurance providers and personal requirements of the surgical team are a factor in such a surgical decision. Non-the-less, there are many peer-review papers (such as the one above) "approved" and published by the Undersea, Hyperbaric Medical Society (UHMS) that clearly demonstrate that more than ten HBOT treatments are needed for limb-salvage.

Which bring up the terrible plight of the two women with necrotizing fasciitis and the decision to cut and cut and cut.

More “OLD” science.

Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements.

(PMID:2237764) 

Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS

Memorial Medical Center, Southern Illinois University, Springfield.

Surgery [1990, 108(5):847-50]

'The addition of HBO therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity (number of debridements) in this study, especially among nonclostridial infections. 
We conclude that HBO should be used routinely in the treatment of necrotizing fasciitis.'

 http://ukpmc.ac.uk/abstract/MED/2237764/reload=0;jsessionid=qAMDIGsT3OjdEAKDm8jg.34

Hyperbaric oxygen therapy in acute necrotizing infections

with a special reference to the effects on tissue gas tensions.

 Korhonen K.Source: Department of Surgery, University of Turku, Turku, Finland.

 "Between January 1971 and April 1997, 53 patients with Clostridial gas gangrene were treated in the Department of Surgery, University of Turku. The patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen treatments at 2.5 atmospheres absolute pressure (ATA). Twelve patients died (22.6%). Hyperbaric oxygen therapy in gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy instituted promptly

When examining the subcutaneous PO2 levels measured from patients with necrotizing fasciitis, the PO2 was regularly higher in the vicinity of the infected area than in healthy tissue. In general, HBO treatment resulted in a marked increase in tissue oxygenation in both healthy tissue and in the vicinity of infected tissue. 
The hyper-oxygenated tissue zone surrounding the infected area may be of significance in preventing the extension of invading microorganisms.

Today's Huffington Post and Reuters

Lana Kuykendall Flesh-Eating Bacteria: 36-Year-Old Mom Has Undergone 7 Operations

"She still has a long road ahead of her," Swaffer said. "We're thankful that the infection is contained to just her legs. Her organs, her vitals are good. She's got a great team of doctors."  A hospital spokesperson said Kuykendall remained in critical but stable condition on Sunday.

Another victim of a flesh-eating infection, 24-year-old Georgia student Aimee Copeland, remained in critical condition on Sunday at Doctors Hospital of Augusta, hospital spokeswoman Barclay Bishop said.


Copeland has had one leg amputated and was told she would have to have her hands and remaining foot removed. The hospital would not confirm whether those surgeries have taken place."

Sandsie's Comment:

World renowned surgeon, Dr. Fredrick Cramer in his book "Hyperbaric Surgery: Perioperative Care" (Best Publishing) is adamant that Gangrene cases go first to a hyperbaric chamber and then surgical debridement,  whereas Necrotzing Fasciitis goes to surgery first and then into a hyperbaric chamber.

Both hospitals  have large hyperbaric medicine departments with chambers that can cope with critical-care, intubated patients. However the media has reported that the Georgia student was finally "approved" for ten HBOT Tx. after 20 days, but only received four of these since there was a concern for "sepsis" by her surgeons.

There has been no confirmation that the Mom with twins has received any HBOT at all.

Again, not being privy to medical considerations, to venture an opinion is  like trying to give a haircut over the telephone. Again, there is a lot of old science that agrees with Dr. Cramer (who has not commented publicly on these two instances.) However, here is another "for-instance."

San Diego Muscoskeletal Pain Speecialist, Brenton Wynne, M.D. at work.

. A  crushing traumatic injury to a 17 year old soccer star.  Surgeon's advice "The toe cannot be saved and we need to amputate most of the foot." The parents chose HBOT -- 25 treatments at the SDH Center and the young man is now playing University soccer -- with all his toes!

NEXT TIME A SURGEON RECOMMENDS IMMEDIATE SURGERY . . . 

                          get that second and third opinion.

Since May 4th post it is estimated that 216 more Veteran suicides have taken place.

Post Traumatic Stress Disorder (PTSD)  is not imaginary!

Copyright WebMD.
http://www.webmd.com/brain/ss/slideshow-concussions-brain-injuries
WORTH A LOOK

    Twelve days ago, on May 4^th, I posted a tribute to Junior Seau and linked his suicide with post-concussion syndrome (“PCS”) as being the same as that of our veterans returning from the Iraq and Afghan Wars experience. This leads to what is known as chronic traumatic encephalopathy (“CTE”)  which is evidenced with post traumatic stress disorder ("PTSD").

    The CTE/PTSD causes neurological decay. It is linked with personality changes, impaired judgement, depression and "mental cloudiness." Domestic violence, divorce and suicide statistics are spiking among returning veterans. 

Since posting on May 4^th, it is estimated that another 216 more of our veterans have killed themselves.

    Since 2001, 2.3 million troops have served in those two theatres. The military estimate that about one quarter million of these have traumatic brain injury. Many experts believe that this number is deliberately conservative and much higher – even double. There is no way of estimating how many of the combat veterans will develop significant and permanent symptoms.

    Today’s report in the New York Times “justifies the obvious” presented in that May 4^th  posting. Worth scrolling  back to read it.

Here are excerpts from the well written and precise presentation of journalist James Dao. The ‘Times is always worth the subscription price.

Brain Ailments in Veterans Likened to Those in Athletes

Scientists who have studied a degenerative brain disease in athletes have found the same condition in combat veterans exposed to roadside bombs in Iraq and Afghanistan, concluding that such explosions injure the brain in ways strikingly similar to punishing tackles and knockout punches.  . . . 

“Our paper points out in a profound and definitive way that there is an organic, structural problem in the brain associated with blast exposure,” said Dr. Lee E. Goldstein of Boston University’s School of Medicine and a lead author of the paper, which was published online Wednesday by the peer-reviewed journal Science Translational Medicine.

Dr. Goldstein and his co-lead author, Dr. Ann McKee, co-director of the Center for the Study of Traumatic Encephalopathy at Boston University, assert that their paper shows that many of those veterans probably have organic brain injuries and should be given appropriate treatment and disability compensation.

The paper also seems likely to fuel a debate that has raged for decades over whether veterans who struggle emotionally and psychologically after returning from war suffer from psychiatric problems or brain injuries.

http://www.nytimes.com/2012/05/17/us/brain-disease-is-found-in-veterans-exposed-to-bombs.html?_r=1

Sandsie’s Comment:

    A careful read of the ‘Times article already shows a wrangle between the leading “experts” No doubt some of these “experts” will come out and testify for the professional football owners that are being sued by their players for their accumulated injuries.

    Other “experts” will try to either deny veterans proper compensation for their own injuries. Or, working for bigPHARMA will seek research dollars for a pharmaceutical response. Already suggested are massive, zombiefieing doses of the beta blocker drug propranolol by using it as a memory dampener.

There has to be a better way. 

Throwing money at research groups will likely help but not soon enough. Giving to charitable groups that actually work hands-on with the veterans is a better way.

    And then of course, there is my 30 years of experience with hyperbaric oxygen therapy. Promising trials are under way and . . . the good news is that America has lots of hospital grade chambers out there waiting and ready to treat sport’s injuries and PTSD veterans at a cost less than a tenth of that charged in hospitals.

Sandsie with a hospital-quality "Sands S-200" chamber. Large enough to hold a 460lb patient.

    All you have to do to find such a center is Google “Hyperbaric Oxygen Therapy (plus the city or location in the US)""and up will pop a bundle of Centers. All you then need is a physician's prescription. All high quality non-hospital centers have an M.D. medical director for consult.

Lyme Disease and Hyperbaric Oxygen Therapy
Is the oxidative stress "bad" for the Lyme patient?

Worth  4 minutes of your time to view this YouTube of Julie.

.http://www.youtube.com/watch?v=z63DBrrlzzI

Are Free-Radicals Good or Bad?

I received this email earlier this week:

Hi Bob,

Becky is consulting with a new Lyme doctor who seems to really be on the ball in most ways. The one thing she said that didn't ring true is that hyperbarics are bad for you because they cause oxidative stress. I recall you addressing this at some point and wondered if there were any research papers or scholarly articles that would rebut that point of view. I'd like to educate her.

Sandsie's Comment:

"To answer your question regarding free radicals. In a nutshell, the stress caused during a HBOT treatment is actually therapeutic and kills bugs. HBOT is unique in that it produces a stack of reactive oxygen species (ROS) and a lot of reactive nitrogen species (RNS) However, after the HBOT session, the body 'buffers' the excess there is a rapid scavenging when the body puts out super-oxide dismutase  (SOD)"

WHEN YOU HAVE AN EXCESS OF FREE-RADICALS WHEN YOU NEED THEM. . . THAT IS GOOD!

As needed by Lyme patients for aerobic killing of Bb and to be sustained through endotoxic shock.

WHEN YOU HAVE TOO MANY FREE RADICALS WHEN YOU DO NOT NEED THEM . . . THAT IS BAD!

Anyway, this is not what I say, it is what the scientist say

 Stephen Thom, M.D, Professor of Emergency Medicine, Chief of Environmental Medicine, University of Pennsylvania is a leader in this field of science and courageously educates physicians (who should know their science) with the facts.

Oxidative stress is fundamental to hyperbaric oxygen therapy

1. Stephen R. Thom

 "In review, oxidative stress responses triggered by HBO₂ improve outcome from a wide variety of postischemic/inflammatory insults. HBO₂ also improves ischemic tolerance when used in a prophylactic manner. The basis for these effects is only partially understood. Augmented synthesis of reactive species temporarily inhibits endothelial sequestration of neutrophils by inhibiting β₂-integrin function and in many tissues HBO₂ will induce antioxidant enzymes and anti-inflammatory proteins.

Previous SectionNext Section

SUMMARY

This review has highlighted some of the beneficial actions of HBO₂ and the data that indicate oxidative stress brought about by hyperoxia can have therapeutic effects. Figure 1 provides a summary of mechanisms, all of which appear to stem from elevations in reactive species. Although there has been substantial advancement of the field in recent years, more work is required to establish the breadth of HBO₂ utilization in 21st century medicine. Investigations of fundamental mechanisms are still needed, and on the clinical front, patient selection criteria must be clarified to truly make HBO₂ a cost-effective treatment modality."

Previous SectionNext Section

GRANTS

This work was supported by grants from the Office of Naval Research and from the National Institute of Digestive and Kidney Diseases (DK-080376).

• Copyright © 2009 the American Physiological Society

http://jap.physiology.org/content/106/3/988.full

Are the so-called mildHyperbaric (inflatable)  Chambers useful for Lyme patients?

Sandsie with an inflatable "bag" chamber.

THE ANSWER IS AN EMPHATIC "NO."

These low pressure chambers simply cannot reach the required pressures of 100% OXYGEN that are referred to in Professor Thom's article. More on "Soft " chambers in my next blog.