Opioids: Where Your Doctor Is Trained Impacts What He/She Prescribes for You

A new study by economists at Princeton University shows that where a doctor is trained effects the prescriptions he or she writes.

The study focused on opioids, and differences in prescription-writing between graduates of top and bottom-ranked medical schools. Key findings:

• Doctors graduating from lower ranked medical schools write a much larger volume of opioid prescriptions than those from top medical schools.

From 2006 to 2014, “If all general practitioners had prescribed like those from the top-ranked school [Harvard], we would have had 56.5% fewer opioid prescriptions and 8.5% fewer overdose deaths,” said Janet M. Currie, the Henry Putnam Professor of Economics and Public Affairs at Princeton’s Woodrow Wilson School of Public and International Affairs. Currie conducted the study with Molly Schnell, a Princeton Ph.D. candidate in economics.(1)

• Doctors who receive additional training in pain management write fewer opioid prescriptions than their peers.
• Doctors trained in the Caribbean write more opioid prescriptions than foreign-born doctors trained elsewhere outside the US.
• More recent medical graduates are writing fewer opioid prescriptions than are older physicians.  That again raises the question of how well some veteran doctors are keeping up with new trends and issues.

A counter-argument is that doctors lack good alternatives to opioids for management of pain.(3) However, according to the Princeton research, many doctors may simply not understand the choices they are making in writing a script or the options that may be available.

Why should the impact of training be limited to opioid prescriptions? Why shouldn’t it impact other treatment and drug choices?

What you need to consider:

The framed degree on your doctor’s wall is more than a decoration. You need to read it. If the degree is from a school with which you are unfamiliar, you need to get a conversation going about what other training he/she has taken. If the answers aren’t suitable, you need to consider finding another doctor.

A list of the top medical schools for primary care is available at

https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

In the 2017 rankings, the top 20 for primary care (there are separate rankings for research, but the focus in this article is on patient care) are (4):

1. University of Washington
2. University of North Carolina – Chapel Hill
3. University of California – San Francisco
4. Oregon Health and Science University
5. University of Michigan
6. University of California – Los Angeles
7. University of Minnesota
8. (tie) Baylor
9. (tie) University of Colorado
10. (tie) University of Pennsylvania
11. (tie) University of Texas, Southwest Medical Center (Dallas)
12. University of California – San Diego
13. University of Pittsburgh
14. (tie) University of Massachusetts – Worchester
15. (tie) University of Wisconsin – Madison
16. Harvard University
17. University of Nebraska
18. (tie) University of California – Davis
19. University of New Mexico
20. East Carolina State University (Brody)

 

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Sources:

1. Molly Schnell, Janet Currie. Addressing the Opioid Epidemic: Is There a Role for Physician Education? NBER, August 2017 DOI: 10.3386/w23645
2. Princeton University, Woodrow Wilson School of Public and International Affairs. “Doctors trained at lowest-ranked medical schools prescribe more opioids.” ScienceDaily. ScienceDaily, 14 August 2017. <www.sciencedaily.com/releases/2017/08/170814134811.htm>
3. Malcolm Thaler, MD, “Why Is Opioid Addiction Happening to So Many of Us?” Live Strong, 29 August 2016. http://www.livestrong.com/article/1012275-opioid-addiction-happening-many-us/?utm_source=aol.com&utm_medium=referral&utm_content=opioid-addiction-happening-many-us&utm_campaign=AOL-Wellness
4. https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

 

Antidepressants, Alzheimer’s and Brain Injuries: making bad worse

What we knew:

• Use of antidepressants with Alzheimer’s patients increases the risk for falls and hip fractures
• There is a protein found in the brain cells of persons with dementia and brain injuries that causes the Axon in the cell (electronic message transmitter) to swell and shut down. This protein is absent from normal cells. Elimination of the protein can cause the axon to start functioning again. (References are in previous blog.)

What the University of Eastern Finland has added to what we know:

• Use of antidepressants with Alzheimer’s patients results in an increased incidence of traumatic brain injuries among these patients

The mechanism for the injury is probably falling. With slower mental processing and thus slower reflexes, these patients are less able to protect themselves when falling. That means a higher rate of concussions.

This ties back to another previous post on this blog — “deprescribing”. Drugs may have a value in one stage of a person’s life and be counterproductive at another stage. Doctors know how to prescribe drugs, but there are few protocols (apart for drug interactions) regarding when to stop taking a drug.  There is a group in Canada developing guidelines for deprescription, and while NIH has published articles on the topic, I’m not aware of any similar projects to develop guidelines in the US. Some US physicians appear to be doing this on an ad hoc basis.

I suspect deprescription is not a popular topic among pharmaceutical executives, but it needs to be addressed. Continuation of unnecessary medication is just one of many factors that bloats medical costs in the US — and why spending level no longer indicates quality of care. Unnecessary medication poses risks to some patients.

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Sources:

1. Heidi Taipale, Marjaana Koponen, Antti Tanskanen, Piia Lavikainen, Reijo Sund, Jari Tiihonen, Sirpa Hartikainen, Anna-Maija Tolppanen. Risk of head and traumatic brain injuries associated with antidepressant use among community-dwelling persons with Alzheimer’s disease: a nationwide matched cohort study. Alzheimer’s Research & Therapy, 2017; 9 (1) DOI: 10.1186/s13195-017-0285-3
2. University of Eastern Finland. “Antidepressant use increases risk of head injuries among persons with Alzheimer’s disease.” ScienceDaily. ScienceDaily, 9 August 2017. <www.sciencedaily.com/releases/2017/08/170809073627.htm>.
3. Gurusamy Sivagnanam, “Deprescription: The prescription metabolism,”
   J Pharmacol Pharmacother. 2016 Jul-Sep; 7(3): 133–137.

   doi:  10.4103/0976-500X.189680
4. http://deprescribing.org/
5. http://www.drjohnm.org/2014/10/to-deprescribe-adding-a-new-verb-to-the-language-of-doctoring/
6. Joaquín Hortal Carmon, IvánAguilar Cruz, FranciscoParrilla Ruiz, “A prudent deprescription model,” Science Direct, Medicina Clínica, Volume 144, Issue 8, 20 April 2015, Pages 362-369.

 

Situational American Morality

A new study from the University of Illinois at Chicago has implications for both politicians and advertisers — and should scare anyone who cares about ethics.

The study involved having consumers

. . . read a political monologue about federal funding for Planned Parenthood that they believed was previously aired over public radio.

Respondents were randomly assigned one of two feedback conditions where upon completion they were informed that the monologue they had just read was either true or false.

Consumers were then asked whether they felt the monologue was justified. The bottom line:

1. If the consumer agreed with the monologue, they were less critical of it, regardless of whether they were told it was true or false.
2. If the consumer disagreed with the monologue, they were more critical of it regardless of whether they were told it was true or false.

In other words, in today’s America, it doesn’t matter if someone is telling the truth or lying as long as the consumer agrees with what they are saying. Functionally, that’s a blank check for a politician or advertiser to say anything as long as it includes something the consumer wants to hear.

Unfortunately, this “culture of lying” has consequences. It affects where people want to live, work and spend their money.

As an Airbnb host, we’ve been getting an earful from foreign travelers who don’t want to live here as well as workers who are asking for transfer back to their home countries. We have a doctor who views the level of medical errors in the US as unacceptable and disgusting. We have the Irani who says that, if she becomes ill, she will return to Iran for treatment rather than seek treatment in the US. We have a mother from Europe who is leaving so her daughter won’t become “Americanized”. We have the black teacher who grew up in the US and now works in Saudi Arabia, and says that her quality of life is better there than it ever was in the US.

We have the realtor from Kansas who lives in an American enclave near Mexico City and has seen a 41% increase in sales to Americans moving south this year. Mexico claims that it has 2 million Yanquis living there, most undocumented immigrants. South Korea has close to 1 million Yankee civilians; there are other large pockets in UK, Saudi Arabia, Costa Rica, Australia and other countries. The US Government itself is mum on the number of Americans leaving the country. (All of these numbers exclude military and government personnel stationed outside the US.)

A primary complaint among expats is that they want to escape what the US political culture has become. That brings us back to our topic — the moral acceptability of lying.

For some of us, lying remains unacceptable regardless of the excuse.

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Sources:

1. Allison B. Mueller, Linda J. Skitka. Liars, Damned Liars, and Zealots. Social Psychological and Personality Science, 2017; 194855061772027 DOI: 10.1177/1948550617720272
2. University of Illinois at Chicago. “We tolerate political lies for shared views, study suggests.” ScienceDaily. ScienceDaily, 3 August 2017. <www.sciencedaily.com/releases/2017/08/170803145640.htm>

Jumpstarting Yourself

If you read, every once in a while, you’ll find something and say, “why does that just apply to X? Why wouldn’t that work for Y, Z  and W?”

Sometimes, the topic is medical — like noticing that the same protein is involved in both Alzheimer’s and concussions. (See previous blog.) Sometimes, the topic is far more universal.

Science Daily reports on a mind-training technique that improves the performance of athletes. (1) From the brief description, the program uses a step method (what program these days doesn’t?) and meditation to enable athletes to exclude mental distraction and focus on performance. Athletes who have gone through the program have been able to improve performance and importantly maintain the improvement over time.

The authors talk about enabling the athlete to block out distractions such as anxiety.

The basic premise is that half of athletic performance is mental and that conventional sports training ignores that aspect of the game.

I can certainly accept that. Great athletes have the ability to pay attention at a greater level than others. It’s said that legendary hitter Carl Yastrezmski could see the spin on a fastball and legendary racer Dale Earnhardt could see the wind coming off the car in front of him. The difference from others is in their uncanny ability to focus.

What could you do with that ability?

The larger questions is: what human activity isn’t at least 50% mental? That rule seems to apply to everything including sex.

• Great levers aren’t great because of some physical attribute but because of their ability to focus on their partner.
• Great teachers can sense what their students needs, whether the student is a visual or oral learner or requires some other form of coaching and instruction.
• Great leaders don’t just have vision about where to go, but the ability to motivate their followers or employees — knowing what will get them going.

We even know that the ability to survive and recover from serious illness is largely mental. Part of the sales pitch for supplemental insurance is about removing financial distractions to enable patients to focus on recovery.

And who doesn’t have distractions like anxiety?

So, who wouldn’t benefit from “mindfulness training”? The authors focus on athletes because of the money to be made there, but the concept applies to everyone in all aspects of life.

I’m not endorsing the book or specific method that’s the subject of this citation. However, there’s a lot to be said for improving the ability to focus and exclude distractions. The ability to focus can improve everything you do. There are a number of roads to that goal — including meditation and tai chi. Which method will work for you is something you learn by trying. So try.

There’s even an app for that!  (4) No, I’m not endorsing that either, at least not until I try it myself.

 

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Sources:

1. American Psychological Association. “New mindfulness method helps coaches, athletes score: Sessions can help athletes at all levels develop mental edge, psychologist says.” ScienceDaily. ScienceDaily, 4 August 2017. http://www.sciencedaily.com/releases/2017/08/170804091350.htm.
2. https://greatergood.berkeley.edu/mindfulness/definition
3. https://www.pocketmindfulness.com/6-mindfulness-exercises-you-can-try-today/
4. https://itunes.apple.com/us/app/the-mindfulness-app-meditation-for-everyone/id417071430?mt=8
5. https://www.mindful.org/meditation/mindfulness-getting-started/

Restoring Brain Function

I don’t usually write about early or animal-phase research, but this is potentially quite important for those dealing with dementia, related illnesses, and brain injury.

The protein amyloid beta is believed to be the major cause of Alzheimer’s disease. This protein basically clogs cells and causes neurotransmitters in cells to become hyperactive, generating noise that interferes with thinking and memory.

That leaves three interesting questions:

• What triggers the production of this protein?
• Is there a way to shut production of the protein down?
• What happens if we do?

A team of researchers at the University of Munich (Germany) have identified one such substance, of a category known as BACE inhibitors, that is effective in reducing the amount of amyloid beta in brain cells. Tested in mice, with the inhibitor included in their food for eight weeks, the result when beyond what the researchers expected:

As expected, the mice had less amyloid beta in their brain after this period, since its production was inhibited. However, the effect of the substance was much more far-reaching: the animals’ brain functions actually normalized. There were fewer hyperactive nerve cells, and the slow-wave brain patterns once again resembled those in healthy mice. A key finding for the scientists was the observation that the animals’ memory also improved.
(1 is the original journal article; 2 is the report in Science Daily for non-technical readers.)

Basically, functioning was restored to a level comparable to healthy animals who had never had the disease.

These researchers are planning a human clinical trial.

What makes this a really big deal is that amyloid beta is also a factor in traumatic brain injury (TBI). This presents a possible and quick route to restoration of brain function for both dementia and TBI victims. It is not a “cure” for either, but for the victim and their family, the potential is life-changing.

It’s amazing what you can find buried in a list of breaking scientific news.

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Sources:

1. A. D. Keskin, M. Kekuš, H. Adelsberger, U. Neumann, D. R. Shimshek, B. Song, B. Zott, T. Peng, H. Förstl, M. Staufenbiel, I. Nelken, B. Sakmann, A. Konnerth, and M. A. Busche. BACE inhibition-dependent repair of Alzheimer’s pathophysiology. Proceedings of the National Academy of Sciences, 2017 DOI: 10.1073/pnas.1708106114
2. Technical University of Munich (TUM). “Dementia: BACE inhibitor improves brain function: BACE inhibitor successfully tested in Alzheimer’s animal model.” ScienceDaily. ScienceDaily, 28 July 2017. <www.sciencedaily.com/releases/2017/07/170728100937.htm>
3. Hong YT, Veenith T, Dewar D, Outtrim JG, Mani V, Williams C, Pimlott S, Hutchinson PJ, Tavares A, Canales R, Mathis CA, Klunk WE, Aigbirhio FI, Coles JP, Baron JC, Pickard JD, Fryer TD, Stewart W, Menon DK. Amyloid imaging with carbon 11-labeled Pittsburgh compound B for traumatic brain injury. JAMA Neurol. 2014 Jan;71(1):23-31. PubMed.
4. ALZFORUM, “Imaging Reveals Amyloid Up To a Year After Traumatic Brain Injury,” 16 November 2013. http://www.alzforum.org/news/research-news/imaging-reveals-amyloid-year-after-traumatic-brain-injury
5. VE Johnson et. al., “Traumatic brain injury and amyloid-β pathology: a link to Alzheimer’s disease?” Nat Rev Neurosci. 2010 May;11(5):361-70. doi: 10.1038/nrn2808.
6. Rebekah C. Mannix and Michael J. Whalen, “Traumatic Brain Injury, Microglia, and Beta Amyloid,” International Journal of Alzheimer’s Disease, Volume 2012 (2012), Article ID 608732, 5 pages. http://dx.doi.org/10.1155/2012/608732

Chipping Humans

To paraphrase Franklin, the person who would sacrifice liberty for safety will have neither.

We put microchips in pets so we can locate them. We can attach chips to keys so we know where they are.

Now a company in Wisconsin is microchipping employees.

At this point, the employees are volunteers and the benefits for doing this  include:

• Ease of accessing computers,
• Ease of access to secure areas, and
• Making purchases and vending machines using the chips.

The drawbacks?

• The employer can know where the  employee is 24×7. Spend too long at lunch? The company will know. Privacy? Forgetaboutit.
• The technology represents another level of electronic radiation exposure, and we don’t know about the long term effects of that.

The chips are tiny and can be injected under the skin with a syringe developed by a Swedish firm.

Obviously, the manufacturer wants to see this technology in widespread use.

“Eventually, this technology will become standardized allowing you to use this as your passport, public transit, all purchasing opportunities,” and more . . . . (2)

It’s easy to see where this is going. We can expect a push to implant chips in children, hospital patients and the elderly. That would make kidnapping obsolete and reduce medical errors. It also would make it easy to locate lost hikers and wandering dementia victims. However, it would also mean that with two generations, virtually the entire population would be chipped. Go to a political rally or demonstration? People will know where you are. Criminals will be able to know when a home is empty or when someone is visiting a bank or ATM. Of course, the police will be able to identify and locate the person who robs you.

Further, chips aren’t secure. Any technology can be reversed engineered — meaning that you could create a chip with someone else’s code and use it in a crime.

How do you feel about being chipped?

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Sources:

1. Megan Trimble, “Wisconsin tech company to implant microchips in employees,” USNews, 24 July 2017. https://www.aol.com/article/finance/2017/07/24/wisconsin-tech-company-to-implant-microchips-in-employees/23045620/?brand=finance&ncid=txtlnkusaolp00002412
2. Angela Moscaritolo, “Wisconsin Company to Microchip Employees,” CNET, 24 July 2017. https://www.pcmag.com/news/355140/wisconsin-company-to-microchip-employees?utm_source=email&utm_campaign=dailynews&utm_medium=title

 

Stress and Health

Everybody has a story.

• The unreasonable boss or lousy job,
• The injury or illness
• Money problems
• The loved one with an addiction
• Something.

Most of the stories are real — things with which the person has to deal every day. (A few people make up stories to get attention; that’s a different topic for another time.)

In the lexicon of research, all of these things are stimuli. They’re things that happen that require some kind of response. In physics, Newton’s Third Law makes it easy —

For every action, there is an equal but opposite reaction.

Unfortunately, that doesn’t apply to thought and emotions. Instead, human responses can be —

• Proportional (optimal)
• Inadequate (hypofunction/allostasis, or inadequate adaptation to a stimuli)
• Excessive (hyperfunction).

In neurology, these stimuli are called “stressors.” How you respond to them is the “stress response” or “stress.” Stressors are perceived threats, and the human body reacts to them in ways not unlike when early humans stumbled into the path of a dinosaur. The body releases a variety of hormones that impact almost all major systems in the body.

The stress response is mediated by the stress system, partly located in the central nervous system and partly in peripheral organs. The central, greatly interconnected effectors of this system include the hypothalamic hormones arginine vasopressin, corticotropin-releasing hormone and pro-opiomelanocortin-derived peptides, and the locus ceruleus and autonomic norepinephrine centers in the brainstem. Targets of these effectors include the executive and/or cognitive, reward and fear systems, the wake–sleep centers of the brain, the growth, reproductive and thyroid hormone axes, and the gastrointestinal, cardiorespiratory, metabolic, and immune systems.  (1, emphasis added)

Inadequate or excessive stress reactions are linked to a massive array of both physical and behavioral problems.

• Physical: Asthma, exzema, migraines, low or high blood pressure, cardiovascular disease, indigestion, diarrhea, constipation, obesity and Type II diabetes, sleep disorders, panic attacks and psychotic episodes. In children, it may be related to stunted growth. In women, osteoporosis.
  • Recent research is placing greater emphasis on the role of stress in cardiovascular disease.(2)
• Emotional: Anxiety, depression, mental errors, loss of sex drive, OCD, alcoholism, etc.

Dr. Chrousos argues that stress response hormones were designed for limited use (e.g., see dinosaur, release hormones; lose dinosaur, stop release). In the modern environment in which stressors operate continuously over a long period of time (e.g., the bad boss), long term release of these hormones can have profound negative effects on the functioning of the body.

The portion of the brain that controls emotions is the amygdala. Recent research has shows that severe stressors cause physical chances in the amygdala, most notably enlarging it. (3)

What’s Important to Know:

1. Stress (or the stress response) is inside you. It’s not what someone does to you; it’s how you react.
2. Some of the stress response is automatic. You don’t tell you body to release hormones. And when someone is chasing you down a dark alley, be grateful that’s true.
3. However, you may have some ability to influence how long those hormones are released and the damage your body sustains.
   • You can take yourself out of a stressful situation.
   • You can “let go” of something that’s happened after it’s over.
   • You can use meditation, yoga, tai chi or other tools to moderate reaction to stressors.

Keeping the stress reaction alive when it’s not needed hurts you, not the stressor.

 

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Sources:

1. George P. Chrousos, “Stress and Disorders of the Stress System,” Medscape, 2009. http://www.medscape.com/viewarticle/704866
   Dr. Crousos is professor and chair of the Department of Pediatrics at the University of Athens, Greece. With 1,100 articles, he is one of the most quoted doctors and researchers on the planet.
2. Marlene Busko, “Study Links Stress-Related Amygdala Activity to Future CVD Events,” Medscape, 13 January 2017. http://www.medscape.com/viewarticle/874435
3. Megan Brooks, “PTSD May Be Physical, Not Just Psychological,” Medscape, 21 July 2017. http://www.medscape.com/viewarticle/883251