yeah. Blame docs for street drug overdoses

I am sick and tired of being told that if we docs had given our patients non narcotics for pain, there would not be an opioid epidemic.

a picture is worth a thousand words:''

the push to relieve pain, even if it mean using narcotics, started in 2000.

Some of those drugs resulted in addiction, but more were used, sometimes in high doses, and allowed people to live pain free.

A lot of the "natural and semi synthetic opioids", i.e. codiene, morphine, etc, are pain killers. Some were of course stolen or diverted/sold and caused overdoses by those not prescribed the medicine. Others caused overdoses to commit suicide, or because the person was mixing drugs or decided to take an extra dose either to relieve pain or (alas too common) to get high..., or (in the elderly) became weak or confused and the drug slowed their respiration enough to cause death. (i.e. accidental overdose).

But the real increase is in heroin or Fentanyl, both drugs bought and sold on the street.

notice the spike since 2010?

That isn't docs: that was street drugs. The drug dealers knew Marijuana was being legalized, so were switching their product. And since they already catered to folks who like to get high, guess what happened?

every thing costs more. duh

Scidaily reports why health care costs have gone up:

the major drivers of high healthcare costs in the U.S. appear to be higher prices for nearly everything -- from physician and hospital services to diagnostic tests to pharmaceuticals -- and administrative complexity.

administrative complexity, as in paper work.

and higher cost for drugs and equipment.

But commonly held beliefs for these differences appear at odds with the evidence, the study found. Key findings included:

Belief: The U.S. uses more healthcare services than peer countries, thus leading to higher costs. Evidence: The U.S. has lower rates of physician visits and days spent in the hospital than other nations.

Belief: The U.S. has too many specialists and not enough primary care physicians. Evidence: The primary care versus specialist mix in the U.S. is roughly the same as that of the average of other countries.

Belief: The U.S. provides too much inpatient hospital care. Evidence: Only 19% of total healthcare spending in the U.S. is spent on inpatient services -- among the lowest proportion of similar countries.

Belief: The U.S. spends too little on social services and this may contribute to higher healthcare costs among certain populations. Evidence: The U.S. does spend a bit less on social services than other countries but is not an outlier.

Belief: The quality of healthcare is much lower in the U.S. than in other countries. Evidence: Overall, quality of care in the U.S. isn't markedly different from that of other countries, and in fact excels in many areas. For example, the U.S. appears to have the best outcomes for those who have heart attacks or strokes, but is below average for avoidable hospitalizations for patients with diabetes and asthma.

so what costs so much?

Administrative costs of care -- activities related to planning, regulating, and managing health systems and services -- accounted for 8% of total healthcare costs, compared with a range of 1%-3% for other countries. 

Per capita spending for pharmaceuticals was $1,443 in the U.S., compared with a range of $466 to $939 in other nations. For several commonly used brand-name pharmaceuticals, the U.S. had substantially higher prices than other countries, often double the next highest price. 

The average salary for a general practice physician in the U.S. was $218,173, while in other countries the salary range was $86,607-$154,126.

Stephen Hawkings: showing disability doesn't mean inability

BBC notes the Hawkings helped public see disability differently.

Prof Hawking's only advice on disability was to focus on what could be achieved.
"My advice to other disabled people would be, concentrate on things your disability doesn't prevent you doing well, and don't regret the things it interferes with. Don't be disabled in spirit, as well as physically," he said in an interview with the New York Times.

Perfumes, bah humbug

I sneeze when exposed to pollen, perfume, or some cats,and during allergy season, my chronic nasal stuffiness morphs into asthma. Often it is a combination: during hayfever season, things I could normally tolerate cause problems.

I found cortisone based nasal spray worked fine, and during allergy season, a cortisone lung inhaler as prevention.

An alternative (which I use here in the Philippines) is anti histamines, but they make me sleepy, so I keep the dose to a minimum, mainly at night, and run my airconditioner for sleeping: even when it is cool, I use the air con fan and a hepa filter in the aircon. 

and I develop nervousness and dermatographia when I eat too much at salad bars, foods with nitrates, bagoong, or eat too many big macs. So I avoid such things, which is easy here in the Philippines.

But at women's conferences, they make a big deal of this: no perfumes especially. Well, since perfumes were first made to cover up body odor, or to attract men, I can't figure out why women would overdo perfumes at feminist converences anyway.

Well, this Science daily article claims:

One in four Americans suffer when exposed to common chemicals...University of Melbourne research reveals that one in four Americans report chemical sensitivity, with nearly half this group medically diagnosed with Multiple Chemical Sensitivities (MCS), suffering health problems from exposure to common chemical products and pollutants such as insect spray, paint, cleaning supplies, fragrances and petrochemical fumes.

well, this found all the "green" enemies of course, leaving out the "organic" stuff like bagoong and pollen.

But you know, most of us never went to a doc to get diagnosed for such things, and I had less than a half dozen patients with "multiple chemical sensitivities" as a diagnosis (and most of them were neurotic women).

The study also found that 71 per cent of people with MCS are asthmatic, and 86.2 per cent with MCS report health problems from fragranced consumer products, such as air fresheners, scented laundry products, cleaning supplies, fragranced candles, perfume and personal care products. In addition, an estimated 22 million Americans with MCS have lost work days or a job in the past year due to illness from exposure to fragranced consumer products in the workplace.

again, asthma? Really? or is this from pollen, cigarette smoke, etc.

so 22 million Americans lot days from work because of perfume?

really?

Sheesh. just take a Clariten and work on, ladies.

and I say "ladies" because I suspect they are neurotic ladies.

Every couple of years, there is a new fad explaining why they are neurotic and you get studies like this.

and I have all of these problems: Neurosis, allergies, sensitive to "chemicals" (e.g. sneeze with perfume), hypoglycemia (and have the GTT to prove it).

Like my aches and pains from arthritis, you cope.

But why do I think this is a study to prove the evils of modern chemicals? In this case, perfume:

To reduce health risks and costs, Professor Steinemann recommends choosing products without any fragrance, and implementing fragrance-free policies in workplaces, health care facilities, schools and other indoor environments.

I should note that in Idaho, where dry skin was a problem, I did have a lot of people who itched from perfumed soap and/or fabric softener in their clothing. But again, I didn't see this as much in areas where the humidity was higher.

so why does the article annoy me? Because it "medicalizes" ordinary aches and pains.

We went into medicine to treat the sick, not to treat ordinary aches and pains and minor stuff that most people in the past managed to live with, without making a "federal case over it", as the saying goes.

But then, the expresssion "don't make a federal case about it" no longer applies given the huge expansion of federal law to punish trivia.

It's the placenta stupid

many many years ago, when a lot of us GP's got out of Obstetrics because of the sudden huge increase in our malpractice insurance due to lawsuits over brain damaged babies, we were told that we should have all placentas examined for inflammatory and other changes, to prove the brain damage occured before birth (i.e. toxins, viruses, etc).

Science Daily reports on one prenatal cause that has been dicovered that are causes of dead babies or late miscarriages.

The role of the placenta in fetal development is being seriously under-appreciated according to scientists. A team studied 103 mutations linked to prenatal death in mice and showed that almost 70 percent affect the placenta. The team also found that some placenta defects could be directly linked to the cause of death. As such, a significant number of prenatal deaths may be due to the placenta, not just the embryo.

transgender problems

VirtueOnLine has a summary of various of longitudinal studies of transgender people.

In her sworn declaration to the federal court, Adkins called the standard account of sex--an organism's sexual organization--"an extremely outdated view of biological sex."

Dr. Lawrence Mayer responded in his rebuttal declaration: "This statement is stunning. I have searched dozens of references in biology, medicine and genetics--even Wiki!--and can find no alternative scientific definition. In fact, the only references to a more fluid definition of biological sex are in the social policy literature."

Just so. Mayer is a scholar in residence in the Department of Psychiatry at the Johns Hopkins University School of Medicine and a professor of statistics and biostatistics at Arizona State University. Modern science shows that our sexual organization begins with our DNA and development in the womb, and that sex differences manifest themselves in many bodily systems and organs, all the way down to the molecular level.

In other words, our physical organization for one of two functions in reproduction shapes us organically, from the beginning of life, at every level of our being. Cosmetic surgery and cross-sex hormones can't change us into the opposite sex. They can affect appearances. They can stunt or damage some outward expressions of our reproductive organization. But they can't transform it. They can't turn us from one sex into the other. "Scientifically speaking, transgender men are not biological men and transgender women are not biological women. The claims to the contrary are not supported by a scintilla of scientific evidence," explains Mayer.

as one writer quipped: They don't want to be women: They want to be teenaged prom queens.

Various studies show most men continue to be promiscuous as men.
Some are gay, of course, and there is a lot of confusion between transgender and cross dressing queens.

Women, however, are also complicated: Often they are lesbians or others who just want to have the freedom of a male role model.

the local transvestites and gays are part of society here in the Philippines, no big deal. Family ties are more important to acceptance than morality or a political agenda.


but the problem with the "gender" and "transgender" arguments that I have read it that they are not about people with gender identification disorders, but actually about an agenda that wants men and women to be interchangable, marriage to be anything they want it to be, and with a hatred of normal sexuality.

In other words, the radicals have taken over, with a broad gender agenda.

One suspects the ordinary folks who just want to be accepted for who they are are the real victims and be blamed for the radicals who insult and even persecute those who are old fashioned enough to say "but it moves he has a Y chromosome"

pushing non narcotics with fake news

when I was in medical school, we learned that the only pain killer that worked better statistically than various pain killers was morphine. The reason? There is a large placebo effect.

So the placebo effect screws up the data.

I remember an anecdote about a doctor who gave out "green pills": ordinary sugar pills, with a long lecture. Or docs who would give prescriptions of them, to increase the placebo effect. And of course, expensive pills work better than cheap ones.

the whole point is that NSAIDs and tylenol are often cheap and over the counter: make them expensive and they will work better because of the placebo effect.

Similarly, I once heard a lecture by a nephrologist about the problems of NSAIDS in causing kidney disease/failure. But after the lecture, he was asked what he took, and he admitted that he took NSAIDS because the pain relief from Tylenol was lousy.

In my own life, I prefer NSAIDS: even after surgery, I found better pain relief from this than the pecocet that I was prescribed, but you know, in the post op period, the problem was they were giving me two percocet every six hours, meaning I slept for three hours, was good for one, and hurt for two hours. So I took the pills and hid one and gave myself the medicine as needed, not as prescribed.

This is also why long acting medicines (MSContin, Fentanyl patches) work so well: They relieve pain without sedation, without the swing from high to low.



So now the NYTimes is insisting tylenol works as well as narcotics for osteoarthritis pain.

“Should we use opioids if nonopioids don’t work?” asked the lead author, Dr. Erin E. Krebs of the Minneapolis Veterans Affairs Health Care System. She answered her own question: “No. We tried four different nonopioids — don’t give up on them too soon — and we should also be using exercise and rehab for most osteoarthritic pain.”

the study was in the VA system. So not a broad population group.

and remember: Most people just buy over the counter medicine in the first place for this type of pain, so those needing pain pills come for one of three reasons:

one: They hurt despite over the counter medicine. (the reason assumed in the study). Of course, being motivated to be in a study makes the pills magic, and maybe you will take the pills correctly for pain relief, (you have to take pills on schedule so severe pain never develops: Wait until you can't stand the pain and it takes a much higher dose. using over the counter medicine is taken as needed, rarely according to schedule)...so some will get better pain relief for this reason.

two: They are druggies (how many of the drop outs are these).

Three: The pills are free and they think they are getting magic pills that work because they are in a clinical study. In other words, a better placebo effect.

25 people out of the 240 who finished the study means that ten percent dropped out.

long discussion of the problem of drop outs in clinical studies.


Did they drop out because they hurt?

And how many self medicated with alcohol or borrowing a pain pill.

the P pare not that good either.

In other words, for chronic arthritis, of course you use NSAIDs when possible or tylenol. But how many couldn't sleep at night? (I often gave my patients just a few percocet for night pain).

and how many developed bleeding ulcers or renal problems from the non opioids?

update:

The Power of Nothing: a 2011 article from the New Yorker.