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N.O.R.M.A.L.
Neuroplastic Optimization and Reduction
of Medication for Adaptive Living
Disclosure Declaration
•
Michael Moskowitz, MD has disclosed that he has
financial interest or other relationship with the
manufacturers of the following medical commercial
products: Neuroplastic Partners, LLC
•
Michael Moskowitz, MD declares that discussion of any
medical commercial product known to him as unlabeled,
or outside of FDA approved indications will be clearly
revealed by him to the audience as such.
•
Michael Moskowitz, MD declares that discussion of any
investigational medical commercial product outside of
FDA approved indications will be clearly revealed by him
to the audience as such.
Disclosure Declaration
•
Marla D. Golden, DO has disclosed that she has financial
interest or other relationship with the manufacturers of the
following medical commercial products: Neuroplastic
Partners, LLC
•
Marla D. Golden, DO declares that discussion of any
medical commercial product known to her as unlabeled,
or outside of FDA approved indications will be clearly
revealed by her to the audience as such.
•
Marla D. Golden, DO declares that discussion of any
investigational medical commercial product outside of
FDA approved indications will be clearly revealed by her
to the audience as such.
Objectives
To describe a treatment paradigm
incorporating neuroplastic treatment to
optimize and reduce medication usage
To delineate the neuroplastic and
somatoplastic changes caused by long-term
medication usage
To identify the role of optimal medication
adjustments within a phasic treatment plan
Fight Fire with Fire
Persistent pain is a neuroplastic process
The core treatment must create neuroplastic
change
As the patient changes, so does the patient’s
treatment needs
Change treatment with changes in treatment
needs
N.O.R.M.A.L.
Neuroplastic Optimization for Reduction of
Medications for Adaptive Living
Medications cannot be the hub of treatment
Side Effects
Drug Interactions
Tolerance
Medications and
Persistent Pain
Suppression of Neuroplastic and
Somatoplastic Processes
Promote patient passivity
Brain and Body adapt to medications with
increasing pain over time
Medications become part of patient identity
Patients on
Medications
By design medications mask symptoms
Symptoms give us clues about treatment
options
Often patients do less
Lives become more contracted
Higher pain, anxiety and depression over time
The New Normal
Teach patients Neuroplastic Treatment
approaches as the hub treatment
R.A.F.T. Treatment Phases use medications
and interventions early to promote Adjustment
phase
Neuroplastic Training using workbook and
website
Core concepts of
N.O.R.M.A.L.
Resist resistance
Emphasize active vs. passive treatment
Make Neuroplastic treatment a requirement
Gradually lower medications as neuroplastic
treatments improve
All medications, not just opioids, lowered as
part of neuroplastic treatment
Core concepts of
N.O.R.M.A.L.
Goal of all treatment is to stop persistent pain
Invasive treatment, medications, manual
therapy, psychosocial treatments should fade
into self directed care
Neuroplastic approaches that are self directed,
portable, effective, evolving and cost-effective
need to be integrated into daily routines
Replace pain with pleasure
R.A.F.T.
Phases of Treatment for Persistent Pain
Rescue
Adjustment
Functionality
Transformation
Medications and
R.A.F.T.
Rescue Phase: Help the person out of
unbearable pain and hopelessness
People feel overwhelmed by pain, anxiety and
depression- pain is not leaving on its own
Utilize medications that work immediately with
minimal side effects- set expectation of possible
short term treatment: N.O.R.M.A.L.
Introduction of idea of Neuroplastic treatment as
hub treatment
Goal: Reduce pain, anxiety and depression- give
hope
Medications and
R.A.F.T.
Adjustment Phase: Reduce pain in a multimodal
treatment program
Finding the combination of medications that works
best for the individual patient
Medications integrated into routines of invasive
treatment, manual therapy and psychosocial
treatment- Biopsychosocial Approach
Develop effective Neuroplastic treatments
Goal is to stabilize the patient
Medications and
R.A.F.T.
Functionality Phase: Rebalance and Focus on
Functional Improvement
Neuroplastic treatment regimes practiced and become
more effective
Patients become more active and take greater role in
direction of their own care
Medications are reduced and replaced with NT
strategies
Goal is to help patient become more self -sufficient
Medications and
R.A.F.T.
Transformational Phase: Meaningful life balancing
pleasure and well being
Neuroplastic treatment regimes are integrated into
daily living routines
Patients take over leadership role with emphasis on
self-care
Medications reduced and/or eliminated to PRN use for
flares
Goal is to help patient become independent with skills
and enjoying life
www.neuroplastix.com
The Art of N.O.R.M.A.L.
Start with systematic review of
medications
When started
Why were they added
How do they work
Adverse effects
Drug–Drug Interactions
Where do we start?
The Art of N.O.R.M.A.L.
Start with a look at side effects: determine which
medications are most likely culprits and start with
reduction of those medications
Consolidate within classes of medications
Explore fear about pain and losing pain control
Emphasize opportunity to replace pain fear with
interest and curiosity about pain and new
neuroplastic strategies to control it
Wean everything slowly
The Art of N.O.R.M.A.L.
Predict pain rebound during lowering and distinguish that from
underlying pain
Emphasize neuroplastic strategies
If patient hits wall with one medication, switch to lowering
another
Stabilize at current dose
Keep track and give feedback at each visit of percentage of
each medication lowered
Encourage temporary medication increase for pain flares that
last
The Art of N.O.R.M.A.L.
Keep trying to introduce new neuroplastic treatment
ideas
Solicit patient ideas and opinions
Which medication to reduce
How much medication to reduce
New neuroplastic strategies to use
Give positive feedback for taking control of own life
Ask patients who are doing well, how they would
recommend helping your other patients, who are
struggling
The Art of N.O.R.M.A.L.
Anti-Epilepsy Drugs
Indication:
Neuropathic pain
Fibromyalgia
Optimizing: substitution vs. wean
Approaches to weaning-slow and stabilize if pain
worse
The Art of N.O.R.M.A.L.
Anti-Epilepsy Drugs
Patient–Practitioner interaction: expect and
discuss short-term rebound pain, rotate weaning
to another medication
Monitoring Response: cognitive and memory
improvement, change in pain pattern and
symptoms
Neuroplastic approaches: Self-soothing, GABA
The Art of N.O.R.M.A.L.
Opioids
Indication:
Nociceptive
Neuropathic pain
Optimizing: rotation vs. wean, minimum effective
dose, short-acting vs long-acting, do not rush
reduction
Approaches to weaning- lower long-acting first,
timing
The Art of N.O.R.M.A.L.
Opioids
Patient–Practitioner interaction- explain advantages re:
tolerance, give options to slow wean or stop, rotate
weaning to another medication, reassure about first few
days of symptoms, allow for stabilization at lower dose
before continuing, address fear
Monitoring Response: withdrawal symptoms,
constipation, first few days of possible mild withdrawal
symptoms
Neuroplastic approaches: slow weaning reduces mu
receptor induced NMDAR population, peppermint
The Art of N.O.R.M.A.L.
NSAIDs
Indication:
Nociceptive
Inflammatory pain
Optimizing: minimum dose/shortest time, avoid in
>65 population
Approaches to weaning: lower, then PRN, use
diet, sequential supplements, raw cacao,
curcumin
The Art of N.O.R.M.A.L.
NSAIDs
Patient–Practitioner interaction: expect and
discuss short-term rebound pain
Monitoring Response: Look for recurrent
symptoms and signs of inflammation
Neuroplastic approaches: visualizations of
brain/CTS interactions, music–
psychoneuroimmunology
The Art of N.O.R.M.A.L.
Antidepressants
Indication:
Anxiety
Depression
Neuropathic pain
Fibromyalgia
Optimizing: rotation, addition, streamline
redundancy
Approaches to weaning: slow and stop
The Art of N.O.R.M.A.L.
Antidepressants
Patient–Practitioner interaction:
Rotate
Weaning to another medication
Explain withdrawal
Monitoring Response: Explore what patient
means by recurrent depression before restarting
Neuroplastic approaches: self-soothing, visualize
brain releasing GABA, BDNF
The Art of N.O.R.M.A.L.
Benzodiazepines
Indication:
Anxiety
Panic
Sleep
Pain relief
Muscle spasm
Optimizing: match drug to symptoms, use lowest dose
possible if truly indicated
Approaches to weaning: slow wean, never stop
abruptly
The Art of N.O.R.M.A.L.
Benzodiazepines
Patient–Practitioner interaction:
Discuss patients expectation for this class
Discuss fear and source of underlying anxiety
Monitoring Response: watch for increased
symptoms and withdrawal
Neuroplastic approaches: Touch, Manual therapy,
self-soothing, peppermint, EMDR, meditation,
sound/music
The Art of N.O.R.M.A.L.
Muscle Relaxants
Indication:
Muscle spasm
Not for sleep
Optimizing: convert from carisoprodol, caution with
cyclobenzaprine
Approaches to weaning: use sparingly and prn,
consider centrally acting agents like baclofen
The Art of N.O.R.M.A.L.
Muscle Relaxants
Patient–Practitioner interaction: discuss reasons for
adding and using
Monitoring Response: palpate muscles, discrete
vs. widespread, spasm vs. other symptoms
Neuroplastic approaches: Isometric exercises,
movement, stretching, self-massage, Manual
therapy, progressive muscle relaxation
The Art of N.O.R.M.A.L.
Headache Medications
Indication: head pain–cervicogenic, true migraine,
chronic daily headache, drug effect or interaction, prior
infection, TBI/post-concussive
Optimizing: treat underlying cause, caution with
abortives
Approaches to weaning: opioids as rescue, preventives
The Art of N.O.R.M.A.L.
Headache Medications
Patient–Practitioner interaction: evaluate cervical spine,
first rib dysfunction, TMJ, HEENT pathology, history of
falls or trauma, leg length discrepancy and scoliosis
Monitoring Response: change in frequency, intensity
and duration
Neuroplastic approaches: soothing sound, self massage
ear and scalp, Craniosacral therapy
The Art of N.O.R.M.A.L.
Refining the Art
Side effects: look them up
Serotonin Syndrome
Drug-Drug Interactions
Neuroplastic effect of chronic medications
Loss of homeostasis
Receptor populations
Slowing or altering the nervous system
Cardiac effects
Respiratory effects
ABOVE ALL, DO NO HARM
Hub Treatment:
Neuroplastic Transformation
Bibliography
Stokes JA, Corr M, Yaksh TLl. Spinal toll-like receptor signaling and nociceptive processing: regulatory balance
between TIRAP and TRIF cascades mediated by TNF and IFNB. Pain. 2013 May; 154(5):733-742.
Dickinson BD, Head CA, Gitlow S, Osbahr AJ III. Maldynia: pathophysiology and management of neuropathic
and maladaptive pain—a report of the AMA Council on Science and Public Health. Pain Med. 2010;11:16351653.
Moskowitz M, Fishman, SM. The neurobiological and therapeutic intersections of pain and affective disorders.
Focus. 2006;4(4):465-471.
Bliss T, Collingridge G, Morris R. Synaptic plasticity in the hippocampus. In: Anderson P, Morris R, Amaral D,
Bliss T, O’Keefe J. The Hippocampus Book. New York, NY: Oxford University Press; 2007:343-474.
Ge S, Yang C, Hsu K, Ming G, Song H. A critical period for enhanced synaptic plasticity in newly generated
neurons of the adult brain. Neuron. 2007;54(May 24, 2007):559-556.
Dudek SM, Bear MF. Homosynaptic long-term depression in area CA1 of hippo- campus and effects of nmethyl-d-aspartate receptor blockade. Proc Natl Acad Sci USA. 1992;89(10)4363-4367.
Craig AM, Lichtman JW. Synaptic formation and maturation. In: Cowen WM, Südhof TC, Stevens CF, eds.
Synapses. Baltimore, MD: The Johns Hopkins University Press; 2001:571-612.
Cowen WM, Kandal ER. A brief history of synapses and synaptic transmission. In: Cowen WM, Südhof TC,
Stevens CF, eds. Synapses. Baltimore, MD: The Johns Hopkins University Press; 2001:1-88.
Favero M, Cangiano A, Busetto G. Hebb-based rules of neural plasticity: are they ubiquitously important for the
refinement of synaptic connections in devel- opment? Neuroscientist. 2014;20(1):8-14.
Bibliography
Stettler DD,Yamahachi H,Li W,Denk W,Gilbert CD.Axons and Synaptic Boutons are Highly Dynamic in Adult
Visual Dortex. Neuron. 2006;49(6):877–887.
Zhang TC, Janik JJ, Grill WM. Modeling the effects of spinal cord stimulation on wide dynamic range dorsal
horn neurons: influence of stimulation frequency and GABAergic inhibition. J Neurophysiol. April 30, 2014,
epub ahead of print.
MoskowitzMH.Centralinfluencesonpain.In:SlipmanCW,DerbyR,Simeone FA, Mayer TG, eds. Interventional
Spine: An Algorithmic Approach. Philadelphia, PA: Saunders Elsevier; 2008:39-52.
Price DD.PsychologicalMechanismsofPainandAnalgesia.(Progress in Pain Research and Management, V. 15).
Seattle, WA: IASP Press; 1999.
WoolfCJ,SalterMW.Neuronalplasticity: Increasing the Gain in Pain.Science. 2000; 288(5472):1765-1769.
ShengMH-T.Thepostsynapticspecialization.In:CowenWM,SüdhofTC, Stevens CF, eds. Synapses. Baltimore,
MD: The Johns Hopkins University Press; 2001:315-356.
Mantyh PW.Neurobiology of Substance-P and the NK-1 Receptor.JClin Psychiatry. 2002;63(Suppl 11):6-10.
Muñoz M, Coveñas R. Involvement of Substance-P and theNK-1 Receptor in Human Pathology. Amino Acids.
2014;April 6 [e-pub ahead of print].
Reed RK,Rubin K.Transcapillary Exchange: Role and Importance of the Interstitial Fluid Pressure and the
Extracellular Matrix. Cardiovasc Res. 2010;87(2):211-217.
Baliki MN, Geha PY, Apkarian AV .Parsing Pain Perception Between Nociceptive Representation and
Magnitude Estimation. J Neurophysiol. 2009;101(2):875-887.
Bibliography
Rauch SL, Shin LM, Phelps EA. Neurocircuitry models of posttraumatic stress disorder and extinction: human
neuroimaging research—past, present, and future. Biol Psychiatry. 2006;60(4): 376-382.
Mathew SJ, Coplan JD, Schoepp DD, Smith EL, Rosenblum LA, Gorman JM. Glutamate-hypothalamicpituitary adrenal axis interactions: implications for mood and anxiety disorders. CNS Spectr. 2001;6(7):555556, 561-564.
Seminowicz DA, Wideman TH, Naso L, et al. Effective treatment of chronic low back pain in humans reverses
abnormal brain anatomy and function. J Neurosci. 2011;31(20):7540-7550.
Siegel DJ. The Mindful Brain. New York, NY: WW Norton and Co; 2007.
BalikiMN,BariaAT,ApkarianAV.Thecorticalrhythmsofchronicbackpain.J Neurosci. 2011;31(39):13981-13990.
WatkinsLR,HutchinsonMR,LedeboerA,Wieseler-FrankJ,MillganED,Maier SF. Glia as the “bad guys”:
implications for improving clinical pain control and the clinical utility of opioids. Brain Behav Immun.
2007;21(2)131-146.
MoskowitzMH,GoldenMD.NeuroplasticTransformationWorkbook.Sausalito, CA: Neuroplastic Partners, LLC;
2013.
Moskowitz MH, Golden MD. Neuroplastic Transformation workbook. Neuroplastix.
http://www.neuroplastix.com/styled-6/workbook.html
Napadow, V, et al, Decreased Intrinsic Brain Connectivity is Associated with Reduced Clinical Pain in
Fibromyalgia, Arthritis & Rheumatism, July, 2012Volume 64, Number 7, 2398-2407.
Dosi R, Ambaliya A, Joshi H, Patell R, Serotonin Syndrome versus Neuroleptic Malignant Syndrome: A
Challenging Clinical Quandary, British Medical Journal Case Report 2014 Jun 23;2014.
Bibliography
Chaparro LE1, Wiffen PJ, Moore RA, Gilron I. Combination Pharmacotherapy for the Treatment of Neuropathic
Pain in Adults. Cochrane Database Syst Rev. 2012 Jul 11;7
Wallace, JL, NSAID Gastropathy and Enteropathy: Distinct Pathogenesis Likely Necessitates Distinct
Prevention Strategies, British Journal of Pharmacology (2012) 165 67–74.
Sahbaie, P, Curcumin Treatment Attenuates Pain and Enhances Functional Recovery After Incision,
Anesthesia and analgesia (2014) volume: 118 issue: 6 page: 1336-1344.
Cheatle, MD, Barker, C, Improving Opioid Prescription Practices and Reducing Patient Risk in the Primary
Care Setting, Journal of Pain Research 2014:7 301–311.
Peltier, A, Goutman, SA, Callahan, BC, Painful Diabetic Neuropathy, BMJ. 2014 May 6;348:g1799.
Tse SA1, Atayee RS, Best BM, Pesce AJ, Evaluating the Relationship Between Carisoprodol Concentrations
and Meprobamate Formation and Inter-subject and Intra-subject Variability in Urinary Excretion Data of Pain
Patients, J Anal Toxicol. 2012 May;36(4):221-231.
Paquin AM1, Zimmerman K, Rudolph JL, Risk Versus Risk: A Review of Benzodiazepine Reduction in Older
Adults, Expert Opin Drug Saf. 2014 Jul;13(7):919-934.
Lader M. Benzodiazepine Harm: How Can It Be Reduced? British Journal Clinical Pharmacolology, 2014
Feb;77(2):295-301.
Munksgaard SB1, Jensen RH, Medication Overuse Headache. Headache. 2014 Jul 2. doi:
10.1111/head.12408. [Epub ahead of print].
Grazzi L., et al, Evaluation of Immune Parameters in Chronic Migraine with Medication Overuse, Neurological
sciences (2014) volume: 35 Suppl 1 page: 171-173.