Sunday, 3 February 2019

Returning to an old exercise routine? Here’s what you need to know

Using medications to treat opioid use disorder is a lifesaving cornerstone of treatment — much like insulin for type 1 diabetes. The flawed but widely held view that medications like methadone or buprenorphine are “replacing one addiction for another” prevents many people from getting the treatment they need. In actuality, people successfully treated with these medications carefully follow a prescribed medication regimen, which results in positive health and social consequences — as in patients with many types of chronic medical conditions.

However, even among those who embrace treating opioid use disorder (OUD) with medication, there is a difference of opinion as to which medications are most effective. A new study offers important insight into the advantages and disadvantages of the two medications for OUD that can be prescribed in a doctor’s office (that is, on an outpatient basis). These medications are buprenorphine and extended-release (ER) naltrexone. This study was widely covered in the press, and many of the sound bites and headlines reporting the two treatments to be equally effective were a bit misleading.
The advantages and disadvantages of buprenorphine (Suboxone, Subutex, Zubsolv, Probuphine, Sublocade)

Buprenorphine is a partial opioid agonist medication. This medication activates the same receptors in the brain as any opioid, but only partly. Because its effects are long-lasting, it can be taken once a day to relieve cravings, prevent withdrawal, and restore normal functioning in someone with opioid use disorder. Because it is a partial agonist, it has a ceiling effect. This means once all the receptors are occupied by the medication, even if a person takes 20 more tablets she wouldn’t feel any additional effect or be at risk of overdose.

Any doctor who has completed special training (a primary care provider, addiction specialist, OB/GYN, etc.) can prescribe buprenorphine. The advantage is, theoretically, that a person with OUD could receive treatment from any provider he or she might see for a routine health issue. I say theoretically because, despite its availability, only about 4% of physicians have done the necessary training to be able to prescribe it. The research on buprenorphine is robust, with multiple studies showing it reduces the risk of death by more than 50%, helps people stay in treatment, reduces the risk that they will turn to other opioids (like heroin), and improves quality of life in many ways.
The advantages and disadvantages of naltrexone (Vivitrol, Revia)

Naltrexone is a pure opioid antagonist. It sticks to an opioid receptor, but instead of activating it to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect. The research on naltrexone has been mixed. Naltrexone in pill form is basically no better than placebo because people simply stop taking it. Studies on extended-release naltrexone are more promising and have shown it to be better than no medication at all. However, there has never been a US trial comparing extended-release naltrexone to either methadone or buprenorphine, until this study.
The X-BOT study: Comparing buprenorphine and extended-release naltrexone

This study enrolled individuals with opioid use disorder who had voluntarily gone to a detoxification program. Researchers then randomly assigned them to either daily buprenorphine or monthly extended-release naltrexone. Both groups were followed for 24 weeks, to see how many people relapsed.

One of the most important things investigators learned is just how hard it was to get participants onto extended-release naltrexone, revealing a potential barrier to its usefulness. Before a person can start taking ER naltrexone, they must be completely off opioids for seven to 10 days. Only 72% of the group assigned to ER naltrexone even got the first dose, and among those who were randomized during the detoxification process, only 53% started the medication. In contrast, 94% of the group assigned to buprenorphine started the medication.

The other important finding was what happened with relapses. The researchers analyzed their data using an “intention to treat analysis.” This means that once a person is randomly assigned to a treatment (or placebo), their data counts even if they don’t stick with the treatment. Here’s why this is important: if you don’t include that data, then you miss other important outcomes that influence how effective a treatment really is. Thanks to this type of analysis, researchers learned that relapse was significantly more likely in the extended-release naltrexone group (65% compared to 57% in the buprenorphine group).

Immediate relapses were even more likely in the naltrexone group due to failures to start the medication — 25% of the naltrexone group had a relapse on day 21, compared to 3% in the buprenorphine group. Overall there were more overdoses in the naltrexone group, but no difference in fatal overdoses between the groups. Most of the overdoses occurred after the study medication was stopped, highlighting the lifesaving importance of getting on, and staying on, treatment. The naltrexone group also had a longer length of stay in inpatient detoxification programs, which may be an important consideration when we think about overall healthcare costs.

So, why did many headlines claim extended-release naltrexone was as effective as buprenorphine? Well, that was the finding of a separate analysis that looked only at people who successfully started each medication. When the data was viewed that way, there was no difference between the two medications, but that’s just part of the picture. If it’s harder to get a person to successfully start and stick with a medication, that should factor in evaluating its “effectiveness.”
Take-home messages from X-BOT

This is an incredibly important study. The findings are generally consistent with what I see in my clinical practice. Overall buprenorphine is a more effective treatment for opioid use disorder, in part because it’s easier to get patients started on it and they are more likely to stick with it. Extended-release naltrexone may be as good for people who can successfully complete the detoxification required before starting on it. Both medications have a place, but as with so many conditions and treatments, one size does not fit all.
Whether you and your family are embracing the pleasures of the winter season with ice skating and snowball fights, or reluctantly venturing outdoors to walk the dog and shovel snow, be aware of the health hazards of this cold snap… like frostbite.
Here’s why you don’t want to mess with frostbite

Frostbite can occur even after minutes of exposure to sub-freezing temperatures and wind chill. It develops after exposure to severe cold leads to freezing and injury of tissue with destruction of cells. The inflammation that follows frostbite can cause further tissue damage. The more commonly affected areas are the ears, face, fingers, and toes.
So how do you recognize trouble?

A precursor to frostbite is frostnip, when the cold hasn’t caused any permanent tissue damage. The skin might be red or pale and painful. As early-stage frostbite sets in, the affected areas might feel numb. The skin may feel cold and harder, and become paler or grayish-yellow, and later develop blisters.

Some conditions and situations can increase the risk for frostbite, like dehydration, circulation problems, nicotine and alcohol use, or inadequate shelter and clothing. Also, always be mindful that infants and young children are more vulnerable, and may not be able to recognize these early symptoms and take steps to protect themselves.
What to do if you think someone has frostbite

If you think you are dealing with frostbite, try to get to warmth as soon as possible. However, don’t try to rewarm the frostbitten areas if there is a chance of refreezing, since that can lead to even more tissue damage. Similarly, avoid walking on frostbitten feet, but if that’s not possible and you must walk to get to a warm environment, do not try to rewarm your feet until out of the cold. Once you are out of the cold, safer ways to rewarm the frostbitten areas are with body heat (e.g., fingers into the armpits) and warm (not hot!) water. Don’t try to warm frostbitten tissue by rubbing or using a heating pad, stove, or the heat of a fire. If symptoms don’t improve, go to the hospital promptly for further medical care.
It’s the beginning of a new calendar year, that time when we resolve to do new and better things. This is such a wonderful idea, because doing new and better things can make us healthier and happier. Resolutions can be particularly good for families to make. Not only is it good to work together on something, it’s a good way to keep everyone accountable.

The best resolutions are the ones that are simple. By simple, I don’t necessarily mean easy (if they were easy, we wouldn’t have to resolve to do them). I mean that they are resolutions that you can lean into and work toward, achievable in whatever way works for you. It also helps, obviously, if the resolutions are fun.

Here are three very simple and very healthy things that all families can resolve to do together and that can be adapted to the realities of family life — and can be fun.

1.  Exercise together. Adults should get 150 minutes of moderate intensity exercise (or 75 minutes of vigorous exercise) a week, and children should be active for an hour a day. Most people do not get that much exercise, sadly. It would be great if each and every one of us could resolve to be more active, and certainly all families should be thinking about ways to get everyone to the gym or sports practice or out for a run more often in 2018. But aside from that, try a family resolution to exercise together, as many times a week as is feasible, with as many family members as is feasible. Keep it simple: go for a walk together, for example (if you have a dog, bring more people along for walks). If going for walks isn’t possible or pleasant where you live, turn on some music, move the furniture, and dance in the living room or kitchen. If there is a pool, go for family swim, or go skating, sledding, or biking. Just be active, and do it together. You will be setting an example, helping to build healthy lifelong habits, and spending time together — all of which can make a big difference.

2.  Eat healthier meals together. Notice I said “healthier.” The idea is to move the needle, not achieve perfection (although if you want to try for perfection, go for it). Add a vegetable or fruit to each meal. Try some new grains, like quinoa — or just more whole grains. Serve water or plain milk with meals, rather than juice or soda. Try out small changes, one at a time, with the goal of having a healthier family diet. If everyone is doing it together, it can make it easier. It may be that you begin simply by eating more meals together. Preparing a meal and eating it as a family not only helps everyone eat better, it helps bring families together, which can be very important for the emotional health of everyone in the family — and leads me to the last resolution…

3.  Spend more time together. Whether it’s by exercising or eating together, or family game night or movie night, or simply hanging out, the time you spend together can not only strengthen each and every one of you, but also give you a chance to touch base and find out what is happening in one another’s lives. Turn off the cell phones (making family meals a phone-free zone is a good idea) and pay attention to each other instead. As a resolution, just try to spend more time together. Start small if small works — and then build on it.
My ancient workout clothes are folded neatly (and squished) beneath a pile of sweaters on a shelf in my closet. They were cute — from the ‘90s — when I cared very much about how I looked at the gym. Decades later, I skip the gym and instead walk most days and do body weight exercises, all while clad in a sweatshirt and yoga pants. But whenever I see my old gym outfit (blue leotard “overalls” with a cropped tee shirt built in), I wonder if maybe I’d get more from a gym workout. It wouldn’t be hard to jump back in, would it?
Just a second

It turns out, it’s smarter to ease back into a gym workout when we’re older, even if we’ve been active. And if you’ve been sedentary for a long time, it’s even more important. Why? Because our bodies change as we age. “We lose muscle mass and strength as we get older, and the muscles become less flexible and less hydrated,” says Dr. Clare Safran-Norton, clinical supervisor of rehabilitation services at Harvard-affiliated Brigham and Women’s Hospital.

There can be are other changes, too: arthritis that weakens joints, and vision changes, neurological disease, joint pain, or inner ear problems that can throw off balance. There may also be underlying conditions we aren’t aware of, such as high blood pressure or heart disease, that can increase the risk for severe health consequences if we try to exercise today with the vigor of our youth.
The downside of jumping right back in

If you’ve been sedentary for a long time, jumping back into a workout sets you up for injury. “Lifting weights that are too heavy or taking an exercise class that’s too strenuous often causes trouble, and it’s usually a muscle tear or a strain,” says Dr. Safran-Norton.

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