Author name: Tony Laughton

High dose opioids kill people

Ome > 100 = 7*rod

The above mathematical formula can be translated as follows.

Patients suffering from chronic non-cancer pain who are on doses of opioid analgesics that exceed the equivalent of morphine 100 mg daily are potentially seven times more likely to die than those not taking opioids to manage their pain.

What is OME?

OME is the oral morphine equivalent: it is an estimate of the potency of the opioid as compared to morphine. For example, oxycodone at a dose of about 60 mg daily is equivalent to morphine 100 mg daily.

What is 7*ROD?

This means seven times higher risk of death.

This is a wake-up call to us all. As doctors we can no longer simply escalate the dose of opioids for our patients who suffer from chronic pain: we cannot chase the pain with opioids as we may have done in the past. We have to focus on patient safety and, in the first instance we need to act to minimise this risk of death. Secondly, we must be cognisant of the other risks associated with long term opioid therapy including the endocrine side effects of adrenal suppression and sexual dysfunction. Not many of our male patients are aware that opioids can cause erectile dysfunction, loss of libido and infertility.

Opioid weaning is now recommended for patients who are on doses of opioids that exceed the 100 mg morphine equivalent per day. The recommended rates vary but are around the 10 percent per week mark. Opioid weans are fraught with angst, especially in those patients that suffer from depression, present with high pain scores, or are already on very high doses of opioids. Nonetheless we cannot ignore the brutal reality of the situation. These are the very patients we should be weaning off opioids for one very important reason: their elevated risk of death

A new study finds people who consume two servings of fruit per day have 36 percent lower odds of developing type 2 diabetes than those who consume less than half a serving. The research was published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

Diabetes is a disease where people have too much sugar in their bloodstream, and it is a huge public health burden. Approximately 463 million adults worldwide were living with diabetes in 2019, and by 2045 this number is expected to rise to 700 million. An estimated 374 million people are at increased risk of developing type 2 diabetes, the most common form of the disease. A healthy diet and lifestyle can play a major role in lowering a person’s diabetes risk.

“We found people who consumed around 2 servings of fruit per day had a 36 percent lower risk of developing type 2 diabetes over the next five years than those who consumed less than half a serving of fruit per day,” said study author Nicola Bondonno, Ph.D., of Edith Cowan University’s Institute for Nutrition Research in Perth, Australia. “We did not see the same patterns for fruit juice. These findings indicate that a healthy diet and lifestyle which includes the consumption of whole fruits is a great strategy to lower your diabetes risk.”

The researchers studied data from 7,675 participants from the Baker Heart and Diabetes Institute’s Australian Diabetes, Obesity and Lifestyle Study who provided information on their fruit and fruit juice intake through a food frequency questionnaire. They found participants who ate more whole fruits had 36 percent lower odds of having diabetes at five years. The researchers found an association between fruit intake and markers of insulin sensitivity, meaning that people who consumed more fruit had to produce less insulin to lower their blood glucose levels.

“This is important because high levels of circulating insulin (hyperinsulinemia) can damage blood vessels and are related not only to diabetes, but also to high blood pressure, obesity and heart disease,” Bondonno said.

Reference: Bondonno NP, Davey RJ, Murray K, et al. Associations between fruit intake and risk of diabetes in the AusDiab cohort. J. Clin. Endocrinol. Metab. 2021;(dgab335). doi: 10.1210/clinem/dgab335

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Binge eating disorder was a diagnosis formulated in the Diagnostic Statistical Manual, 5th edition (DSM5) and represents a step forward towards the formal recognition of food addiction. This term itself is now rendered problematic by DSM5’s change from the term addiction to the term substance use disorder.

The advent of DSM5 has heralded a re-evaluation of the diagnosis of food addiction. The following criteria for food addiction have been proposed as modifications of the current DSM5 criteria for substance use disorder

1. Food often consumed in larger amounts or over a longer period than was intended

2. Persistent desire of unsuccessful efforts to cut down or control food intake

3. Great deal of time is spent in activities necessary to obtain or overeat on foods or recover from its effects

4. Craving, or a strong desire or urge to eat specific foods

5. Recurrent overeating resulting in a failure to fulfill major role obligations at work, school, or home

6. Continued overeating despite having persistent or recurrent social or interpersonal problems causes or exacerbated by the effects of specific foods

7. Important social, occupational, or recreational activities are given up or reduced because of overeating on foods

8. Recurrent overeating in situations in which it is physically hazardous

9. Overeating is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by overeating on foods

10. Tolerance defined as a need for markedly increased amounts of food to achieve desired effect or a markedly diminished effect with continued use of the same amount of food

11. Withdrawal defined as a withdrawal syndrome when refraining from eating specific foods or when specific foods are eaten to relieve or avoid withdrawal symptoms

The diagnosis of food addiction according to the above would require the presence of at least two symptoms, however, one of the criticisms of this rubric is the potential for overdiagnosis of food addiction, especially when one considers that non-obese patients who struggle with the cycle of overeating and dieting may endorse at least two criteria.

The Yale Food Addiction Scale version 2 (YFAS2) has been developed as a tool for the diagnosis of food addiction. It has thirty-five questions which are based on the current eleven substance use disorder criteria described by DSM5.

Obesity, food addiction and binge eating disorders can be seen to be closely related, but nonetheless distinct clinical entities each with their own diagnostic criteria.

Obesity is diagnosed when the body mass index is more than 30 kg/m2. Binge eating disorder is diagnosed when binges (consumption of large amounts of food in a limited time frame such as two hours) occur at least weekly for the last three months and where these binges are associated with a loss of control of eating and significant distress to the patient.

Using the YFAS2 the prevalence of food addiction in those with obesity ranges from 20-50%, in those with anorexia nervosa, 70% in those with anorexia nervosa, 80% in those with binge eating disorder and 95% in those with bulimia nervosa.

Therefore, the management of both obesity and binge eating disorder can be approached from the perspective of addiction treatment. Such paradigms already exist, e.g., “Food Addicts In Recovery Anonymous”. Whilst medication can play a role in the management of these conditions it is important to understand, identify and manage the underlying psychological issues that predispose to and perpetuate these food related behaviours. Failure to do so results in an ongoing cycle of emotionally driven overeating and self-loathing.

The American College of Lifestyle Medicine defines lifestyle medicine as
“the use of evidence-based lifestyle therapeutic intervention—including a whole-food, plant-predominant eating pattern, regular physical activity, restorative sleep, stress management, avoidance of risky substances, and positive social connection—as a primary modality, delivered by clinicians trained and certified in this specialty, to prevent, treat, and often reverse chronic disease”

But what does it mean in practice? I think of lifestyle medicine as the management of chronic diseases within a socio-psycho-bio-medical framework that incorporates the three Fs and the three Ss.

What is the socio-psycho-bio-medical approach I hear you say?

This approach to chronic disease management considers all aspects of a person’s care including social supports, psychological therapies, biological therapies and medical interventions. It emphasises the role of lifestyle but does not replace or exclude appropriate pharmaceutical or surgical management of chronic diseases.

What are the three Fs and the three Ss? They are the following.

Feet
Fork
Fingers

Sleep
Stress management
Socialisation

Feet
Feet reminds us to consider exercise as a lifestyle medicine intervention. It is recommended for most adults that they engage in at least 150 minutes of brisk walking (or equivalent exercise) per week.

Fork
Fork reminds us to consider diet as part of a lifestyle intervention. As per the definition above, a lifestyle medicine practitioner would recommend a whole-food, plant-predominant eating pattern to maintain a normal weight and nutritional balance.

Fingers
Fingers remind us to consider abstinence from cigarettes and other illicit drugs. They also remind us to limit alcohol intake to no more than ten units per week and no more than four units on any given day.

Sleep
This reminds us that most adults need between seven to nine hours of sleep per night. The days of the sleep-deprived hero are over. Evidence now demonstrates the health benefits of a good night’s sleep which one dismisses at one’s peril.

Stress
Stress is known to contribute to and exacerbate the burden of chronic disease. Stress management interventions should be incorporated into any lifestyle medicine plan of care.

Socialisation
Socialisation reminds us that we are social animals designed to engage positively, purposefully, and meaningfully with our tribe. Loneliness is now known to affect chronic diseases and put us at risk of premature death. Treating loneliness and encouraging the development of positive, purposeful, and meaningful social networks is an important part of a lifestyle medicine plan.

Dr Ferghal is both qualified and experienced in the field of lifestyle medicine.