Friday, September 20, 2019

Herbs and Nutritionals Series: Medical Cannabis

"What do you think about CBD?" 
Photo by Sharon McCutcheon on Unsplash


This question comes up for me pretty much every week for me now. CBD--cannabidiol (CAN-uh-bi-DI-all)--is a chemical found in varieties of hemp or cannabis, the two plant names are essentially interchangable. Cannabis comes in three major species: sativa, indica, and ruderalis. The first two are the varieties that are most famously associated with their use for their mind-altering properties; the ruderalis--and not all botanists agree that it's a separate species--has not been subject to cultivation and selective breeding. It's considered "wild" cannabis, although even these are beginning to be bred by some cannabis horticulturists.

"Hemp"--a casual term for the plant--has come to specifically refer to industrial hemp grown for fiber that can be used in fabric, paper-making, and other consumer products. The species isn't as important as the strain of species when considering what a cannabis plant is to be used for. It's selective breeding that drives the end product in cannabis farming. This means that the Cannabis sativa grown in Iowa for fiber might be tall, with light foliage, few flowers, strong fibers, and almost none of the chemicals that make people "high." On the other hand, the C. sativa grown at a recreational marijuana farm in Washington State could be shorter, leafy, with plentiful, resinous flowers saturated with those chemicals. C. indica and C. ruderalis are shorter and less desirable as a source of industrial fiber, and so these are not bred for any purpose other than the psychoactive chemicals that people find desirable for medical or recreational use.
Industrial Hemp. Note the long, thin stems and lack of
significant flowers. Photo: "Valyxyz" on Pixabay
Psychoactive marijuana. Shorter, bushier, with many
resinous flowers. Photo: "futurefilmworks" on Pixabay

So it's breeding and strain that determines what's in a batch of marijuana. This has become a big business! Hundreds of nurseries, farms, growers, labs, and marketers form a new industry catering to both medical and recreational marijuana. So today I'll share a few points that my readers might find useful.

The chemicals that cause users to feel high are tetrahydrocannabinols (tet-ra-HYDRO-can-NA-bin-alls) or "THCs", mainly THC-9, and a lesser amount of THC-8. THCs resemble a naturally occurring brain chemical, or "neurotransmitter", called anandamide (ah-NAN-dah-mide), which comes from the Sanskrit word for "pleasure"--so it should come as no surprise that marijuana is something many people find pleasurable!

But activating anandamide circuits in the brain also comes with some sensations that some people find uncomfortable: It can raise emotional arousal, so it can feel like anxiety to some. It alters processing of sound and vision to a small extent, and while some find these experiences fun (or at least not bothersome), others can find the experience weird and unpleasant. So as I tell my pharmacology students: any drug that affects the mind can have unintended effects on susceptible brains. The THC in cannabis is no different. In some ways, psychiatric drugs and homeopathy are the same--one size never fits all!

There are several other psychoactive chemicals in marijuana. I won't go into all of them here, but the talk of the town these days is CBD.

CBD is a sedative, for the most part. It quiets the nervous system, which is why it was originally legalized in Pennsylvania, after parents of children with intractable seizures testified to the legislature. Since legalization in 2016, regulations have been developed and medical dispensaries have sprung up. To get it, a person has to be diagnosed with one of 21 medical conditions and see a PA-licensed physician who is authorized to write a recommendation letter for marijuana--so not all providers are in that program. The dispensaries distribute products in various forms (edibles, oils, resins, flowers, etc.) that contain various ratios of THC and CBD.

The other chemicals are usually not listed but are also less directly related to the therapeutic effects most people are aware of. More on this later.

Industrial hemp also contains varying amounts of CBD, and because it doesn't contain any significant THC, CBD is being sold--legally as far as everyone's concerned--in hemp oil-based products. So basically we have two industries: a highly regulated medical marijuana supply system that starts with a visit to a PA-licensed physician who is on the state's provider registry, and allows access to quality-validated, marijuana-derived products that contain various amounts of THC and CBD. And we have an unregulated, hemp oil supply system that starts with a visit to an online or local retailer--or even just a 7-Eleven! In this system let the buyer beware.

In my next installment, I'll talk about what CBD does, and a bit about some of the other features of medical marijuana that have effects on health and well-being.

Sunday, June 16, 2019

Herbs and Nutritionals Series: The Curious Case of Echinacea

Ok people, we're back to herbs and supplements. This week: Echinacea.

This is a medicinal herb that a lot of people know about. It's supposed to be good for respiratory infections, and a web search turns up others like urinary tract infections, skin infections and so forth.

Echinaeca spp. (species, plural) commercially are mainly comprised of 3 specific species, E. purpurea, E. angustifolia and E. pallida (there are said to be 10 species altogether). Over the years I've seen various formulations of these: some contain all three species, some contain only one, with purpurea and angustifolia being the most common, and among the best studied. However, all three have pharmacological activity, especially the flowers and roots. Like many herbal products, potency varies from species to species, crop to crop, and even plant to plant. Some companies who market effective versions of this herb will use wildcrafting knowledge or domestic cultivation techniques to arrive at a harvest of material of greater potency within the natural range of the plant. Some may use post-harvest laboratory testing to validate the potency of a crop, or to survey a crop's variability so as to then blend the harvest to achieve a known potency level.

This was a technique that has been around since the late 19th Century, when mainstream medicine used a lot of herbal medicines as part of its armamentarium, for such drugs as foxglove (digitalis) and nightshade (belladonna).

Echinacea's Actions in Living Creatures
This section title should signal to the reader that a lot of this study has been done in rats and mice, but these studies help us to understand more about how it is that echinacea found its way into North American aboriginal medicine. I've pointed out that plants are complex, and this complexity can lead to two main, positive phenomena: 1) some plants can seem to treat a wide array of problems--which is counter-intuitive to our ideas about Western biomedicine in which one drug treats one thing, and has a very specific effect. 2) While there may be drug actions that predominate, other chemicals in plant medicines often modify those effects.

Echinacea contains a number of active constituents. Alkamides (AL-kam-ides) are long-chain hydrocarbons that appear to modify several immune system activities. One such action is that alkamides stimulate the activity of the "first line soldiers" of the immune system. These white blood cells (some of which actually live in tissue spaces, such as skin, rather than the blood) are the first line of defense against bacterial invaders. Alkamides boost this effect. Interestingly, alkamides also attach to CB-2 receptors--one of two receptors that marijuana products bind to--to moderate immune response by reducing the chemicals that aggravate inflammation.

Another constituent is polysaccharides--literally "many sugar" molecules. This doesn't mean white sugar or anything like it! Polysaccharides are large molecules that have many functions in both nutrition and cell structure. They include starches and cellulose, and are made up of many smaller sugar molecules. Fun fact: foreign polysaccharides are one of the things those "soldier cells" react to--thus, the invasion of bacterial polysaccharide material is one of the things that gets the immune system started. This is believed to be one way that echinacea stimulates immunity.

I'll refer interested readers to an article by Azadeh Manayi and colleagues (2015)--if you really want to get into the weeds on this subject. For now it's sufficient to say that there's real evidence that echinaceas have the ability to both enhance immunity and moderate the harmful effects of inflammation.

Echinacea's Effects in Humans
There's been a lot of study of echinacea, but much of this work is limited by a couple of factors. The first is that, because single herbal medicines are unpatentable, clinical studies have tended to be small and few. There's no money in it. Attempts to combine the results of such smaller and varied studies have led to somewhat confusing results. Researchers have also used different methods--even different preparations--to study clinical effects in people. The second factor is that there's just not as much interest in much of the world in herbal medicines, although poverty (India, Africa) and tradition (Germany, China) have fueled some research into plant-based medicine. The paper by Manayi et al. in Pharmacognosy Reviews I mentioned above was an Iranian team. There's a lot of herbal medicine study out of Iran, perhaps because economic sanctions have led to turning to Nature as a pharmacy in lieu of the easy import of regular drugs. In short: although we have a copious traditional literature about echinacea, the hard science literature is both smaller and more nuanced.

I recently gave a talk to a group of nurse practitioners, doctors, and PAs about herbal medicines, and I covered this plant, so I'll share my summary of some of that nuance here. The research is clear that echinacea modifies immunity toward activation aimed at fighting bacteria and viruses. I've read reviews that suggest that echinacea can be used--if used when symptoms first start--to reduce the duration of or abort symptoms in the common cold. I recently read a review that suggests it can't. One review concluded that it isn't effective to prevent the common cold. A more recent review says it will. Years ago it was reported that, because echinacea really does stimulate immunity, using it daily will eventually cause that part of the immune system to "burn out" and work less well. A more recent report denies this occurs, and indeed 19th Century eclectic physicians often prescribed it for daily use without ill effects in this regard. Another concern is that, because echinacea can activate the immune system, it may cause people with asthma or autoimmune diseases to suffer from aggravations of their disease.

What I've Seen in the Clinic
Echinacea works. Early on I used it strictly for the treatment of things like colds and flus, when plant medicine was desired (as opposed to regular medicines, like Tamiflu), and I have found that it works most of the time to either stop (if taken within 6 hours or so of the very first symptom) or shorten a cold (if taken at any time afterward). The longer the cold or flu has been going on, the less well it works.

Years ago I began to turn to elderberry as a first line treatment for colds and flus because it has fewer theoretical safety concerns, and because it's become very easy to get at regular retail pharmacies (because you know, people tend to get sick on evenings, weekends, and holidays!) and the quality is generally known to be good. These days I tend to use echinacea for cases of other types of early infection, such as minor skin infections, dental abscess, "stomach flu", and urinary tract infection (UTI). I do still use it sometimes for respiratory infections as well.

One problem I tend to see with it is that potency matters, and many people purchase products that are likely to be of low potency, such a dried-powdered herb in capsules. In my practice I tend to recommend either a liquid product (in alcohol or glycerine) or a standardized liquid or solid extract (in gel caps) as the approach-of-choice, as these are products that have the potency needed to achieve clinical results. You may see such products labelled as "standardized" to a certain percent by weight or milligram strength of "echinacosides", which are caffeic acids, themselves not necessarily immune-stimulating, but a marker of plant potency.

What about the downsides suggested in some reports?

Based on my clinical experience, most of these are overstated, and even authorities on this subject suggest that these concerns are more theoretical than actual. In my own practice I have seen a few cases in which mis-use of echineca led to activation of asthma and rheumatoid arthritis, and even a couple of cases in which the supposed "immune burnout" actually occurred.

This is how I view echinacea now:

  • It can be used preventively for short periods to keep from getting a cold or flu. An example of this use would be when one is preparing for air travel (commercial airplanes are basically a germ-recycling system!) or other situation in which a lot of exposures may occur. A short period would be a few days before, and then during such exposure.
  • It can be used as a treatment for colds and flus, but is best used within 48 hours of symptom onset, and is even more effective within 4-6 hours of onset of the very first symptom. I usually suggest continued use for up to 10 days, but have seen good results with even just a few days' worth of use.
  • It can be used as a treatment for various other infections such as UTIs and minor skin infections, but again, it should be used early.
  • People with asthma, rheumatoid arthritis, lupus, colitis, and other inflammatory or autoimmune conditions ought to only use echinacea under professional supervision.
  • Let the buyer beware! There's no regulation of these products, so I am skeptical of casual sources of them. There are validated, professional quality products available through a number of sources. Wellevate is one such source (disclaimer: I have an online store through Wellevate), but there are others. Amazon, Walmart, etc.--they're cheap but may or may not be what they say they are. The United States does not regulate these. Wellevate, Thorne Research, Integrative Therapeutics and others are self-policing industry outlets.
  • I never recommend daily, uninterrupted use of echinacea. I'm just not convinced this is safe or necessary.
  • Liquids (alcohol or glycerine-based) or standardized extracts are my "go-to" choices for medical use. The echinacea teas available at grocery stores are generally weak, although I have suggested--in a pinch--that using 2 or 3 teabags per cup, and letting that tea steep for 5-10 minutes can also work. 

Overall, my feeling about echinacea has changed with time. I tend to view it as a choice that should be used with professional guidance, but have also found that most people won't do themselves any harm using it on their own.

And, in the spirit of my last blog post: If you aren't getting better, and you're getting worse on something like this, seek professional assistance! Don't keep doing the same thing if it isn't working.
On that note, let me add that this article is educational and is no substitute for professional medical advice--you just have to find a professional with an open mind and a bit of experience!

Sunday, June 9, 2019

Hacks and Quacks

Sunday morning, and I'm just surfin' around on YouTube and what have you, and I ran across a video by GeneticallyModifiedSkeptic about how the quackbuster Sam Harris "beats quacks every time." Now I like this kid (real name: Drew McCoy). He's a young guy whose channel specializes in discussion of argument, belief, and reason, mostly centered on his own experience of moving from theism to atheism. He also explores the arguments of various proponents of contemporary intellectual positions like those of Jordan Peterson, religious cults, PragerU, and so on. So most of this broadly falls into the categories of general philosophy and epistemology--the "study of knowledge". His Facebook page lists one of his subspecialties as "debunks alternative medicine."

I emphasize that I like this guy, because I think he's smart and constructs his own arguments in a clear and accessible way. This blog post isn't meant to criticize him alone; rather his videos on alternative medicine--along with another bit of news I picked up on Google News this morning--inspired me to write about how we think about medicine, and why we think it.

The other bit of news comes form The Independent and concerns the sentencing for manslaughter the parents of a 7-year-old Italian boy, because his death was determined to be from the choice of homeopathic remedies for an ear infection, instead of giving him antibiotics.

This got me to thinking: what's really going on here?

Let's start with the Italian boy. I read the story. The homeopathic practitioner was said to have "underestimated the seriousness of the illness" when he persisted "despite recrudescence of the symptoms." In plain English, this means someone tried something that could have worked, and when it didn't and the kid got worse, the practitioner didn't punt to something else.

That doesn't have anything to do with homeopathy. Let me explain by analogy.

My mom was in a car accident. In the accident, her leg was pierced by an umbrella rib from a folded umbrella that was in the passenger-side door pocket. The wound got infected. She went to her doctor, who gave her an antibiotic. By the time she called me, the infection had gotten pretty bad and she told me "He gave me Keflex for a week, but that didn't clear it up so he gave me Keflex for another 10 days."

The infection was still a problem when I saw her, now more than 3 weeks into things. I lanced the wound, packed it, and changed the antibiotic to clindamycin. She was fully better in mere days.

Do antibiotics work? Of course they do, but there's this thing called "antibiotic resistance" and everyone knows about it, and why would you keep doing the same thing if it's not working?

So you can see that the real issue is clinical knowledge and clinical reasoning, not whether or not one should use antibiotics--or homeopathy, or essential oils, or prayer, or meditation, or whatever. Look, it's an axiom of clinical medicine that she might have gotten better with simple hot packs applied to the wound. Or...not, and so then we do something else. Get it?

McCoy does make one effective argument: why not just use something that has been proven to work? But that's not an epistemic question. It's still just a question of good clinical reasoning. And since he's not a clinician, I have to ask why he'd feel comfortable getting into an area that is so fraught with unknowns.

Take hypothyroidism, or low thyroid hormone levels. It's a mostly straightforward clinical problem, and the thing that cures it is T4 replacement therapy. I have not found any evidence that anything works as well as T4 for this problem. When people ask me if there's a homeopathic "cure" for hypothyroidism, I tell them "Take the drug. Think of it as food"--and technically it is, as the first treatments that effectively treated what was called "myxedema" (hypothyroidism) in the olden days was little hamburgers made out of cow thyroid gland.

Now take depression. Although there are some theories about the biological basis of depression, we really don't know what's going on. Furthermore, we don't have any good diagnostic instrument to measure depression. It's a black box. We know some general things. We know that many people improve on various antidepressants, but we can't predict which class of antidepressant will work in any given case, and we don't know what dose will work in any given case. And we don't know in any given case if antidepressants will work. I teach my students that prescribers can make general predictions: pure serotonin-focused drugs will often be somewhat sedating, so those drugs are a better first choice if the person has depression with anxiety or insomnia. Serotonin-norepinephrine focused drugs might be better if the depressed person lacks energy and sleeps too much. You get the idea.

I also teach my students that it takes time to see the effects of these drugs--regardless of category or class--and it takes time to find the right dosing. Side effects are many and often troublesome, and may lead to changing the drug as this becomes apparent. In the end, psychopharmacology is a bit of a crapshoot: it's educated guesses combined with active analysis of the ongoing case, with adjustments made ad lib based on results, or the lack thereof.

So to say that T4 works in cases of low thyroid is easy. To say antidepressants work for depression is a problem. That problem is complexity, and the difficulty I have with people who wish to "debunk alternative medicine" is that it ignores the complexity of clinical experience, clinical practice.

This is the issue I have with Harris, McCoy, or any of the many others like Edzard Ernst, David Gorsky and so on.

It is a fair intellectual exercise to experimentally inquire into the uses and effectiveness of various medical alternatives. Inquiring minds want to know--said the old ad tagline from the tabloid The National Enquirer! It is a fair exercise of political and economic policymaking to ask whether or not the costs of a thing justify public funding of its use. It is also fair to discuss the measurable harms to the public when people choose not to vaccinate. It's fair to express concern that people with low qualifications market products with broadly falsifiable claims in the hopes of bilking people out of their money while real medical problems go untreated. However, it is neither fair nor justified to spend one's time in a general enterprise "debunking" medical approaches one knows little about.

What I'll argue here today is related to something I've proposed a few previous times in this blog: These so-called skeptics have an agenda that isn't intellectual, it's psychological. I've written here before about the impulse these critics express as intellectual rectitude. It's the same "I'm right, you're wrong" attitude that affords them with a sense of superiority...or sublimates their woundedness at the harms they've seen when people make choices that don't line up with a logical positivist, materialist worldview. In the former case, it's just smug people behaving badly. In the latter case--usually among practicing doctors and nurses--it's despondency among clinicians who hate to lose patients to what sometimes prove to be bad choices.

But there's another side to this, and that side can probably be found all over South-central Pennsylvania, when some of my patients go back to see their doctors and tell them that I gave them some little white pellets and their __(fill-in-the-blank)__ got better, and stayed better. But you don't hear many doctors saying "Hmm, that's interesting. I wonder what happened there?" They shrug. Some may say something vaguely affirmative (which is at least good bedside manner!), or they may actively argue that the choice made was a poor one, and try to persuade the patient to do otherwise.

McCoy has a sharp mind and lots of promise as an interlocutor online. He--and others like him--falter when they stray into areas beyond topics like whether or not tax dollars should pay for things that have scant proof in the medical literature, or if the value of mass immunization to society exceeds its minimal harms to individuals. When he and others simplistically paint "alternative" medical approaches with a broad epistemic brush, their arguments crash on the realities of clinical experience, and the mysteries of human health and disease.

Sunday, May 12, 2019

Measles Update

I'm interrupting my series on herbal and nutritional medicine to update my audience on the measles outbreak. Now the Centers for Disease Control reports 764 cases in 22 states.
How this compares to recent years...
And, writing this on a Sunday morning, I just heard that NPR's Hidden Brain will be running an episode on how we know what's "true", one story featuring a woman who was an "anti-vaxxer" and now has come around to the view that vaccines are important and that they work. In Washington State, New York City, and elsewhere health authorities and legislatures are tightening restrictions on both public-space access for the unvaccinated and exemptions to vaccination.

Interestingly--and despite the warning that measles is "deadly" and causes "severe complications"--the CDC reports that no deaths or encephalitis cases have been filed from any location in the U.S. There were 66 hospitalizations, and these include 3 cases of pneumonia. 71% of cases through April 2019 were in unvaccinated persons. 25% were in infants too young to be immunized with the MMR vaccine. And another 24% were too young to have been fully immunized (2 doses) at age 4. The remaining 51% were distributed among adolescents and adults.

One way to look at this is that 628 people who were unvaccinated or whose immunity status was unknown are now immunized against measles. Another interesting conclusion is that 11 cases of measles were in people who were fully immunized, much smaller than the number suggested by published reports of 98-99% long term protection in those who are immunized (that's good, right?). CDC data also suggest that the peak of this outbreak was in the 3rd week of March; by the end of April, measles had dropped to about 11 new cases nationwide. This is consistent with how most infectious disease outbreaks trend. Eventually, the epidemic fades.

I've written before (1, 2, 3, others) about what I believe are the real issues in the "vaccine controversy" or "vaccine debate" or whatever you want to call it, so I won't repeat all that here. But I thought that under the circumstances it might be a useful time to share snapshot of the reality of the current episode.

This outbreak is being sold as a failure. It's a failure of parents who don't "believe" in the science. It's a failure of doctors and nurses to sufficiently coerce parents into getting their kids immunized. It's a failure of state governments to restrict vaccine exemptions to only the most extreme circumstances (like an actual medical allergy). It's a failure of our society to "get on board" with this public health measure.

I think it is a failure too. For me it's a failure of our society to have a more effective conversation about health, disease, and health care. For anti-vaxxers whose kids just got over the measles without anything catastrophic happening, it just confirms what they already believed: measles isn't a very bad disease, and their kids turned out okay without the use of measles immunization. This news will spread throughout social media and further serve to undermine the messages of public health authorities, nurses, and doctors who promote immunization.

Stalemate.

What won't be discussed is that the reason this outbreak--so far--hasn't caused a wave of medical calamity (deaths, brain damage), is that this isn't a very serious disease. Older doctors who report how "devastating" measles was in the past, causing deafness, mental retardation, and of course death, don't address how much different public health and medical care were 40 or 50 years ago. That measles tends to cause complications in the poor, the undernourished, is not discussed. I have stated before that poverty, nutrition, safety, and hygiene are known to be key reasons for health problems and deaths that can occur from even simple illnesses like the flu, measles, or infant diarrhea.

This allows us to ignore the disparities in society. We can turn our sights away from systemic, societal problems--like racism, poverty, and hunger--and attribute disease outbreaks to stubborn parents who refuse to follow along in the hymnal like the rest of us righteous folk.

From NPR and ABC
Recently, I saw this report on how actress Maureen McCormick and other former cast members of The Brady Bunch are upset that the episode "Is There a Doctor in the House?" is being viewed by people who avoid vaccinating their kids as confirmation of the non-seriousness of measles. In that episode, the kids get the measles, and home-bound hijinks ensue (cue laugh track).

Interesting too is the story's report on how Merck Co. helped to shift the public's perception of the mildness of measles through educational campaigns like "Mission: Measles--The Story of a Vaccine." Of course, this was good for Merck. More immunizations = more dollars; witness this story from the New York Times about ever-higher vaccine costs.

I remember this episode of The Brady Bunch (we were a family of eight too, so we saw ourselves in that show), and although it can be argued that in the 1960s, there were worse diseases that did make measles seem less serious (smallpox, polio), maybe the impulse to make all diseases seem serious--no matter how little their real risk--does society a disservice. Maybe it distracts us from what we ought to be paying attention to, from what social and political policies really need to be changed.

And with that, I wish you all good health!

Monday, May 6, 2019

Herbs and Nutritionals Series: Allergies

The University's local Commencement was Saturday. As the graduates commence their journey forward, I commence with summer break. I'll start with some writing. Recently I promised a series on herbal medicines, so I'll start there.

Spring brings with it high pollen counts and if you are sensitive to it, it can be pretty miserable. I suffered from allergies (in the fall) for years, but no longer. I find the best treatment for allergies is a carefully-selected homeopathic remedy. If you're not quite there though, or still in the need-for-support stage, here are some things that can help. Caveat: This piece is educational and is no substitute for personalized medical advice.

Vitamin C
In high doses this vitamin is anti-inflammatory. "High" means several thousand milligrams a day. I learned that naturopaths prescribe this "to bowel tolerance" meaning you keep upping the dose until the bowels become a bit loose. However I find that 3,000-6,000 mg per day is often helpful. I tell patients to take it in "divided doses"--meaning one spreads that out over the course of the day, for example 1,000 mg three times a day. 

Quercetin
This is a naturally-occurring nutrient found in grapes, cherries, berries, kale, tomatoes, and broccoli, among others. Quercetin is a component of cell-walls, and having a diet with enough of this nutrient ensures that cell walls have all they need. The thinking is that strong cell walls means that they're less likely to break. "Mast cells" are in the body to protect against certain kinds of infections. When organisms try to get into the body, mast cells break open to release histamine which brings white blood cells to the area. Some studies have found that taking quercetin reduces the "breakability" of mast cells just enough to reduce histamine release. You can get this from foods or from supplements. The latter will often be compounded with plant-based digestive enzymes like bromelain or papain to help the quercetin be absorbed.

Image result for neti potNasal Lavage ("neti pot")
This is a nice, "nursey" hygiene measure. The neti pot is a specially-designed pot so the user can washout the nasal passages.
 It's been in use for thousands of years, and can wash away the inhaled pollen and collected mucus that leads to symptoms. There's lots of stuff on the internet one can look up for the details, but I always emphasize with my patients that the pot should be cleaned with hot water with each use, to reduce the risk of sinus infection. The washing solution is salt water, and there are premixed solutions available, or a person can make their own. I also emphasize lukewarm water! Very hot or cold water can cause problems. Saline nasal sprays are a less messy means to achieve the same "wash out", but may not be as effective.

Image result for stinging nettlesStinging Nettles (Urtica dioica)
This is a plant that actually suppresses T-cell function, which is one of the main causes of allergies. Without getting into too many details, T-cells are a type of cell that "memorizes" allergy and initiates the reaction that pops mast cells. 

One has to be a little careful with this one for two reasons. First, the plant must be picked and processed at a certain part of its life cycle to avoid the "cystoliths"--tiny hard bits of calcium carbonate--that are said to cause kidney and liver damage. Some sources dispute this, but it isn't hard to stick to young plants that are pretty much cystolith-free, so why take the chance? For my patients, I always recommend verified professional-quality nettles.

Second--and this is not in dispute--is that this stuff actually works to get at the source of allergy symptoms. T-cell suppression isn't as strong as some of the drugs that also do this (as in drugs for autoimmune diseases), but I have observed that when used for too long, sometimes the user will actually catch a cold! So for my patients, I tell them to limit daily use to only a couple of weeks at a time.

That's it for now. Look for a few more highlights of various herbs and nutritionals in this series.

Sunday, March 24, 2019

A Wave From the Fast Lane

This is one of my busiest times of the year, but I felt the need to reach out and just let all of you know I'm still here. We're coming to the last month of the semester, spring yard work season has just begun, and there's a lot going on. So here's a few things going on in science and medicine--just to keep you in the loop.

The Cannabis Debate Heats Up

In just a few short months since Governor Wolf's re-election, when he said recreational weed was off the agenda for the moment, to now, where Lt. Governor Fetterman has undertaken a "listening tour" to get a real sense of how Pennsylvanians come down on this matter, the debate has resisted being put "on hold."

Intuitively, a lot of us cleave to the notion that adding more intoxicating substances to the social mix just has to be a bad idea. Others of us choose a more libertarian way: let grown-ups do whatever they want, as long as it's properly regulated for the sake of the safety of the general public. What one thinks is one's personal view and is formed from any number of influences, including one's own experiences and reflections, as well as the resulting personal politics and spirituality.

But there's also a scientific debate and it's broader than just medical science, and includes criminal justice, sociology, psychology, economics, and political science. That's all over the place right now! One example currently flooding the internet is the link between schizophrenia and marijuana use. I'm seeing a lot of this on Facebook right now. I addressed this in great detail in my previous blog entry, so I won't do so further here. I will place this debate in the framework of a new debate that's emerged this week.

What is Science, Really?

The new debate is around the real meaning of positive or, by extension, negative results in scientific studies. In a piece published last week in Nature Valentin Amrhein and colleagues--as well as over 800 other scientists--argue that it's time to retire the concept of statistical significance. A discussion of this concept is nicely done in this article in Vox, so I won't get deeply into it here. But a very short version of the whole thing is that the culture of science has grown dependent on this very complicated and subtle concept. They argue that statistical significance has led us to many unsupported conclusions, conflicting study results that perplex the public, and a false dichotomy that suggests that a thing either "works" or it doesn't, that a thing is "there" or "not there."

I see this in my office when people come in and say something like "Last year medical science said that a little red wine is good for my heart. But last week I heard that it's bad for your heart. Which is it?" This is often followed by either throwing up of the hands as if to say "I give up!" or by a kind of defeated reconciliation that "nobody really knows what's true, so why should I care?"

Having taught research methods for many years, I can say that I heartily agree with Amrhein's group: there's too little nuance in interpreting scientific results, but good news bites require that nuance be tossed out the window. Click bait has no time for Deep Thought.

I find that one of the most useful services I provide for my patients, and my students, is to help them understand how to sort this all out. I'm not sure how this change of heart will play out over the next decade, but I like the direction we're heading. Science isn't a destination; it's a journey.

The Complicated Fabric of Science and Society

So there's other science-y stuff in the news: genetically engineered babies in a Chinese research lab, new data about daily aspirin use in people who have never had a heart attack or stroke, climate change and whether or not we should pursue or abandon nuclear power...as well as the whole medical/recreational marijuana thing. We are interested in science for its own sake, just the sheer beauty of understanding our world. We are interested in it because it leads to technologies that can improve our lives. And of course we are interested in it because it helps us make public policy.

It's on this last point that I'd like to emphasize that in policy matters, people have opinions that are wholly personal, religious, or aesthetic. A technocracy is governance based purely on objectively good science with a utilitarian aim. Alternatively such a government might serve an agreed-to philosophical or political good. Historian Loren R. Graham reported that nearly 90% of Soviet Politburo members were engineers--science in the service of a communist ideal was their aim.

While much of the world doesn't operate with technocratic governance, science is still used to tell us things about how fossil fuel use affects our climate, how vaccines affect public health, what sorts of medicine are effective for what uses, how to grow food, how markets work, and so on. It is what's in our hearts that determines how science is then used to inform what actions we take as a society. It is important to note that knowledge is constantly evolving. We learn new things. We develop better methods of "knowing" the truth of the world we live in. All the while, our hearts moderate the incoming information, and color our opinions of it with our personal views.

Knowing that's the case, and explicitly acknowledging that in any conversation about objective scientific information, could really improve our public discourse. And knowing that what we know now is only the best estimation of the objective truth right now, might remind us to reserve a little skepticism about what the future might hold.

Peace...and happy springtime!
Image: G. Hodan in public domain search

Sunday, February 3, 2019

Legal Marijuana--Is this a good idea?

My dad sent me an article from a little magazine, Imprimus, a publication of Hillsdale College, a private liberal-arts college in Michigan. I've linked its Wikipedia entry here, but I'll summarize two points here: first, that it's a true liberal arts college, with a curriculum based on the so-called "Great Books" of Western civilization (Ref 1), and second it has "worked to establish ties to the conservative political establishment" (Politico, cited in Ref 2). This latter fact alone doesn't negate arguments Hillsdale publishes, but it provides context.

The writer is a journalist, formerly of the New York Times, and more recently an author of spy and corporate thrillers. The article is from a speech he gave at Hillsdale this year.

In it he shares how he shares what he learned from his wife, a psychiatrist who formerly worked with severe mental illness among incarcerated inmates at a hospital for the criminally insane in New York. In a discussion, she off-handedly notes that all of the inmates smoke marijuana, and the conclusion to be inferred was that marijuana use led to their insanity. 

The author--a libertarian who admits that he was generally pro-legalization of drugs--investigated and came to the conclusion that marijuana use causes violence, and a lot of it, and he implies that the "elite media" (whatever that is) conspires to keep this fact out of the news, and further, that legalization moves us toward a more violent society. It's a pretty nicely written piece.

Except that like a lot of opinion pieces about cannabis, it cherry-picks data and draws unsupported conclusions from available research. So what's really the case?

Marijuana and Schizophrenia

As early as 1977 a scientific review by Ernest Abel published in the APA's Psychological Bulletin found that while the majority of people using cannabis are not prone to violence, a few susceptible individuals, and subject to certain situations of set and setting (Ref 3), marijuana use may result in violence. More recently a number of studies have found a correlation between marijuana use and schizophrenia, a condition in which people's brains falter, leading to psychosis. Psychosis includes hearing voices, hallucinations, and disturbances of thought that can include paranoia, altered perception of reality, and catatonia. It's a pretty serious psychiatric illness, and in some it does lead to violence, either reactive violence (acting out when feeling threatened) or proactive violence (homicide, suicide).

More recently there have been a number of studies that confirm an association but not a causation between marijuana use and schizophrenia. That is, yes, it does seem people with this illness use marijuana more, but does that cause the problem, or is it merely part of a multi-factor stage upon which this problem is built? Some researchers admit that those with schizophrenia may be using marijuana to self-medicate. Others note that the complex factors that can precipitate schizophrenia are simply also associated with marijuana availability and use. An example would be a poor person from a violent neighborhood where drugs are plentiful: Did the plentiful marijuana cause the disease, or was it caused by the surrounding violence and resulting fear, or is it a combination of several factors, including a local lack of mental health services?

A more recent article in Scandinavian Journal of Public Health found that for every 10% increase in cannabis use, they can project a 0.4% increase in violence. That's not the disease schizophrenia, but hey, we're probably all on the same page and agree that more violence in society is undesirable. On this argument, maintaining marijuana's status as illegal makes sense. 

But What Is It Really?

Is this all the just the interaction of a chemical--or chemicals--in marijuana causing a direct and predictable violence reaction in all humans? 

I'll begin by saying the author of the Imprimus article, Alex Berenson, is not equipped by background or education to decode scientific studies. That doesn't mean he can't read them and begin to draw some conclusions, but to be fair he should be more sensitive to his own level of training in this before drawing what end up being pretty dire conclusions. His wife, a physician, should know better, but as a clinician myself who has dealt with many people using drugs and also having mental illness, I'll admit that--in the trenches--it's easy to start seeing the whole world in one color.

Next, I'll note that almost all of the sound research out there on this freely admits that there's a lot we don't know. One example pertinent to this topic is a 2018 study in Molecular Psychiatry that demonstrated a link between variants in the serotonin 2B receptor gene and risk for psychotic reactions to THC, the psychoactive chemical in marijuana that gets people high.

I teach a class on drugs and drug abuse at Penn State, and one of the things I try to get across to my students is that yes, drugs have predictable effects, but only to a point. Some people will experience untoward effects, unpleasant symptoms, or even permanent damage from certain drugs. In my pharmacology class, I teach my students that pharmacogenetics--the science of studying genetic variations in how people respond to drugs--is still a very young science, but one that will certainly influence their future careers as nurses.

I use pharmacogenetic testing in my practice now, but there's still a lack of consensus on when and how it should be used. Indeed the vast majority of our allopathic drug prescriptions are written on the basis of a vague faith that most patients will respond as predicted. Only a handful of drugs in US have genetic testing routines that guide what we will prescribe, and the fastest-growing class of drugs in which this testing has been studied is among cancer treatment drugs.

Then Why Is Marijuana Legalization Expanding?

THC is a chemical very similar to the neurotransmitter anandamide, which is naturally occurring in humans, and bonds to special receptors in the brain--cannabis receptors! (CB1 and CB2) "Anandamide" comes from the Sanskrit word for bliss. People use cannabis because it makes them feel good, blissful, happy, whatever. Roughly a hundred years of tightening restrictions on all psychoactive drugs, marijuana included, have not led to significant declines in drug use or the criminality that defines its black market. I show my class a couple of diagrams, based on the science, of drug use harms. 
From: w:de:Benutzer:Dosenfant [Public domain], via Wikimedia Commons

From: Pmillerrhodes [Public domain], from Wikimedia Commons
As one can see from the above diagrams, none of these drugs is harmless, and none comes without some risks to society, but there is a definable scale of harms. Interestingly, caffeine, the most widely used drug on the planet (Starbucks, anyone?) isn't listed in either diagram, but does cause dependence and in some people causes physical symptoms, and rarely actual danger (mostly cardiac).

Marijuana legalization is expanding for several reasons.
  • It's fun, and people--voters--like to have fun. But this is nothing without the second reason.
  • It's not harmless, but demonstrably less harmful than other, legal, drugs in ours and other cultures.
  • It's not especially deadly--in fact no case of direct fatal overdose from cannabis alone has been reported. (This may change with novel delivery systems, and increasing cannabis potency.)
  • And as I tell my students: "Don't tell people drugs will kill them. If they try a drug, and it doesn't kill them, then they'll just think you're a propagandist and liar." Marijuana simply didn't live up to it's hype as "deadly" and "a gateway" to other drug use. 
  • And of course, there's the money. I put this last because for a long time, the money was there. It's why there was a multibillion dollar black market in cannabis. If the other reasons didn't obtain, we wouldn't be having this conversation.
In the textbook I use to teach my "Drugs of Abuse" course, the authors propose a theory of holistic self-awareness, which argues that the best way to be in the world is drug free, open and tuned in to all the sensations, thoughts, and experiences the world has to offer. I think this is an admirable argument, but ignores the tremendous variety in human bodies, human experience, and human potential. It is an ascetic argument. That's valid on its face, but only if one accepts it as so. It does not logically follow that it must be the only way to exist in the world.

I try to get my students to understand that the use of mind-altering drugs is very personal. I also try to help them understand that regulating a society is more complicated than simply saying "drugs are bad" or by arguing that all drugs are equally harmful, or that even the small harms from some drugs outweigh the benefits of particular drugs to some people. 

There is commonsense regulation available. Young brains are more adversely affected by cannabis than older brains. Driving while intoxicated is hazardous. And some people using drugs might benefit more if we redesigned our health care system such that people didn't feel compelled to self-medicate. Would a legal market improve the drugs we use (a wider variety of marijuana potencies, rather than the only very potent stuff on the black market now)? Could regulation and product testing improve safety?

As I tell my students, all mental health drugs can cause weird, unpredictable reactions in some patients. If they didn't, medical psychiatry would be way better than it is now. All mental health drugs come with a downside--which is why some people stop taking them (sometimes with tragic results!) but we don't outlaw those drugs. In a similar vein, why must we treat all, currently-illegal, mind-altering drugs with the same level of fear, disdain, and criminal sanction? 

Recreational marijuana is coming now. Almost a century of restriction is one cause of our relative lack of good, impartial data about how now-illegal drugs can be harmful and helpful. A century of political coddling and regulatory exclusivity given to the pharmaceutical industry has come with its own disappointments. I look forward to the new age of openness and hope that we can have a productive conversation about how to balance personal freedom and social safety, how to balance the possibilities in psychopharmacology and ethical regulation. 

Now go out and enjoy this glorious(ly not too freezing) day!
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Reference 1: "Great Books", at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Great_books.
Reference 2: "Hillsdale College" , at Wikipedia, accessed on February 3, 2019 at https://en.wikipedia.org/wiki/Hillsdale_College.
Reference 3: "Set" is the mental state the user is in at the time of drug use. "Setting" is where and when the drug is used. Example: A person using cannabis to calm down before a stressful event has the mental set "This will calm me down" in the setting "before my stressful event." I'm not stating whether this is healthy or not, but as a way to understand the way mind-altering drugs work.


Sunday, January 13, 2019

Ethics & Medicine: A Philosophy Lesson

Ok, the title sounds a little pedantic, but the lesson doesn't have to be. Anyway, thanks to all who follow this, for your patience while I've been taking care of some business during the holiday break. The semester just began, so I'm back!

Photo credit CDC/Judy Schmidt
The inspiration here is an article I read online back around Thanksgiving Update on the Ethics of Mandating HPV [human papilloma virus] Vaccination. HPV is a virus that comes in many strains, and a few strains can increase risk for cervical cancer. Women, especially, will appreciate it as a concern that has driven regular check-ups--"Pap tests"--over their adult lives. Catching the cancerous changes early has a 100% cure rate, and numerous studies over the decades showed that regular Pap tests reduced the rate of cervical cancer to a rarity. HPV vaccines were introduced in 2006, and public health experts pronounced that this was "the first vaccine that prevents cancer" and that it should be used throughout the population.

In the following 12+ years there have been arguments pro and con. I shared the former above. The con arguments ran to these...

  • Use of the vaccine would lead young people to conclude that sexual activity outside of marriage is ok.
  • The vaccine probably had hidden dangers that would not be known for years "and my kid's not going to be a guinea pig!"
  • Big Pharma was making up reasons to sell us more pharmaceuticals.
  • The vaccine was too expensive.
  • Once again we're targeting women's sexuality for "treatment"--a feminist argument.
...and so on. Use of the vaccine languished for a number of years. Some state legislatures tried to mandate that HPV vaccine be included in the required immunizations for attendance at public school. That didn't always go over well with parents who were also voters. Since then, the Centers for Disease Control report that immunization rates have increased. There's more acceptance of it, and its use has been expanded to include boys. (After all, girls have to get the virus from somewhere!) 

From Merck, Inc.
Advertising helped. Check out this ad from Merck in which adorable young people ask their parents if they knew about this vaccine that can "prevent...cancers". I mean, what parent wouldn't feel guilty about not paying whatever it costs to immunize their kid against cancer? (In fairness: many insurance companies now cover the cost of HPV vaccination.) But this article is about the ethics of medical technology and medical decision-making, so let's go there next.

Ethical Theory

Our sense of right and wrong is governed by two things: ethics and morals. Morality is a personal framework for the determination of right and wrong, and guides us in how we should act in society. It may include our religious or spiritual beliefs, and so its application may be limited by some circumstances. For example, some Christians believe that God rules against abortion, and so for those folks, abortion is wrong. Someone who doesn't subscribe to that religious view may believe that abortion is a suitable choice in some circumstances, and what circumstances permit that choice may also vary among individuals based on even more specific values. Morality is determined by culture, religion, psychology, and a variety of other factors.

Ethics has a similar dictionary definition, but more precisely it's a body of theory that attempts to help people choose right from wrong using broader social and historical bases. It's a branch of philosophy and so it's unbound by any specific religion. Here are a few examples of ethical theories, some of which the reader may be familiar with, but this list is not exhaustive--just some examples!

Utilitarianism: the theory that suggests that we should do the thing that does the greatest good for the greatest number of people.

Duty: philosophers will recognize this as "deontology", the theory that suggests that formal rules of conduct--the laws of a society--determine what is right or wrong.

Contractarian: and if you recognize the word "contract" in there, you can see that this would be the theory that argues that what is right and wrong is based on what everyone involved agrees is right or wrong.

Making an argument on ethics means making an argument within a theoretical framework, and there are parts to that framework. Autonomy is something that most of us in America feel is an important feature of our personhood. Being able to "be ourselves", to pursue "life, liberty, and...happiness" is a thread that runs through medical decisions. We should be able to choose medical therapies based on what we want, not what we are told to do by a doctor or a nurse. In mainstream American ethical thinking, autonomy is very important. In some cultures, not so much. For example, some of my colleagues at Hershey Medical Center work with many Amish, and in some situations Amish families may decline life-saving medical treatment because the "greater good" (utilitarianism) is better served by foregoing expensive treatment that seems to go against God's will and can cost the community a lot of money, when that money could better used elsewhere. You get the idea.

Ethical Tension in the Immunization Debate

As I've suggested elsewhere in this blog, a lot of the passion about whether or not to immunize comes down to different ethical approaches to this issue of what's right and wrong. In the article I referenced above in Infectious Disease Advisor, lawyer and professor of medicine at Georgetown University, Lawrence Gostin, states "I think that mandating the vaccine has public health benefits far beyond the small intrusion on individual rights. Thus, a mandate should be in place for all recipients recommended by the CDC unless there is a genuine religious objection — that exemption should be quite narrow." 

Gostin is making a utilitarian argument. What's better for all should be chosen over what's thought by some to be better for themselves. He argues that giving up a little bit of personal autonomy is more right than wrong because it is in the "best interest of the children receiving it"--although I'll be quick to note that neither Gostin nor the article's author provides statistical estimates of just how many people would benefit. However, I dug around a bit and found that a team did use mathematical modeling to estimate how much disease and death could be prevented (Van Kreikinge, 2014). 















Here, I've just shared one part of one of the results they share that's relevant to Americans. Basically it says that the more people you vaccinate, the more lives are saved. I have a couple of problems with this estimation. First, I used to do gynecology and examined (literally) over a thousand women for cervical cancer surveillance. What I found was that if women were poor, without insurance, or otherwise limited in capacity for self-care, they could get full-blown cervical cancer. Women with good education, good health care, reasonable hope for a prosperous future, and so on would not get past the very early stages of cancerous change. Simple outpatient treatment was 100% effective.

Second, two of the study's authors are paid employees of Merck, Inc. Think there's any financial incentive to create a rosy mathematical model that underscores the importance of getting immunized? Do you think that the study included in its estimates the impacts of wealth inequality, war, food insecurity, unfair labor practices, or any of the host of social and economic factors that also have an effect on what kind of health girls--or boys--receive? It did not.

"Ethical" Pronouncements as an Excuse for Ethical Truth

I get it. Doctors, nurses, public health advocates and policy makers all want to believe they are doing the right thing. They take one little thing they can run with, whether that's vaccines, or medicines like statins, or healthy eating or whatever, and they use it as a pivot to make the argument that people should do this because it's the "right thing", and it may be small, but it will help.

Where this goes wrong is the argument that follows on: if you aren't doing this, then you are wrong. It's the same argument that doctors use to vilify alternative medicine practitioners. It is unethical to use homeopathy with patients, or to recommend supplements, or to suggest vaping over smoking. "There's no evidence" (well, there often is, but it's not "enough" evidence). 

Really, this is all just an excuse for moralizing over someone else's choices, when the evidence for harm from such things may be minimal. Ethical truth is a personal, moral state of thoughtful calculation that considers the autonomy of another person, and the importance of valuing imagination and cooperation, over a static moral framework and its use to dominate others in order to feel superior. 

While I am aware of the value of HPV vaccine in preventing some cancers in susceptible persons--as the author of the article I shared notes--I do not agree with the ethical calculus. I would argue that it's an excuse to avoid talking about bigger social problems that lead to the deaths they would like to prevent. Further, it's an excuse to write a prescription in a few seconds, rather than to work with people to understand and help them build upon their own health choices.

Be well!
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Reference: Van Kreikinge et al., 2014 in Vaccine, Feb 3;32(6):733-9. doi: 10.1016/j.vaccine.2013.11.049. Epub 2013 Nov 26.

Monday, November 19, 2018



Do We Have Free Will?

This might seem like a question for philosophers, and in fact it has been for millennia. It really is a question for all of us. Do we choose? Or are our choices chosen for us, perhaps by a creator, perhaps by biology? On Saturday the radio program This American Life aired an episode that focused on will. The will to make a thing happen. Acts of volition. The first couple of segments were stories that spoke to how people exercised their will to achieve or change something. The last segment flipped the thing on its head. In talking with neuroscientists at Harvard and elsewhere  journalist David Kastenbaum heard the argument that we, our acts, our behaviors, are the mostly-deterministic result of firing neurons, action potentials, and the electro-chemical currents of the brain-machine.

In short, you think no thoughts that are yours, inasmuch as you cannot anticipate the origin of a thought.

Ok, that sounds a bit crazy. Let me try again. Let us say that you think a thought, like, "I am thinking now.” Where and when did your thought start? We intuitively feel that we are thinking, coming up with ideas, making decisions. Neuroscientists argue that measurements of thought and action don’t support this view. They aregue that to think is to work a biomachine called a brain. But what started it working? Mapping the function of the brain has led scientists to question a fundamental belief of what it means to be human: that we originate our thoughts.

Now that we've mapped this--and I'm not saying anyone claims to understand it--it has become increasing evident that "thoughts" must spring into existence unbidden. A thought had to have been preceded by a prior thought, and so on. The only logical interpretation, these scientists argue, is that at no time have we initiated anything. All thought, all decision, is a burst of neural activity that we did not—even could not—have decided upon beforehand. The implication: We choose nothing. Each of us is a slave to an unfolding sequence of electrical action potentials that snap from one to the other, not always in a straight line, and in fact mostly in bursts, clusters, and linked tracks that would resemble the chaining of a series of fireworks, each burst seeming to set off another burst elsewhere, but none of it truly under our control.

Makes a cool mental picture, but the implications are profound for who we are. Stick with me here. I know this is dense, but I’m going somewhere with it.

One can make an argument based in religion or metaphysics. But metaphysics by their nature are unknowable and therefore untestable. What I'm talking about here neither proves nor negates religion or religious spirituality. So maybe we are aware of ourselves, maybe we have free will, because a god wills it. I'm not equipped to tackle this, and anyway, it's not necessary.

I do think this is a medically important question, and a relevant question in any healing work. Determinism, and that's what we're talking about here, can persuade both the sick and the healthy to decide that there's little that can be done. It induces inertia and guilt. "I am the product of my genes, of connected neural impulses. I have no control." Worse, it suggests that any sense of control is itself an illusion of control.

So back to the radio show.

These scientists were all kind of on the same page. The evidence points in this direction. The conclusion is inevitable. (And if this sounds like kind of depressing, yeah, it is.) But here's what's wrong with this thinking.

We've seen it before. At the end of the 19th century, classical physics had developed to the point to which it was believed possible that we could know everything. They believed the universe unfolded like a clock. It was mechanical, followed rules, and was ultimately deterministic. However, in the background, the math was falling apart, and this would lead to Einstein's and Planck's theories in the early 20th century. Those theories, later experimentally validated, suggest that the very small world of atomic physics is full of things that wink into and out of existence, and perhaps even travel backward or forward in time. Weird stuff.

The guests on TAL acknowledged the random, probablistic nature of quantum physics, as perhaps the origin of something, maybe thoughts, maybe consciousness. One guest posed the "quack like a duck" argument. We know free will exists because it seems like it does. "If it walks like a duck, and quacks like a duck, it is a duck." It just seems intuitively right that we have the will to choose.

Yet their digression at that point only serves to underscore my own argument. Why must the physiology of the brain necessarily point to only one possible conclusion about where thoughts come from? Earlier I proposed that this is "machine thinking", that the human body is a machine. The brain itself is a machine. This has implications that reach deeply into our conception of self, and touch upon something that is profoundly reassuring to all of us. If we are machines, then we can be "fixed". Everything can be fixed, if we just understand how the machine works. This is important, because the notion is framed by our shared sense of the tools we feel we have available to us: drugs, surgery, counseling and behavioral therapies, physical and occupational therapies, prosthetics, and so on. These available tools fit with a machine-based conception of human life very well.

This way of thinking about human consciousness is quite binary. We have free will or we don’t. We are machines or we aren’t.

We love binary choices. Nature versus nurture. Determinism versus free will. It is essentially a mechanic's choice. How to fix the world? Turn a screw here. Add some some solder there. Connect a few wires. It's done, and we can cure diseases, increase our food supply, and clean our world. It is the conceit of people who need to know there's an answer that they are equipped to understand.

I believe this is a fundamentally faulty approach to the question of consciousness. My proposition is based on the idea that we don’t yet know what we don’t know. We therefore choose to frame such questions in terms of only what we know now. That doesn’t make the unknowable less real, just farther out of reach. The experimental evidence suggests to some that “thought” is a sequence or cascade of spontaneous “origin thoughts” that we don’t come up with on our own. We behave, in a sense, like animals. I argue that we should be more imaginative about these findings.

What if free will is the aggregated electrical impulses of spontaneous “origin thoughts” but then these coalesce into a “consciousness experience” that is both intuitive and creates feedback that can control the general direction of subsequent thoughts? This would violate neither the sense that we can think and choose, nor the experimental evidence about how brains function in real time.

It could be that. Or it could be something else. In either case, it is the failure to step outside of classical frameworks of scientific understanding that hold us back. This failure leads to really interesting findings in the physical world of experimental study becoming very limiting philosophical conclusions that solve nothing. In medicine, a more imaginative view of this evidence can lead us to more imaginative conceptions of health and disease. For individuals, we might recognize that we are at once subject to spontaneous impulses that arise from the deep recesses of our brains, but at the same time, this activity itself creates a field effect, a force, or self-regulating effort that returns to us some control, some will.

Monday, November 12, 2018

The Annual Flu Freakout

It's that time of year again, when doctors, nurses, pharmacies, and pretty much everyone including your grandma is advising to "Get your flu shot!" News stories breathlessly warn of flu seasons that are "terrible" and "alarming" and sure to bring death upon the unprotected masses. I've written elsewhere about the flu, flu shots, and even about some home remedies one can try to shorten the flu and make it less uncomfortable. In this short piece I'd like to just share some of the things that I think are important to know and remember about this annual viral pest.

First, "Do I need a flu shot?" Well it depends on your what you consider important. Most years the flu shot isn't terribly effective, but it still does protect some people from getting the flu. You can't "get" the flu from it, but you could get something like the flu that's caused by something else, or you could get the flu because the vaccine didn't have enough time (usually at least a week) to help you build up antibodies to the virus. So the main downside: it may not work.

Next "Can the flu shot cause me to have problems?" The mainstream answer to this is "Mostly no, and the really bad stuff is rare." This is true, sort of. In homeopathy, we observe that exposing the system to any infection can in some people cause unusual problems. Certainly when I am treating someone constitutionally, I find that flu shots can sometimes cause people to backslide, relapsing into what we were successfully treating, whether that's migraines, ADHD, Lyme, or whatever. I have seen cases in which a simple flu vaccine seemed to be connected to issues that are difficult to fix after the fact. The science doesn't show this because vaccine safety studies aren't designed to find this sort of thing.

"Isn't the flu deadly? That's what they say on the news." Well, I know it certainly makes one feel like one is dying! And it does kill people--but the vast majority of deaths are in persons over 80. Basically, even a self-limiting disease can cause death in people who are very compromised. Most people do not die of the flu.

In short, the reality doesn't live up to the hype.

In my practice I have three bits of advice. Risk of getting the flu can be greatly reduced by good hand hygiene. Getting a flu shot may provide additional protection and in many cases won't cause new problems, but its value is way overstated. Finally, if you are leery of getting a flu shot, just remember that there are ways to reduce its impact if you should come into contact with it.

What's interesting is that one way to reduce its impact is to take your constitutional remedy. I find that people in constitutional homeopathic treatment are less likely to get sick, and when do get sick, it's usually not as bad. Elsewhere in my blog I talk about the use of some herbs to help boost immunity and soothe the soreness that comes with the flu. Any treatment for any sort of viral illness like the flu is best done early! So if you start feeling poorly, start your echinacea and call for a consult at your earliest opportunity.

We know it's coming, and there's a lot one can do to prepare. So stock up on your herbs and enjoy the good stuff that comes along this time of the year. Yes, it's flu season, but it's also The Holidays, so stay healthy and have some fun with friends and family.
Be well!

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