The Narcotic Epidemic

The country is in an epidemic of narcotic abuse. Aside from heroin, the prescription drugs, such as OxyContin, have become more and more abused.

I am told that a 90 pill prescription here in Las Vegas costs about $200, but can sell on the street for almost $3,000.

In November 2014 I had a bicycle accident and needed quite a few stitches. As I was leaving the ER I was handed a prescription for 90 OxyContin pills. Not only did I refuse the prescription, but I never needed even one pain pill.

So what is going on. Once again I point the finger directly at the pharmaceutical companies. Here we have a potent and very addictive drug whose use should be extremely restricted to the most severe pain (for my injury perhaps a mild codeine would have been the maximum). But that doesn't make much money.

Below is an expose about what really happened when Abbott marketed the drug so that sales went from 49 million to 1.6 billion in 6 years. Unfortunately most doctors are susceptible to sdvertising - that's another problem!

Marketing of Narcotics

Pregnancy Deaths and Abortion in the New Reality

Because of pregnancy, younger women have some unique health issues and costs that do not affect men. Especially the men who seem intent on creating laws that discriminate against them.

As one of the few civilized countries without universal health care, even with the success of the Affordable Care Act, there are many women who cannot afford prenatal care.

In a recent study (MacDorman MF et al., Obstet Gynecol 2016 Sep 128:447) the authors note that maternal death rates (from complications of delivery) in the US are much higher than in other countries. They stated "these data are “an international embarrassment” as they represent the first estimate of maternal mortality in the U.S. since 2007. Chronic underfunding of the public health infrastructure, including vital statistics systems, not only results in poor health outcomes but contributes to lack of understanding of important trends. Globally, the U.S. is among 15% of countries with worsening maternal mortality since 2000."

California (of course) has developed specific interventions to reduce maternal mortality, and death rates have dropped by 25% since 2003. On the other hand, maternal mortality in Texas has doubled since 2010. Whether the sudden increase in maternal mortality in Texas was caused by the closing of Planned Parenthood clinics is unclear, although the events seem temporally related.

When will the politicians understand this? Not soon I think since their children and families get the best care through the excellent (and free) congressional health care policies.

In another study, researchers looked at some of the newer abortion regulations that have begun to try and restrict medical terminations. There is an FDA approved combination of drugs that can induce early pregnancy termination. The combination was originally approved with a specific dose that did not work well and recently the FDA changed its recommendations.

In what seemed to be an attempt to prevent the use of these drugs, the Ohio legislature (you remember John Kasich, our "favorite" republican?) and several other states enacted laws requiring adherence to the original FDA-approved regimen for abortion with these drugs (mifepristone and misoprostol). This is somewhat unprecedented as physicians are almost never mandated by law as to how they use drugs.

So what happened? Compared with women who had abortions prior to the law, those who did so after the law were more likely to require additional interventions (4.9% vs. 14.3%) and additional visits (4.2% vs. 6.8%), report adverse events (8.4% vs. 15.6%), and pay more (16% increase in charges). The proportion of abortions that were medication abortions fell from 22% to 5%. We must also remember that abortion (one of the safest clinical procedures performed in the U.S.) presents less risk to a woman's health than carrying a pregnancy to term. Upadhyay UD et al., PLoS Med 2016 Aug 30; 13:e1002110

In the few countries where abortion is still illegal, the rates of abortion are the same as in legal countries; just the complications and death rates much higher. Whatever your personal feelings are, I cannot condone anyone who feels it is better for a woman to die or have serious complications if she makes that choice. And it should be her choice, not some old man in government.

Exercise and Staying healthy

Exercise is promoted as a way to stay healthy. It makes sense, but is there any real proof?

To evaluate this, researchers analysed the risks of 5 diseases comparing those who exercised more.

As expected (thankfully for those of us who love exercise) they found that more exercise as even better:

High activity was associated with the following relative risk reductions:

• Diabetes: 28% lower risk

• Stroke: 26%

• Heart disease: 25%

• Colon cancer: 21%

• Breast cancer: 14%

Most benefits appeared to occur at 3000–4000 MET minutes per week; gains beyond that level of activity were minimal. (To achieve 3000 MET minutes/week, a person could climb stairs for 10 minutes, vacuum for 15, garden for 20, run for 20, and walk or bicycle for 25 minutes every day.) This is above the current recommendations.

I'm off to cycle - see you later!

Vitamins and Supplements - More may be worse!

Supplement companies are quick to advertise their unsubstantiated claims for success. Indeed, a small study that has marginal impact can lead to an explosion of vitamin recommendations (it was found that turmeric supplement in 13 mice resulted in a small improvement in their ability to run a maze; this article was quoted in many turmeric supplements as medical proof that it prevents Alzheimer's!!).

Now some reports have surfaced that certain vitamins can be harmful when used in excess; and excess can mean amounts just above therapeutic recommendations!

Could High Maternal Folate and B12 Levels Be Linked to Autism?

Although previous studies have found that adequate folic acid supplementation is associated with reduced autism risk, in this report researchers looked at the mothers' serum folate and B12 levels within 1–3 days of giving birth. Women with very high folate levels (above 59 nmol/L) had roughly twice the risk for having a child who developed autism, relative to women with lower levels. In addition, high B12 levels (above 600 pmol/L) were associated with three times the risk for autism — and if both levels were high, the child had 17 times the risk. So more may not be better!

http://www.eurekalert.org/pub_releases/2016-05/jhub-tmf050916.php

Calcium Supplements Linked to Dementia Risk

In a study released recently (Neurology 10.1212), using Swedish registries, researchers followed 700 women aged 70 to 92 without dementia at baseline. Roughly 14% were using calcium supplements at baseline, and about half were still doing so at follow-up 5 years later.

Some 59 women developed dementia during the study. Calcium use at baseline was associated with increased risk for dementia -- but only among women with a history of stroke or evidence of arteriosclerosis. This is definitely NOT a cause and effect, but suggests that calcium supplementation should only be used if there is a real indication and proof that it helps. Currently we do not even know that it prevents or helps with osteoporosis! Guidelines suggest no more than 500 mg per day.

Why are we paying so much for drugs?

Drug companies develop many life altering drugs that are desperately needed. However, they have managed to maintain profit margins of about 20% and up to 42%, substantially higher than other corporations of their size.

They do this through pricing and marketing. As a physician it makes me ashamed to note that most doctors succumb to these techniques to prescribe drugs where there are equivalent generics at far lower cost. And they also write for medication with little or no proven effect!

For example, in 2013, trials with two new (and very expensive) diabetes drugs, saxagliptin (Onglyza) and alogliptin (Nesina) — found no effect on preventing heart attacks and strokes even though they did lower the sugar a small amount. And we are not treating diabetes just to lower the sugars; we really want to prevent the complications; which these drugs apparently do not. Sanjay Kaul, a frequent FDA adviser, pointed out "So, we have a drug that yields modest glycemic efficacy [lowering sugar], is neutral with respect to cardiometabolic factors (lipids, weight, blood pressure), does not kill you or land you in a hospital, and yet is a blockbuster drug nearly five times over! What is the big news here? That it does not kill you or land you in a hospital? Or that it is a blockbuster drug nearly five times over without evidence of microvascular or macrovascular outcome benefit? Miracle of medicine or miracle of marketing?"

In a recent article in JAMA, it was found that substituting equally effective generic drugs could save $70 billion dollars from 2010-2012. Researchers interviewed 100,000 U.S. people about their prescription drug use. Over 3 years, an estimated $760 billion was spent on prescription drugs. Excess expenditure because a brand-name drug was used instead of a generic within the same class accounted for roughly 10% of total prescribed medication expenditure. One of the worst culprits was cholesterol drugs. In my practice I spend many visits changing patients from overpriced brand drugs (about $150-$200 a month) - usually prescribed by cardiologists - to generics (about $5 per month) that are equally effective.

It seems that physicians will never learn and we need to allow insurance companies and the government to negotiate with Big Pharma!

Advances in Medicine - Almost Magical

Medical science has been advancing by leaps and bounds, and here I describe some of the almost magical breakthroughs that will soon (hopefully) become available:

NanoParticle Vaccines

The recent outbreaks of Ebola and Zika virus has reminded us how difficult it is to treat and prevent viral illnesses. The most effective way we have is a vaccine, but these can take 6 months or more to develop.

A team at the Massachusetts Institute of Technology and Harvard created nanoparticles that contained a “payload” of RNA that coded for particular non-toxic viral proteins. Once inside the body, this RNA replicon can keep churning out that protein and lead to an anti-body response. Injecting mice with single doses of vaccines for influenza, and Ebolavirus provided long term protection to mice against lethal doses of each of those microbes, without adverse effects.

This would truly be an amazing advance!

Chahal JS et al., Proc Natl Acad Sci U S A 2016 Jul 19; 113:E4133

A Cure For Diabetes in a Single Treatment

The brain controls our appetites, and may have a weight thermostat setting that makes it difficult for us to keep the pounds off. A team of researchers injected a growth factor molecule into the brain of mice who had been bred to have obesity and type 2 diabetes. They expected a transient drop in sugar, but within one week, and before any significant weight loss, the mice were cured of their diabetes. They also continued to lose weight to a normal level and maintain a normal sugar level for 5 months!- this after one treatment!

The treatment also worked in 2 other animal models, and is effective if the molecule is inhaled rather than injected into the brain! Is this result too good to be true? Stay tuned.

Scarlett JM et al., Nat Med 2016 Jul 22:800

NanoParticles to Prevent Obesity

In humans, the much more prevalent white fat cells store fat, but brown fat cells burn fat. There are several molecules that can convert white fat into brown fat, but the restricting factor is how to get these molecules to their target.

Now, a team created nanoparticles with two properties: (1) they contained these molecules; (2) they adhered selectively to blood vessels of white fat. In obese mice, these nanoparticles homed to white fat, transformed white fat into brown fat, inhibited weight gain, and improved blood levels of cholesterol, triglycerides, and insulin.

Xue Y et al., Proc Natl Acad Sci U S A 2016 May 17; 113:5552

Trends in Obesity and the Worst Restaurants

Medical science has been struggling with the causes and ways to prevent obesity, which is one of the worst health issues in this country.

First, we need to once again address our diet! The Center for Science in the Public Interest has called out nine unhealthy dishes at restaurant chains in its annual Xtreme Eating Awards.

https://cspinet.org/news/dave-busters-uno-among-2016-xtreme-eating-award-recipients-20160801

One of this year's nine winners is the Whole Hog Burger at Uno Pizzeria & Grill, which has five types of meat and four types of cheese. It packs more calories than an adult needs in a day, along with six days' worth of sodium. This does not help!

In Golden NH et al., Pediatrics 2016 Aug 22, the researchers summarized some knowledge about obesity in children:

The following behaviors are associated with obesity and eating disorders in adolescents:

• Dieting: associated with a 2.0-fold increased risk for becoming overweight and a 1.5-fold increased risk for binge eating.

• Family meals: improve the quality of dietary intake and provide opportunities for modeling healthy food choices.

• Weight talk: comments made by parentsabout their own weight or to encourage their child's weight loss may be perceived as hurtful, even when well-intended.

• Teasing about weight by a family member.

To help prevent obesity and eating disorders, the report recommends pediatricians do the following:

• Discourage dieting, skipping meals, and diet pills; focus on healthy eating and physical activity rather than on weight.

• Promote a positive body image.

• Suggest more-frequent family meals.

• Encourage families to talk about healthy eating rather than weight.

• Ask overweight and obese adolescents if they are being mistreated or bullied; address issues with patient and family.

• Monitor weight loss in adolescents who should lose weight.

In addition, Trajkovski M and Wollheim CB., reporting in Nature 2016 Jun 9; 534:185, have found the the bacteria growing in the intestine of fat people is different than others, and suggest that this may be related to their diet, the antibiotics they took as children, and, specifically, certain proteins produced by these abnormal bacteria.

In another study, evaluating participants of the show "The Biggest Loser", (Obesity (Silver Spring) 2016 May 2), researchers found that there was an unusual adaption that led to regaining the weight easily. In the past, evolution selected for a trait that helped protect our hungry ancestors: In the face of substantial weight loss, our resting metabolic rate falls. We burn fewer calories, thereby discouraging further weight loss.

However, in fat people, their metabolic rate did not increase when they ate more calories, resulting in rapid weight gain. This may be a genetic adaption that can only be overcome by consistent exercise

Drug Price Rip Offs - Greedy Companies to Blame

Most of you have heard about the huge increase in the price of EpiPen (in the USA only). The company gives vague excuses.

An analysis in the Journal of the American Medical Association, JAMA. 2016;316(8):858-871, has revealed it is only a result of the greed of the pharmaceutical companies.

The researchers found little or no correlation between the cost of the development of a drug (pharma's favorite excuse) and its price in the United States. This country is proud(?) to have the highest price for pharmaceuticals in the world.

They assign blame to two major factors: protection from competition by manufacturers of generic versions and prohibitions against negotiating lower prices (as insisted upon by our heavily lobbied congress and senate). Also at fault are government-granted monopoly rights for new drugs and legal (and chemical) maneuverings to extend those monopolies.

The companies are found to charge whatever the market can bear.

You can also review the epipen controversy in the New York Times.

well.blogs.nytimes.com/2016/08/22/epipen-price-rise-sparks-concern-for-allergy-sufferers/

Diet Health Fats and Supplements

There are endless articles on weight loss and the effects of food on our health; from the Mediterranean diet to metabolic supplements. I highlight a few recent research findings:

Calorie Restriction in Normal Weight Adults - Improved Sex, Mood and Sleep

In a study over two years, by restricting calories by 25% adults had an average 16 pound weight loss (about 10% of original weight) , but reported significant improvements in mood, quality of life, sleep and sex.

JAMA Intern Med 2016 May 2

Some Fats are Good for You

In another study of over 32,000 participants over 32 years, researchers found that a diet higher in polyunsaturated fats actually had lower mortality by up to 20%. For specific dietary fats, total mortality was 19% lower among those with the highest intake of polyunsaturated fatty acids and 11% lower among those with the highest intake of monounsaturated fatty acids; in contrast, risk for premature death was 8% higher and 13% higher among those with higher intakes of saturated fats and trans fats, respectively. The benefit of high polyunsaturated fat was attributable mostly to linoleic acid intake. This was not only related to heart disease but death by any cause. The most important thing to remember is to stay away from saturated and trans fats. Check the AHA for information.

JAMA Intern Med 2016 Jul 5

AHA Guidelines

Brain versus Brawn

The stereotype of the dumb muscle man may actually have some basis in fact! Many, if not all body builders, use anabolic steroids to increase muscle mass. So do many elite athletes (like Lance Armstrong the cyclist). In a recent study, it was found that users had significantly decreased brain volumes which continued as long as they used the drugs. This also probably increased their risk for early Alzheimers.

Biol Psychiatry 2016 Jun 30

Pesticides, ALS, Cell Phone Radiation, Brain Tumors and Smoking when Pregnant

We are becoming exposed to so many things in our environment it is a wonder we remain healthy. I often imaging all those radio waves, TV waves, cell phone signals, etc that bombard us and have only been around less than 100 years!

As we examine disease trends more closely we begin to discover the potential toxic effects of our new environment.

However, most of these associations have only a very small effect; you need not panic based on this!

In one study researchers found there was a 5 time increased risk of ALS (Lou Gehrig's Disease) after exposure to certain pesticides and toxins - Blood tests suggested significantly increased ALS risk for the following pollutants: pentachlorobenzene, cis-chlordane, polychlorinated biphenyl (PCB) 175, PCB 202, and polybrominated diphenyl ether (PBDE) 47. Surprisingly lead exposure seemed to have a protective effect!

JAMA Neurol. 2016;73(7):803-811

In a second study of rats, researchers exposed them to cell phone radiation for two years, and found a slightly higher rate of a kind of brain tumor and heart cancer. But this was only in male rats, not females. Because of this odd occurrence it is unknown whether this will even apply to humans. So keep your male rats off the phone for now.

New York Times Article

Finally, we all know that smoking during pregnancy (still 10% of women do!) can result in retarded fetal growth. Using mice as a model, however, researchers found permanent behavioral changes even if the mice were no longer exposed after birth. This included fear responses and learning behavior. Not a great idea.

Nat Neurosci 2016 Jul 19:863

So stick to organics, stay away from plastics, avoid too much radiation from phones and other devices and don't smoke. And don't forget to exercise!

http://www.nytimes.com/2016/05/28/health/cancer-study-radiation-cellphones.html?_r=1

Skin Cancer, Car Windows and Nicotinamide

The risks of skin cancer are enhanced by exposure to UVA sunlight. Anyone who spends time in a tanning booth need not read on; as they already are at very high risk.

But I always thought that glass windows would prevent dangerous sun exposure. In actual fact, a significant amount of UVA light can penetrate most glass. In a recent study, researchers looked at UVA light penetrating the driver's side windows and windshields in 29 automobiles made from 1990–2014. On average, front windshields blocked 96% of UVA light, while side windows blocked 71%. Although windshields were fairly consistent in their protection, side window protection ranged from 55% in some 2013 BMW models to 96% in a 2011 Lexus. Tinting had no effect.

Front windows are shatterproof and have two layers of UV protective plastic.

So you may need to protect yourself if you spend a lot of time behind a sunny window!

jamaophthalmol.2016.1139

In a second, interesting study done in Australia, researchers found that Nicotinamide or Vitamin B3 could prevent about 1/3 of skin cancers (not melanoma unfortunately). These skin cancers, which occur as we age are exceedingly common; and if you have a strong familial tendency this could be a consideration.