A Study From PNAS
Jun12

A Study From PNAS

I just read a piece in Quartz, an international online news reporting service. The article is entitled “A new study of 250 million patients shows medicine is still full of guesswork” and reports on a study published in Proceedings of the National Academy of Sciences. The study makes some assumptions they don’t tell us about. What the study does is aggregate the medical data from 11 sources in 4 countries in a standard way. It’s a great Big Data project and may tell us much. This study of that data though is a study of treatment pathways, and they found interesting things comparing the treatment pathways of diabetes, hypertension and depression. Really the point of this study was to show that study of this issue in an international way is possible and I applaud them for that, but they draw conclusions that go way beyond the data. Here’s a quote from the article “The pathways revealed that the world is moving toward more consistent therapy over time across diseases and across locations, but significant heterogeneity remains among sources, pointing to challenges in generalizing clinical trial results.” They go on to point out that in the case of diabetes over 90% of people get the same first line medication, but that things aren’t “so good” in hypertension. The basic assumption in the study is that what should be happening is that everyone with one of the complex chronic illnesses, all three of which have multiple causes, should get the same first line treatment. And in fact the study shows that over time, more and more people with these three illnesses are being treated with the same first medication. The authors feel this shows an improvement of medical insight. I wonder how many of them have actually practiced medicine. When I read that 90% of people in four countries with adult onset diabetes were started on the same medication my first thought was, “Wow, which one? I bet they have a great marketing department.” It might seem like because Type II Diabetes is a single illness it should have a single treatment, but it doesn’t have a single cause. Illnesses for the most part are final common pathways of multiple pathways. We cannot assume that everyone with the same diagnosis needs the same treatment. What the study actually shows is that medicine is being practiced more and more by fiat of large organizations. Over time doctors are picking the treatment the insurance company wants you to start with, or the one with the best advertising, or the one the government endorses. This was not the case for thousands of years. Dr Osler...

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The Big Short
Jun06

The Big Short

By now, most American’s have heard of the book, The Big Short by Michael Lewis, and the movie of the same name. (To short is to sell something you don’t own because you believe it will go down in price or value a great deal) Most people know that the book is about people who saw the collapse in the housing market before it happened and made money from it. That’s not really what the book’s about. The book is about how hubris and cluelessness of government officials and establishment organizations allowed imbalances to get so great that when they finally balanced (as imbalances always do) the entire financial system was at risk. The fact that individual traders saw the imbalances and acted on them should be no surprise. What is a surprise is that those very traders tried to tell people something was wrong. They went to the rating agencies and told them they were wrong; they went to the big banks and told them they were wrong; they went to the government and told them they were wrong. The reaction of all these people was that the traders didn’t know what they were talking about. “How could they know?” the establishment seemed to say. “The system had worked just fine all these years. Who are they to tell us that there are hidden costs that we don’t see?” Well history has decided who was right and who was wrong on that score, and it was an expensive lesson for all of us. The problem behind the Big Short was the assumption that housing in America could never go down across the country at the same time. It hadn’t happened for over 70 years, so it couldn’t happen, right? As long as it didn’t happen, even the crappiest sub-prime mortgage bond would be good. Turns out the assumption wasn’t true, the bonds were worthless, and the pyramid of derivatives built on them were as well. Is there a “big short” in addiction today? Is there a situation in which entrenched establishment groups or regulators are so sure they are right that they can’t see the hidden costs of their system? Is there a situation based on an assumption so old that no one today can question it? I think there is, and it’s also about 70 years old, but that’s long enough for generations of academics and clinicians to have been trained by people who were trained by people who were trained by people who assumed that this was the truth. The Big Short was a best selling book with hundreds of thousands of copies in print. There’s another bestseller that is...

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The ICU
Feb28

The ICU

The young woman walked out of the ICU knowing she’d never see her friend again. At age 26, this was the second time she’s said good-bye to a childhood playmate in this ICU.  When the first of her friends to die was lying there with a machine breathing for her, there was a constant stream of friends and family coming to say good-bye. Now that her second friend was dead but for the machine pumping air into his lungs, there was the same stream of loving people to say good-bye. Both of her friends had struggled with genetic illnesses all their lives, both had done their best to stay alive, both succumbed. The first one died of cystic fibrosis; the second, of addiction. The friend with CF did everything she knew how to do. Took all the medication her doctors told her to take, ate only the foods her doctors told her to eat, exercised, stayed fit, everything. She had a loving family that got her to the best doctors who gave her the best care. But CF doesn’t have a cure, and it doesn’t have a treatment that does more than extend life into the 20’s. It’s genetic, and it’s unfair, but so is every illness you’re born with. The friend with addiction was really no different except for one thing. When his loving family took him to the best care, he heard that medication wouldn’t help. He heard that he should be able to “recover naturally,” that he didn’t need medication. The best doctors that his family sought out didn’t tell him about evidence based medical treatments for his genetic illness. Instead they told him his illness was caused by drugs and would go away if he just stayed clean and became spiritually fit. So in his 4th or 5th rehab he went to a religious based program to get that spiritual fitness. I don’t know his spiritual status when he died, but I know he couldn’t breathe on his own. I wrote a piece recently about what we die of when we die of something that has a treatment we aren’t offered. The young woman’s first friend died of cystic fibrosis and our inability to treat the illness better. Everyone did everything they could. It’s just beyond us at this point in time. But I’m not sure that the second friend died of addiction. There is a treatment available that has been shown to improve survival rates, but he was told it’s a bad thing to be on. There’s a known neurobiology of his illness, but his treaters were willfully ignorant and disdainful of that knowledge, believing that their spiritual superiority was enough...

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Disease, Ignorance, and Cruelty
Feb19

Disease, Ignorance, and Cruelty

I want to tell you a story about disease, ignorance, and cruelty. To make it interesting, we’ll make you the protagonist. The year is 1665, and you live in London. You’re trying to stay away from people because plague is sweeping through the country, and more than a quarter of the people you know have already died. In spite of your efforts, you wake up one morning feeling weak. Your body hurts. It’s hard to move. You know immediately what’s wrong, or fear you do, and you know there’s no hope. You don’t know anyone who has become symptomatic who has survived though you’ve heard a few rumors that there are such people. You’re eventually able to get up to void your bladder and notice large swollen masses in your groin. You throw up, and the effort has worn you out. You crawl back in bed, and later that day, you die. But what did you die of? I am confident in saying that you died of disease. In this case the disease was bubonic plague, a very virulent illness caused by a bacteria called Yersinia pestis. Now the year is 2000 and you live alone in Arizona about 2 hours from the nearest town. You’re out in your garden digging and you find the skeletal remains of an animal. You think nothing of it. A few days later you wake up feeling weak and feverish. You think it must be the flu because your body hurts and you have a terrible headache. You get out of bed and when you get to the bathroom you throw up, confirming for yourself that it’s the flu. You have a lot of survival gear in the house because you live far away from help. This includes antibiotics like doxycycline, but you know that they don’t help the flu, so you just go back to bed. You try to stay hydrated but it doesn’t work out. By the time you start considering this might be more than the flu you can’t get out of bed. After falling into unconsciousness later that day, you die. But what did you die of? I’d say you died of ignorance; you died of a lack of information. You didn’t know plague bacteria can live in the ground. You didn’t know it could be found in your area. You didn’t know you had plague. You didn’t know you had the cure 20 feet away. You died not knowing that you died of ignorance. Now the year is 2016 and you aren’t living alone. You’re a microbiologist living in a group of other scientists in Arizona. You go out...

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Drug of Choice
Feb12

Drug of Choice

When I think about it, there are few terms in the addiction treatment field that are more silly than “Drug of Choice.” As if we get to choose which drug makes the brain go BAM. When you talk to an addict and ask, “What’s your drug of choice?,” what you get is the answer to “What drug that is available to you lately at a price you can afford that makes you feel better with the least side effects?” Quite a mouthful, huh? Would we ask a diabetic if their toxin of choice is sugar? How did they choose sugar? Why didn’t they choose to have an abnormal reaction to arsenic instead of sugar? What a stupid choice! Using the concept of choice, as in which would you choose if they were all lined up, can confuse us and strengthen the stigma and the idea that addicts are normal people who choose to use drugs. If we asked an addict if they chose to have cocaine work the way it works with them or if they chose to have an abnormal reaction to alcohol we’d hear a resounding “no.” “If I had the choice of what my brain reacted to I’d have picked something a lot cheaper and easier to get than cocaine.” Something like wildflowers or dandelions, no doubt. What is it we really want to know when we ask the question? And why? Well, up to now we really haven’t had a good reason. We just needed a word to write down in the “Drug of Choice” box on the assessment. In many cases it meant something, for instance when the person used only one drug. Most of the time however it doesn’t actually mean much with regard to choosing treatment. However because researchers like things that come in boxes there has been a lot of research on “Drug of Choice.” It’s been used to predict treatment outcomes with regard to which treatment is used. One example of such a research question would be, “Do alcoholics or opioid addicts do better when given naltrexone?” By dividing people up by “Drug of Choice” we manage to make one population (alcoholics) which is heterogeneous sound different from another (opioid addicts) which is heterogeneous in a different and overlapping way with regard to neurobiology. It’s really no wonder most addiction research doesn’t make much sense. But still insurance companies ask the question and the government asks the question so we ask the question, as if we get to choose. But modern science actually gives us a new reason to ask a question about “Drug of Choice.” It’s just not the question we’ve...

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What’s Up in Tennessee? Redux
Feb11

What’s Up in Tennessee? Redux

About a year ago I wrote a blog titled What’s Up in Tennessee? looking at the unenlightened state policies that I thought would make that state’s addiction problem, particularly addiction involving opioids, worse instead of better. It’s been a very popular blog post getting me more comments than almost any other I did last year. Well it’s time to take another look, because Tennessee just stepped in it again. Here’s a recent press release from the State of Tennessee: FOR IMMEDIATE RELEASE Thursday, February 10, 2016                 CONTACT: Mike Machak                 OFFICE: 615-532-6597   Heroin, Buprenorphine Drug Busts on the Rise in Tennessee Tennessee Bureau of Investigation data shows prescription drug seizures declining   NASHVILLE – Tennessee’s nearly half-decade long effort, dedicated to limiting easy access to prescription pain medications and similar opioid-based narcotics, has been successful. Since 2012 the state has seen a steady decline in the use and abuse of these substances commonly prescribed by family physicians. 2015 drug seizure data from the Tennessee Bureau of Investigation (TBI) shows a significant drop in law enforcement confiscations of prescription opioids, ie: pain pills.   Steep Decline of Prescription Opioid Drug Seizures: 2012 – 2014         6,988 Opioid seizures in 2012 4,696 Opioid drug seizures in 2014 *Opioid seizures exclude buprenorphine and heroin; data does not reflect amount of drug seized   This success coincided with Tennessee’s Prescription for Success initiative, launched in 2014. While beneficial in reducing demand for prescription drugs it has resulted in some unintended consequences. Today, the growing appetite in most Tennessee counties is for heroin and the painkiller replacement medication buprenorphine, known under brand names Subutex and Suboxone. They’re now widely prescribed as therapies to ease opioid withdrawal symptoms and cravings. “It’s troubling to see these ‘so called’ painkiller replacement therapies dispensed by unlicensed clinics getting patients hooked and dependent on another drug, just as they were to prescription pain pills, “said E. Douglas Varney, Commissioner for the Tennessee Department of Mental Health and Substance Abuse Services. “Our statewide, multi-agency Prescription for Success strategy did an excellent job of reducing demand for prescription pain opioid medications. But once again I’m very concerned about what’s emerging in our state.” Tennessee Bureau of Investigation data on recent drug seizures for heroin and buprenorphine shows both substances surfacing as new illicit drugs of choice in Tennessee.   Heroin and Buprenorphine Drug Seizures Rising: 2009 – 2014 82 Heroin seizures in 2009 has increased to 341 seizures in 2014 437 Buprenorphine seizures in 2009 has grown to 1,085 in 2014 *Data does not reflect amount of drug seized   “There were very few heroin seizures by law enforcement in 2011 and 2012,” said Commissioner...

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