Let’s Talk About Hepatitis C

You’ve probably seen the advertisements for Harvoni, the new medication for Hepatitis C.  Hepatitis C has become more and more common with the rising incidence of IV drug use. About 2.7-3.9 million people in the US have chronic Hepatitis C.  That means that if you don’t have Hepatitis C yourself, you probably know someone who does.

In order to understand how Harvoni works, it helps to understand some things about Hepatitis C. Most people don’t really know the difference between Hepatitis A, B, and C.  They are caused by 3 different viruses. Infection from the Hepatitis A virus usually comes from contaminated food or water. It can be passed through feces.  It’s usually an acute infection that does not become chronic. Hepatitis B virus infection usually occurs when blood or body fluids, such as semen from an infected person, enter the body of an uninfected person. This can occur when IV drug users share needles with other users. Hepatitis B can also be transmitted during birth to the newborn from an infected mother or through sexual contact. Hepatitis B can become chronic though it doesn’t always happen. There are vaccines to prevent hepatitis A and B, but not Hepatitis C.

Hepatitis C is acquired through blood to blood transmission. It can be sexually transmitted if there is some blood/blood exchange, but that isn’t common. The most common cause of Hepatitis C is IV drug use. Hepatitis C can be transmitted to a newborn during birth. Rarely transmission could occur if a non-infected person uses a razor that has blood from an infected person, or if somehow blood from an infected person enters an open wound of a non-infected person, for example needle-sticks in the health care setting.  It can be acquired through tattoos is the tattoo needle was not cleaned properly and has the blood of someone with hepatitis C on it.  People who received blood transfusions or organ transplants before 1992 are at risk because there was no screening for HIV and hepatitis C in blood donors before that.

Common symptoms of Hepatitis C are decreased appetite, abdominal pain, dark urine, or light, grayish stools, or jaundice.

Harvoni is unique in that the dose is only one pill per day. Several years ago, when hepatitis C was treated with interferon, ribavirin, and proteases, patients took up to 18 pills per day and the chance of cure was not that impressive. So a 95 % cure rate with a dose of only one pill per day is pretty amazing. However, there are some caveats.

First of all, patients need to be tested to determine the genotype of their Hepatitis C virus. There are 6 different “strains” of Hepatitis C virus. The most common strain in the US is Genotype 1. Harvoni is effective with genotype 1 Hepatitis C.  Most patients need to take it for 12 weeks though sometimes it only takes 8 weeks.  Or course, people who are generally healthy other than the Hepatitis C usually have the best response.  In January, 2016, two more medications were approved that are effective for the other genotypes. They are just becoming available. So Hepatitis C can be cured.

There are some side effects. Most people taking any of these hepatitis medications feel tired. Some patients feel a little weak or lightheaded or foggy in their thinking.  With the older medications, such as interferon, there was an incidence of severe depression. That is less common with the new medications.

Unfortunately, it can be difficult to get insurance companies to pay for the new drugs until the person has fairly advanced disease. That makes no sense because people are more likely to respond quickly before they are extremely ill. But that’s how insurance companies operate.

If you have risk factors, it is definitely worth being tested for Hepatitis C. Most people don’t even know that they have it early in the course of the disease. Occasionally, some people can clear the virus without treatment. However, if you do have it, you need to be monitored. It can progress to cirrhosis if not treated.

Suboxone: Just Another Addiction?

I heard recently from a friend who attended a continuing education update on suboxone for non-physicians that the addiction counsellors who were there spent the entire session trashing suboxone.  I’m guessing they didn’t learn much. I’m not sure what role the moderator played, but apparently the trashing went on without anyone speaking up for the other side.  So, as a prescriber of suboxone, I’m going to speak up for the other side.

When I hear people criticize suboxone, it is usually based on opinion.  I see addiction, especially opiate addiction, as a medical illness that affects the brain.  I see many of the choices that addicts make as a result of this brain dysfunction.  What often appears to be a choice, is not really a free-will choice. It’s fueled by craving, fear of withdrawal, and for people who have failed many treatments, a sense of hopelessness. We don’t treat other medical illnesses based on opinion. We look at the research.

These are the most common criticisms that I hear about suboxone.

  1. It’s just as bad as the heroin. It’s just another opiate, replacing one opiate with another. You’ve got to be kidding me. You really think that suboxone, an FDA approved medication, is just as bad as heroin? Honestly, I have heard people, even addiction therapists, say this. Suboxone is a partial–opiate agonist, meaning that it binds to opiate receptors, but does not have the full effect of an opiate such as morphine or heroin. People who take suboxone don’t crave opiates because their opiate receptors are occupied, but they don’t feel high.  My patients tell me that they feel “normal.” They feel clear cognitively.
  2. It can be abused just like heroin.  Yes, it can be abused. So can gabapentin, amitriptyline, tramadol, Wellbutrin, Prozac, and many other legally prescribed medications. Oh, and let’s not forget the opiates that are legally prescribed for pain. Because suboxone is a partial–opiate agonist, you have to work hard to abuse it. Most true opiate addicts don’t’ want to bother abusing suboxone because they don’t get the kind of high that they get with the stronger stuff. It’s too much trouble. Plus, the effect of suboxone plateaus after a certain amount. In other words, you can take more but you won’t get any more benefit. This is in contrast to pure opiates which continue to exert effect (mainly getting high) as the dose goes up. This is why addicts take so much of the pure opiates that respiratory suppression occurs and death ensues. Most people who have overdosed on suboxone have other drugs in their system as well, usually benzodiazepines (valium, xanax, ativan). It’s hard to overdose on suboxone alone, but not impossible.  If people are determined to overdose, they will find a way to do it, whether it’s suboxone or something else.
  3. That doctor kept my family member on it for 7 years. Yep, that’s another common complaint. Family members or anti-suboxone therapists feel that patients should be off of suboxone in a few months. It’s the should word again. When suboxone first came out, the thinking was that people could be tapered off in 6-12 months. However, studies have shown that some of those people who were tapered off quickly, relapsed. It seems that people who stayed on it longer, did better. The dose can and should be decreased over time, but it may be that some people manage better with a small amount long-term.  So I would say that if your family member or client is doing well, working, managing family life, contributing in a positive way to society, why are you worried about whether or not they take a pill to treat their addiction? So they’ve been on it for 7 years, or 8 years or 10 years.  We need to accept that this is a chronic, serious, tough to beat illness.
  4. The withdrawal from suboxone is worse than heroin. That’s why you work with a physician who understands suboxone.  It has to be tapered slowly. Some people can taper faster than others. Withdrawal symptoms can be treated. Why rush?   If the client just stops suddenly (which sometimes happens when friends, family, or therapists hassle them about being on suboxone), there will be withdrawal symptoms.
  5. Addicts can do it without medication if they are really motivated. This one really gets me. So that means that if someone fails a treatment, it’s their fault?? That’s called blame the patient when the treatment doesn’t work. Yes, many people can do it without using medication and more power to them. But what about the ones who can’t? Are we to just chalk it up to their lack of commitment? In medicine, if someone fails treatment, we change the treatment, we don’t’ just wave them off as unmotivated. People who have been able to conquer their addiction without medication tend to be the loudest proponents of the “my way is the only correct way to do this” approach. So is there really only one way to achieve sobriety? I just don’t think so.  One belief that underlies this idea that all addicts should be able to get sober on their own without medication is that addiction is just the product of a weak will. PEOPLE, it’s not that simple. READ the studies, look at the science of addiction. If it were really that simple, I think we would have more sober people and fewer deaths from opiate addiction.
  6. If they are taking medication, they aren’t really sober. This is often the AA/NA stance. That’s why many patients on suboxone either don’t go to self-help groups, or they go but don’t reveal that they are on suboxone. That’s too bad. AA and NA have a lot to offer opiate addicts on suboxone. They still need contact with people who are sober, people who have been through what they have. Sometimes they have more than one addiction.  Too bad these groups can’t get past the idea that some people benefit from taking medication for their illness. I often want to ask people who complain about suboxone if they would advise people with diabetes or hypertension to go off their meds because they should be able to control their blood sugar or blood pressure on their own.  By the way, I don’t hear a lot of complaints about people taking the approved medications for alcohol dependence – disulfiram, ReVia, acamprosate.

People who are on suboxone are struggling to get their lives back together. They don’t need to be sabotaged by others who feel that there is only one right way to get clean, their way.  Suboxone is not magic.  Most people on suboxone are also in therapy.  Before you criticize somebody on suboxone, think about whether you would rather have them on a medication that helps them maintain sobriety or at risk of relapse because they have failed other treatments. Would you rather have them alive or dead?

This is one study looking at suboxone versus methadone versus placebo. There are many others published. Go to PubMed (The National Library of Medicine) and search suboxone or buprenorphine. Base your recommendations about suboxone on research rather than opinion.

 

Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.

NOT JUST ANY NEWS

Medical News that Impacts Your Life.

Week of July 11

It happened to Betty Crocker!!

Even Betty Crocker is not immune from recalls. Recently, General Mills announced a recall of two Betty Crocker cake mixes in the US – party rainbow chip and carrot cake mixes. The problem was the Wondra flour used to produce some ingredients in the cake mixes. The flour was recalled after the CDC found E. coli contamination in June. The contaminated flour caused sickness in 38 people.  That is only the latest in a series of E. coli recalls. Remember the recent problems with produce from Mexico.

E. coli is actually common bacteria, and is even found in our bowel. That strain of E coli does not cause illness to humans for the most part, though it can sometimes cause urinary tract infections. But there are over 700 strains of E. coli, and the one causing serious illness is E. coli O157:H7.  This particular E. coli strain releases a toxin called the Shiga toxin. The Shiga toxin is very similar to that released in Shigella infection.  As a matter of fact, one theory is that there was a transfer of genetic material from a Shigella bacterium to a common E. coli bacterium, and that launched E. coli O157:H7.

This strain of E. coli is very easily transmitted, and it doesn’t take a high concentration of the bacteria to make people really sick. The primary symptoms are severe abdominal pain and diarrhea which sometimes progresses to bloody diarrhea. Most people do recover, but those with weaker immune systems, such as the elderly, young children, or people with chronic illnesses, are more likely to die. Antibiotics don’t help, as a matter of fact they can sometimes make it worse. Supportive care is the main treatment. The development of hemolytic-uremic syndrome, which is the result of massive spread of the toxin, causes a shutdown of the kidneys due to small clots in the vessels supplying the kidney with blood.  Once the infection progresses to that point, it is often fatal.

This strain of E. coli has been found in the GI tract of cows and other animals. It ends up in raw meat. If the meat is undercooked, the potential for transmission is there. However, this is not the only source of E. coli O157:H7. It has been found in produce such as lettuce, spinach, carrots, and other field grown crops.  It makes sense the E. coli could end up in meat since it is primarily found in the GI tract of animals, but how does it end up in produce? Scientists think that the soil where the vegetables and fruits were grown was contaminated by manure from infected cattle or wild animals going through the fields leaving droppings or contamination of irrigation water with manure or droppings. However, there is not a definite answer to that question.

For more info about E. coli check out about-ecoli.com. There is a great section on prevention of E. coli infection. The primary method of prevention is fully cooking meat to 160 degrees F for 15 seconds and scrubbing vegetables and fruits.   The site points out that if someone in the house has diarrhea, special care should be taken to avoid contamination by using gloves when assisting that person and scrupulous hand washing.

 

Drunkorexia – Is Your Child At Risk?

There is a new trend on college campuses.  While college students are known for risky behaviors, this one is very hazardous to health. It’s called drunkorexia. Dr. Dipali Rinker, a research assistant in the department of neurology at the University of Houston, reported on a study that she conducted at the Research Society on Alcoholism meeting in New Orleans on June 30, 2016. The phenomenon of intoxication on an empty stomach is not new, but the extreme to which some college students are taking it is very concerning.   According to the findings from Rinker’s study, these students engage in one or more of the following behaviors before or after drinking: excessive exercise, binging and /or purging, or extreme calorie restriction. The main purpose of the behaviors is to enhance the euphoria from drinking, though some students reported that they also wanted to decrease calories from the alcohol. Rinker reports that in her study, both men and women were equally likely to engage in drunkorexic behaviors to reduce calories from alcohol.  She noted that college women who drank more had more bulimic behaviors and more problems with alcohol as a result of those behaviors.

 

A similar study was reported by Science News (sciencedaily.com) in October of 2011. That study was conducted at the University of Missouri and was reported by Victoria Osborne, assistant professor of social work and public health. She and her colleagues found that 16% of students surveyed had restricted calories in order to save them for drinking alcohol.  In her study, three times more women than men reported these behaviors.  The motivation for drunkorexia in this study included getting drunk more quickly, preventing weight gain and saving money for purchase of alcohol rather than food.

 

Combining excessive drinking with lack of nutrition can lead to both short-term and long –term consequences.  Drinking alcohol on an empty stomach leads to intoxication much more quickly. College students are particularly vulnerable to making bad decisions when very intoxicated. They may be new to college, seeking social approval, feeling both insecure and exhilarated at new-found freedom. The impairment that comes from alcohol intoxication can lead to sexual victimization, violence (as victim or perpetrator), difficulty academically, or life-threatening alcohol poisoning.  For students who came to college with a history of eating disorder issues or substance abuse problems, this combines the two and adds another layer of dangerousness.

 

Chronic alcohol use can result in nutritional deficiencies, especially deficits in folate and thiamine. Though the study subjects were not specifically tested for nutritional deficiencies, it stands to reason that this could be an issue when you combine poor nutrition with excessive drinking, even if it’s binge drinking. Thiamine is important in memory, cognition and muscle coordination. Folate is important in the development of new cells. It is extremely important during pregnancy because low folate can cause neurological birth deficits, especially spina bifida. Of course, college women are definitely of child bearing age, and may not always recognize that they are pregnant immediately. College students are not immune from other chronic diseases such as diabetes, hypertension, and seizures. Excessive drinking can increase the likelihood of seizures especially in someone who already has a seizure disorder. Of course calorie restriction and poor eating habits resulting in poorly controlled blood sugar increase the chances of diabetic complications such as neuropathy and vision problems.

 

So, as a parent, you may be wondering what the take-home message is here. Can anything be done to prevent your child from participating in this behavior?  Your input as a parent can make a difference. Here are some suggestions for the pre-college discussion.

 

  1. Know your child. Has your child had social anxiety, some self esteem-issues? Allow your child to discuss anxiety about adjusting at college. Help your child come up with some ideas for meeting people.  If your child is shy, practice some conversational techniques that may work for them.
  2. Ask your child directly how her friends feel about alcohol and drugs. Sometimes kids are more willing to tell you how their friends feel than how they feel. But chances are, they feel the same way.
  3. Talk with your child about how she might handle some specific scenarios when alcohol is offered. Help her come up with some responses and actions that will work for her when she needs them.
  4. Work on problem solving. If he does find himself in a bad situation, what can he do? Keep communication open. If he is being pressured to drink or is drinking, he needs to be able to talk to you about it without fear.
  5. Don’t be complacent if your child has tried alcohol or drugs during high school and seemingly “learned their lesson.” You may think that the novelty has worn off, and they are not as likely to go overboard, but that isn’t true. These kids are more likely to increase their use of drugs and alcohol in college.
  6. Be aware of how things are going once they get to college. Call and visit. If grades start to deteriorate, they seem distant, they seem tired or speech seems slurred, ask questions.
  7. Be honest with yourself about your own drinking and drug use. You are the role model. If you have a problem, your kids are more vulnerable because of genetic and environmental influences.

 

If you think you may have a problem yourself, start there. You really can’t have the kind of open communication that you desire with your pre-college child if you have not dealt with your own substance use.   If you aren’t sure whether you have a problem, get an assessment from an addiction professional. If you know you have a problem, get treatment. Check out the American Society of Addiction Medicine website (asam.org). Click on Resources and then Find a Doctor.

University of Missouri-Columbia. (2011, October 17). ‘Drunkorexia:’ A recipe for disaster. ScienceDaily. Retrieved July 4, 2016 from www.sciencedaily.com/releases/2011/10/111017171506.htm.

Research Society on Alcoholism. (2016, June 27). Drunkorexia 101: Increasing Alcohol’s Effects Through Diet and Exercise Behaviors. ScienceDaily. Retrieved July 4, 2016 from www.sciencedaily.com/releases/2016/06/160627100223.htm

 

 

 

NOT JUST ANY NEWS

Medical News that Impacts Your Life

Week of July 4, 2016

Physical Activity and Diabetes:  If you are pre-diabetic and frustrated because you haven’t lost weight, take heart. A new study from the Diabetes Prevention Program shows that for some individuals, 150 minutes of brisk walking activity per week reduced their risk of developing diabetes whether or not they actually lost weight. The even better news is that people who were inactive to start with were more likely to see this benefit.

Furthermore, the Diabetes Prevention Program just finished a 15-year study that took 3234 people who were pre-diabetic (overweight, middle aged, and with slightly elevated fasting blood glucose) and randomized them to 3 groups: placebo, medication only, or intensive lifestyle intervention. The placebo and medication groups received some basic instruction about diet initially. The medication group received metformin, a medication to lower blood sugar. The intensive lifestyle intervention group received 16 individual sessions on diet, exercise, and behavior modification plus a group session monthly.  They did not receive medication. The goal was for the intensive lifestyle patients to add 150 minutes of physical activity (usually brisk walking) per week to their regimen. Over the first 3 years, the patients in the intensive lifestyle group were 58% less likely to develop diabetes than those in the placebo group, and over 15 years, they were 27% less likely to develop diabetes.  So for some people it only delayed the onset of diabetes, but this is still a good thing.  You don’t have to be a marathon runner. Brisk walking for 150 minutes per week is possible. You could do 25 minutes per day 6 days per week and meet that goal.

Children and Sleep Apnea:  Most of you have probably heard of obstructive sleep apnea (OSA). It’s usually thought of as a disorder most common in adults. OSA occurs when throat muscles relax during sleep and cause the airway to close. As a result, your breathing stops and starts during the night. Snoring is the hallmark of OSA.  OSA can cause problems during the day such as sleepiness because of poor quality sleep, difficulty with concentration, depression, memory problems, and heart problems. The heart problems occur because, due to the off and on breathing, your oxygen saturation gets very low during the night. This causes the heart to have to work harder to get oxygen to your organs.

OSA can occur in children. At a recent meeting of the Associated Professional Sleep Societies, Sara Honaker, Ph.D., reported on a study showing that the rate at which pediatricians are identifying OSA in children is extremely low. This isn’t because OSA is rare in children; the pediatricians are not properly screening for the disorder. The American Academy of Pediatrics and the America Academy of Sleep Medicine both recommend that children with frequent snoring be referred for an evaluation for OSA. Snoring more than 3 nights per week is a strong indicator of OSA.  Children are subject to the same problems related to OSA as adults are.

If your child seems to snore frequently, talk to your pediatrician about Obstructive Sleep Apnea.

Intimacy versus Isolation: The Struggle Continues

As I’ve thought about Brexit over the last few days (Britain’s exit from the European Union), it reminds me of the struggle that I see in our country and in many of my patients.  There are numerous opinions out there about why the British made this choice. One of the common themes that I’ve heard is “They wanted to take back their country.” The theory is that they were tired of feeling out of control of their borders, and that they did not want their fate to be so tied to the political fortunes of the other members of the union. Of course, as all of the ramifications of the exit became clear, there was some regret. It seems that perhaps the average citizen did not realize how significant the withdrawal effects would be and how interconnected they already were.

Isn’t this really the core issue for all of us whether on a national or personal level?  Erik Erikson, a well-known psychologist active during the 1950’s and 60’s, proposed 8 stages of personality development. The 6th stage was intimacy vs. isolation. Erikson felt that this phase of personality development took place between ages 18 and 40, the time when young adults were beginning intimate relationships beyond the family of origin that could lead to long-term commitment, and a sense of trust, safety, security, and connection within a relationship. Failure to master this phase of personality development could lead to isolation and loneliness both in personal relationships and with the world in general.

How many times have we as individuals and as a country danced between intimacy and isolationism? When an intimate relationship goes bad, the natural tendency is to isolate. “I’ll never date again” is a refrain that I often hear. But rarely do people really stay isolated forever, because deep down, most of us do have a drive to connect and to avoid loneliness and despair.

The same dance seems to occur on a national level. After the devastating effects of World War I, the US moved to a much more isolationist stance. We refused to join the League of Nations because there was concern that we could be drawn into growing conflicts in Europe. Our absence in the League of Nations possibly resulted in that body being much less effective in dealing with the rising conflict in Europe. Finally, we were forced out of this stance by the surprise attack on Pearl Harbor in 1941.  Did we pay a price for our refusal to be more involved in world politics, the equivalent of intimacy vs. isolation in Erikson’s stages of personality development?

As we watch Europe being flooded with refugees, dealing with the uncertainty of who is a terrorist and who isn’t, it is not surprising that we would choose to isolate. We have the advantage of geographical distance from Europe. However, as we have seen, those conflicts can easily move to our country, and they already have. Isolationism doesn’t prevent that. In the same way, avoiding intimate personal relationships doesn’t guarantee happiness. It’s a trade-off; less short-term acute hurt but more long-term depression and despair.

Isolationism, at least in its extreme form, seems to me to be a temporary withdrawal to re-fuel and repair. That may be necessary in some cases. But as we saw pre-World War II, that stance did not keep us from being involved in outside conflicts. Connection with others, whether on a personal or national level, can eventually result in increased communication and understanding of each other’s values. It seems to me that a more connected world is a more tolerant world. If we are more dependent on each other, will that result in more tolerance out of necessity? Being more dependent on others is a scary concept. But is also increases the need to get along. How do we get there? I don’t know exactly. I believe it will take generations to achieve.

Perhaps we can start with thinking about the issue of intimacy vs. isolation in our own lives. Though Erikson was thinking primarily of intimate relationships, I think it applies to our connection with community as well.   It seems to me that trying to connect with people who seem different, people from another culture, or race, or sexual orientation, can only increase understanding of one another.  When people make disparaging remarks about gays or Muslims or another other groups, I wonder if they’ve actually talked to one. I would be willing to bet that the answer is no.  Though it is not a quick fix, I do believe that people who communicate and try to understand one another are less likely to kill each other.

shutterstock_424050601

Should You Be Concerned About Medical Error?

On May 3, the British Medical Journal published a study titled “Medical error- the 3rd leading cause of death in the US.” The authors, Dr. Daniel Makary and Dr. Michael Daniel of Johns Hopkins Department of Surgery, analyzed 4 studies done between 2000 and 2008 looking at rates of death due to medical error in hospitalizations. They then used those death rates and calculated how many deaths due to medical error occurred in 2013 based on 35,416,020 hospitalizations. They concluded that 251,454 deaths occurred in 2013 due to medical error during hospitalization. That’s 9.5% of all deaths each year in the US which would make it the 3rd largest cause of death.  As you can imagine, this has created outrage in the medical world. Most physicians don’t believe it; hospitals are denying it, and patients are upset and anxious.  There are a few medical practitioners who agree with it and suspect that the estimate is actually on the low side.

I admit to some bias here. I’m a doctor. I don’t like to think that there are that many medical errors contributing to so many deaths. Already, I’m seeing various versions of this story splashed over the internet, in newspapers and magazines. I’m not surprised. We aren’t a trusting society anymore, and this is one more piece of evidence that what we thought could be trusted really can’t.

If this study is going to be this widely quoted, I think it is important to really understand the study.   If we are going to make sweeping conclusions about the medical profession, let’s make sure the study really says what we think it does.  Here are some issues that have been raised regarding the study.

  • It’s one study. In any scientific field, one study is not considered proof of anything until it is replicated.   Also, they based their conclusions on data from 4 studies done between 2000 and 2008 looking at medical error in the United States. So you have to look at these studies and really assess whether their methodology was accurate.  This is key.
  • Many doctors take issue with the definition of medical error used by the researchers. They defined medical error as “an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient.” That’s a very broad definition of medical error. Can you really say that a procedure that doesn’t achieve its intended outcome is a medical error?
  • The study is only looking at medical error in the hospital. Remember that people would not be in the hospital unless they had some serious medical problems. They aren’t just healthy people living their lives who are suddenly struck down by medical error.  If you are really going to define medical error as an unintended act of either omission or commission or an act that does not achieve it’s intended outcome, is that more likely to happen with people who are undergoing high-risk medical procedures and who may be more prone to complications due to the seriousness of their illness?  It may still be medical error by definition, but certainly unintended consequences are more likely to occur in very sick, debilitated people undergoing complicated procedures. Does that mean that we should not do those procedures?

There is risk inherent in any procedure, any treatment, any medication. There is risk in taking Tylenol.  How much risk are we willing to accept?  Are we clearly informed of the risk? Informed consent is another controversial issue in the medical field.  Theoretically, patients need to be fully informed. However, the true risk of a treatment may not be that easy to determine. It depends on the underlying general health of the patient, the circumstances (is it an emergency or a planned procedure) and to some extent the facilities of the hospital and experience of the physician. It’s always fair to ask “How many of these procedures have you done?” or “How many times have you used this medication?”

The study is important and deserves recognition. Certainly, there are medical errors.  Ignoring evidence suggesting one course of action in order to follow another without solid reasons, not adequately monitoring effects of a procedure or medication, performing a procedure or using a medication without having proper training, failing to clearly communicate with another professional, team, or facility involved in the patient’s care would all constitute medical errors in my opinion. The study needs to be replicated with a clearer definition of medical error.  As physicians, even with reservations about the article, we can’t ignore the fact that there are more medical errors than there should be.

The field of medicine is not as certain and exact as most people think. There often isn’t one way to do things.  Decision-making in medicine combines what is known based on basic science research with the physician’s assessment of what is best for the patient taking into account many factors particular to that patient. That is where the art of medicine comes in.  Maybe in another 50 years when we practice medicine like Bones did in Star Trek, all medical decision-making will be based on pure science with little input from the physician.  We will simply do what the computer tells us to do.  I’m not looking forward to that day. But until then, we must accept some degree of risk, some degree of uncertainty when it comes to medical decision-making.

 

 

Mindfulness Based Stress Reduction: Keeping the Brain in Shape

Mindfulness Based Stress Reduction at Work.

Mindfulness Based Stress Reduction at Work.

Mindfulness is one of those terms that seems self explanatory, but it really isn’t. We all have minds, so aren’t we all mindful?  Probably not.  The concept of mindfulness is just entering the portal of mainstream medicine. For many years, mindfulness meditation (also known as Mindfulness Based Stress Reduction, MBSR) was thought of as something akin to yoga, practiced mainly by “health nuts” who had the time to sit for hours in a trance, and mainly appealing to people who were interested in Eastern religions. It seemed “experience distant” to most people, meaning that it was interesting but not really relevant to their lives.

First of all, let’s define mindfulness. Jon Kabat-Zinn, who is credited with bringing mindfulness meditation into mainstream medicine, says that mindfulness is the awareness that arises through paying attention on purpose in the present moment nonjudgmentally.  Many people think that mindfulness meditation is about clearing the mind, having a blank mind. That is not the case.   Mindfulness Based Stress Reduction usually begins by sitting quietly and focusing on the breathing. As thoughts begin to intrude, and they will, they aren’t pushed away.  Attention is gently brought back to the present by focusing on breathing.  This back and forth between mind wandering and bringing back attention to the present occurs over and over again for most people, especially when beginning MBSR. The key is that thoughts and/or bodily sensations are not judged as good or bad; they are simply observed.  For example, while engaged in MBSR, you might experience some discomfort, maybe some back pain or a sensation of hunger. You experience that sensation, but you don’t try to resist it. You don’t try to judge it as good or bad. You might be curious about it. You simply experience it. You try to develop the ability to observe your sensations objectively. Most people focus on their breathing during the meditation, but some find it easier to listen to a sound in the back ground or some quiet music.  I will discuss more about the actual practice of mindfulness in the next blog.

What is the purpose of this exercise anyway?   There are actually two components to bodily sensations and emotions.  One component is the actual physical sensation or the emotion, while the other component is our judgment of it, how we perceive it. Do we perceive it as bad, good, pleasurable, noxious?  How we perceive it is really what determines how we respond.  Pain is deemed to be bad because we judge it to be. Kabat-Zinn would say that learning to stand back and observe emotions and sensations more objectively makes them more tolerable.  We have a tendency, understandably, to fight what we see as negative emotions. This simply activates the sympathetic nervous system which increases blood pressure, heart rate, tenses muscles, etc. That is our fight/flight response. But though adaptive in some situations, constantly being in fight/flight mode takes its toll on the body.

Kabat-Zinn and MBSR advocates are not suggesting that we need to learn to like pain or anxiety. But practicing MBSR can keep us from being so overwhelmed by intense sensations or emotions. It’s an acceptance of our present state without letting ourselves go down the slippery slope of negativisms such as “this will ruin my day,” or “I’ll never be free of this pain.”  We are so accustomed to thinking through our day as we drive to work and imagining worst case scenarios.  The concept of simply focusing attention on the present is rather foreign to most of us. How much of the present do we miss by constantly focusing on the past or future?

So far, recent articles have shown that mindfulness training can reduce stress during a period of high workload on military helicopters (Meland et. al. in the International Journal of Aviation Psychology, Oct. 2015), decrease fatigue, anxiety and mood symptoms in breast cancer survivors (Carlson et. al in Psychooncology, May 2016), and decrease pain intensity, pain catastrophizing, interference of pain in daily life and depression in cancer patients (Poulin et. al., Supportive Care of Cancer, May 2016).  There seems to be evidence that MBSR can help patients with addiction by modulating responses to environmental cues that instigate craving.  There is even evidence that MBSR can slow progression of Alzheimer’s Disease (Quintana-Hernandez et. al. Journal of Alzheimer’s Disease, 2015) and improve some problems with memory loss.  It seems to exercise the brain and keep it free of unnecessary debris.

In my next blog, I’ll explain more about the mechanics of Mindfulness Based Stress Reduction, including some tips on getting started.  I’ve included a YouTube video that explains more about mindfulness based stress reduction.    There are numerous YouTube videos on this topic including several by Jon Kabat-Zinn himself.

MENTAL HEALTH AWARENESS MONTH 2016

 

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May is Mental Health Awareness Month.   I’ve written articles for this month before, usually with statistics about the frequency of mental illness, the stigma surrounding mental illness that prevents people from getting treatment, or perhaps about the difficulty that people with mental illness have getting access to good, affordable treatment.  All of those things are important, but they are just facts, opinions. They don’t put a face on the illness. What is it really like to live with severe depression or bipolar disorder. What is it like to live with a family member who is mentally ill?

Now you have an opportunity to find out.  Mental Health America has set up an area for people living with mental illness to post their experiences. Feel free to post your own experience. Go to www.mentalhealthamerica.net/feelslike.

Sometimes we forget that an adult’s mental illness can affect children as well. For example, children growing up with depressed parents have a significantly  increased chance of developing depression themselves. This is due to both biological and environmental influences. Parents who are depressed usually have a hard time really being emotionally present.   Children, as we all know, tend to feel that whatever happens is their fault.  They have fewer positive interactions with parents which can lead to a more negative view of the world. Their self esteem may be lower, and they may not develop the same resilience in the face of adversity that other children have.

I’ve worked with several patients who had parents who were severely mentally ill. Some had parents who were psychotic (probably schizophrenic), severely bipolar, or so depressed that they required institutionalization.  You would think that growing up with mental illness would lead them to seek out mental health treatment, but I don’t find that to be true. Sometimes they have negative perceptions, accurate or not, of mental health treatment based on what they’ve seen with their parent.  I find that they question their own “normality.” They continuously wonder if they are “OK” or if they might really be ill like their parent.

If you are living with mental illness or know someone who is, be aware of the effects on other family members. Your treatment benefits them in the long run. Even if they don’t need treatment themselves, they need a lot of support.   They need contact with other families, they need positive experiences outside the family, at school or in extracurricular activities.   We may not be able to control our genetic makeup, but we can influence the environment that our children experience, and that improves the environment that their children experience. It definitely has a long-term pay off.

Don’t forget to check out www.mentalhealthamerica.net/feelslike.

Love and Addiction

The short answer is – the same way you love everyone else. Love is not always a two-way street.  Have you ever loved someone who desperately needed your love but seemed to reject it? People with addiction are not easy to love because they do unlovable things.    Most of us have struggled with this in one way or another. It’s almost impossible to go through life without experiencing the effects of someone’s addiction.  There are non-substance addictions such as internet, gambling, shopping, even perhaps cell phone.  Some of these addictions may seem more innocuous, less disruptive than, say, heroin addiction. But they are still addictions.

Though I do believe that there is a strong biological component to addiction,  and it resembles other medical illnesses in many ways,  people with addictive disorders have problematic behaviors that affect other people. They steal, they lie, they end up in jail sometimes, they get sick, they become homeless, they need money, they lose jobs. Families and friends have to deal with that. Diabetics may not follow their diet or they may play passive-aggressive games with their medication, but they usually don’t steal money or end up homeless.

I find that people with addiction who grew up in a household surrounded by addiction have a double whammy. They have the genetic predisposition, but they also missed the benefit of good role-modelling.  Good parenting (though no parents are ever perfect) is essential for the development of things like empathy, ability to delay gratification, frustration tolerance, etc.  So when these people stop using drugs, they still don’t function that well because they missed some important developmental tasks.  They need a lot of therapy and support to maintain sobriety.

So what are friends and family to do when they have a child, spouse, friend who is actively using and seems to be skyrocketing downward?  The pat answer has always been “don’t enable them.” But what does that really mean? Assuming that you’ve tried to get them in treatment and they’ve refused, what next?

Refusing to enable someone has usually meant letting them hit rock bottom. It means never giving them money, which they will surely use for drugs rather than food, never allowing them to stay with you as long as they are using, perhaps completely stopping communication with them.  The theory is that this may push them to get treatment. Sometimes it does, sometimes it doesn’t. Sometimes they die.

I wonder how I would handle it if my child suffered from a drug addiction.  Could I really cut them off totally? I’m not sure that I could.   You can always hope that your loved one finally agrees to treatment, but I’m not convinced that totally cutting them off is any guarantee.  However, I realize that sometimes families may need to do this to maintain their own sanity.

How can you provide some basic support for the addicted person, yet not enable their drug addiction? I don’t have easy answers to that.  I have worked with some families who provide food (not money for food) and a place to live – that’s it. No money and no transportation except to doctor’s appointments.   Sometimes they’ve come to that compromise after trying harsher approaches such as kicking the person out.  However, if the addicted person is violent or negatively affecting other people in the family, particularly younger children, then they really can’t be in the home.

Al-Anon is a good resource for families of people with addiction.  It is helpful to talk with other families who are going through the same thing.   Families dealing with addiction often tend to isolate. Don’t do it. It isn’t helpful in the long run.

People with addiction are masters at making their families and friends feel guilty for not helping them – in the way they want help.  Sometimes you have to love someone from afar.  You remind them that you believe that a better life is possible, that you are willing to help them, that you love them. You offer what you think they need, not what they think they need. If they don’t accept it, that is their choice.  It may be a choice fueled by their addiction, but in our society today it is still their choice.