Tuesday, January 28, 2020

What is Dementia?

I ran across this on Facebook:

"One man turned nursing home design on its head when he created this stunning facility."*

It unsettled me. It's sad, it's hopeful. Mostly it endeared me. I have worked with many people living with dementia. Many times they seem blank, distant, unreachable. Occasionally they are irascible, combative, silly, or rude. They can be hilarious and good-natured. They can grope, throw food, or repeat the same word for hours.

They can stare at you like you are the last real person they will ever remember, just because you were there at a particular time.

I have often observed such people to display hallucinations, or speak as if to spirits, or describe the world in detail as it was 50 years ago, but to them it feels like today. I've wondered, "Is she just lucky to have such a pleasant hallucination?" when one has seen many appear to be having pretty frightening delusional experiences.

But then what is "delusional"?

Is it delusional to attempt escape of a fragile and painful body, immobile, perhaps fetid, through the agency of a flight of fancy that seems so real? Or perhaps it's an unsurprising that such a person could find themselves in a fearsome funhouse full of unfamiliar sights and sounds and strangers.

So I read this and found myself really liking the concept. Give in to the delusion. Why fight it? Too often we fight against Nature. There is no winner inasmuch as we all will die. Some believe they will go on to another life...but...why the rush? So much are we tuned into our embodiment of ourselves--our actual bodies--that it becomes hard to imagine actually leaving this mortal life. I feel that way. I like this life. This causes me to wonder if others, whose lives perhaps weren't so lucky, would actually be served by a magical delusion that seems so real.

Except when we interrupt it. Suppress its expression.

There's been a movement in geriatrics that aims at not trying to reorient our memory-challenged elders when they are having a delusion. I've seen this begin to spread in health care, and in fact our own students benefit from this research. So it's getting around. A good idea.

This gives me hope that we are really beginning to put aside our assumptions and lean into Nature. Without that lean we're just regarding things at a distance, struggling with our ignorance, and perhaps robbing people of a sort of restorative humanity they may need in their final days.

Peace.

* Although I did not verify this story, it's plausible, and seems like a pretty good idea in any case.

Sunday, January 26, 2020

Is The End Of Homeopathy Near?

The short answer is "no."

Over the past couple of years the US Food and Drug Administration has been reviewing the regulations governing homeopathic medicines. Mostly they have been trying to get at the issue of new medicines marketed over-the-counter for consumers.

In general I have been supportive of these regulations, since there is evidence that homeopathic remedies, used improperly, can cause harm. It's like I tell my students:

If it's strong enough to cure you, it's strong enough to kill you.

Well, "kill" might be an overstatement. I've never seen a remedy kill anyone! But I have seen some harms, such as when people repeatedly take high potency remedies that were not carefully prescribed. Dr. Hahnemann himself wrote in the Organon of Medicine that strong remedies in high potency leave their mark on a patient. I have referred earlier to an FDA recall of Zicam because of such problems.

Lately, I've been getting a lot of hysterical email blasts from various homeopathic advocacy groups, and a few emails from patients who are alarmed by these reports, which claim the FDA is trying to gain the authority to recall homeopathic single remedies, which are used in classical homeopathy for complex, constitutional cases, acute problems, and other maladies.

This is not true. For support I'll share this very well written report from the American Association of Homeopathic Pharmacists, here in its entirety in the link. But I'll direct the reader's attention to the crux of the report, as I see it:

"AAHP also believes that the greatest existential threat to the industry today is not FDA but rather manufacturers and distributors marketing products not in compliance with current Good Manufacturing Practices [emphasis mine]."

People who access "natural medicine" are often unaware that the manufacturers of such products still live and work in a capitalist world where the object is to make money. It may be many believe they're also doing good...but, they still have to make payroll! I've talked here many times about Big Pharma and how allopathic drug makers are often corrupt, greedy, and frequently develop drugs that are expensive yet have marginal effectiveness. One must not assume that because a product is herbal or nutritional and outside of the pharmaceutical regulation system, it's "okay." In fact it is because these products are lightly regulated that nefarious intentions can lead to economic opportunism. 

If one wishes to contact the FDA about these draft regulations, one of the best things you can tell them is about the benefits of homeopathic single remedies to your health, and the importance of their continued availability. Expressing support about existing homeopathic medical practice reinforces with them that there's a constituency that values access to homeopathic single remedies.

Be well & stay warm!

Sunday, December 1, 2019

Vaping Illness Cause Found


The Centers for Disease Control has reported on the cause of vaping illness nationwide--and it confirms my original theory: a chemical contaminant.

Vitamin E acetate
From Alibaba Market Website.
Vitamin E acetate is "generally recognized as safe" (GRAS) by the US Food and Drug Administration if you consume it by mouth. It's actually pretty bad for you if you heat it up and vaporize it to be inhaled, turns out. This was known prior to the vaping illness outbreak, but I guess it wasn't known to the hundreds of basement chemists and homegrown vape-hackers cooking up juices published on internet discussion forums, or sold in the grey market through online stores. I found this at Alibaba, a China-based worldwide online seller equivalent to Amazon. It's not a substance that we can just stop selling or your vitamin E capsules would cost $100!

As I have mentioned previously, this is what happens in a market that is growing in an atmosphere of conflict between two sides. On one side you have free-market innovators aiming to make a buck and provide a low cost alternatives to tobacco use to people who either wish to quit smoking or to people who would like a safer alternative to nicotine use. Without any guidance or regulation, this vaping illness caused by a chemical made toxic by inhalation was bound to result.

I'm pretty sure that people cooking up new recipes for vape juices (like "Beer" and "Peanut Butter"--I mean really, who wants to inhale the flavor of beer?) aren't also looking to poison people to death. But absent leadership from health experts, researchers, and government agencies, what did you think was going to happen?

On the other side, you have these three players--health experts, researchers, government agencies--and basically all they have done is freak out about people getting addicted to nicotine, tried to ban flavorings, and aim to ban vaping outright. This is not productive, but it reveals the true character of many in the public health field who believe it is their right to legislate their idea of good health behavior.

Trump supporters expressing 
their views on the prospect 
of a vape-flavor ban. 
From CNBC.com
This has led to a peculiar recent political phenomenon as Trump voters began protesting an anticipated federal ban on flavored vaping products.

As I have argued previously, nicotine is not itself especially harmful. Finding this information in official medical databases isn't easy but is possible, and this article from Forbes provides a nice summary. I have also argued that, despite the fact that vaping is not completely harmless (what is harmless? breathing clean air!) it is way less harmful than smoking. So for people trying to quit using tobacco, and for those who don't intend to quit but who would like to reduce their level of harm, it is a reasonable alternative (further research may modify my stance on this, but so far, so good).

Harm reduction  is the approach to managing the instinctive human drive to seek pleasure, often from various substances such as drugs. Measures that would reduce harm in this case include a partnership between government and industry--including small-scale industry and not just Big Tobacco companies--to develop a list of safe ingredients for vape juices; enforced bans on both retail and internet sales of vaping products to young people (whether this ends up being 18 or 21 or somewhere in between); research that avoids the biases against nicotine, and against human pleasure; and perhaps a real conversation about how it is we wish to regulate adult behavior in pursuit of pleasure.

No matter how you feel about the President, he is paying attention to the wishes of a lot of ordinary people, and he seems to understand this libertarian streak, as the ban has been placed on hold for now. It is reasonable to ban behaviors that place the public at great risk, especially when that risk extends to people who don't wish to engage in a behavior but are affected by it. Think, the ban on civilian use of hand grenades, or tightly regulating highly addictive drugs like morphine that can be dangerous even to bystanders when mis-used.

It is reasonable to enforce a ban on children having access to dangerous products-of-pleasure, such as alcohol or the free use of motor vehicles. Kids need time to grow into effective decision-making. It is reasonable to require warnings, or training, or licensure for things that can wreck society around us. But it's not reasonable to pass rules that only satisfy a particular, scolding constituency, or create a more dangerous black market, or end up hampering a potentially harm-reducing phenomenon like vaping.

One might argue about the public health costs of vaping, but I would note that we don't yet know what the costs are and indeed, the benefits in reduced combustible tobacco use might outweigh the less costly harms of vaping. We just don't know yet, so why assume? Furthermore, we must admit that there are cultural and political dimensions that come with evaluating vaping,  because these are the same dimensions that come with considerations of alcohol, tobacco, and now marijuana. On a scale of known harms, alcohol is more harmful than vaping, at least the preliminary evidence strongly suggests. We tried banning alcohol. See where that got us? We need a more honest discussion in our society about personal responsibility, community responsibility, and human nature. This discussion wouldn't focus on a "yes/no" or "us versus them" polarity. Rather, it should be willing to admit human prerogatives in a free society, the limitations of assigning a monetary value to every human decision, and the fact that people aren't perfect, not can we make their lives "perfect"--if we even know what that would be.

Sorry it was so long in writing--it's been a pretty busy semester--but Thanksgiving break has provided a window for me to catch up. So let's all give thanks at this giving time of year.

And now, I'm going to give my students their grades

Sunday, September 29, 2019

Vaping Illness Update

This matters to me because I have found evidence--both in my clinic and in the scientific research (mostly from Britain)--that vaping is 1) less toxic than smoked tobacco, and 2) a means of achieving harm reduction in smokers.

Most people have heard about the 800+ Americans who have suffered from a mysterious lung illness, a kind of pneumonia that doesn't appear to be caused by some germ. It's an "inflammatory pneumonia" and some who have it have gotten so ill they've ended up on breathing machines, and a few have even died. The FDA and Centers for Disease Control have suggested that--until a cause can be found--vaping should be avoided.

What is vaping?  
A vape-pen and vape liquids.
Photo: U.S. Dept. of Defense.

For the unfamiliar, "vaping" is the use of electric vaporizers to heat a liquid so that the resulting vapor can be inhaled. "Vape juice" is usually based on some combination of vegetable glycerin and propylene glycol, a sugar alcohol, and this somewhat thickened base mixture is then flavored to recreate flavor experiences like "tobacco", "cigar", or novel flavor profiles like fruits or candies, or spiced profiles like menthol or clove. Vaping began with nicotine added to recreate the drug experience that tobaccos users seek, but in short order it was obvious that other drugs could be added, mainly THC from marijuana, to create a smokeless product, without the tars, carcinogens, and carbon monoxide of actual smoking.

History and Use

Tobacco smoking has been in decline for the last few decades. Smoking's out of fashion. So-called "e-cigarettes" were developed about two decades ago but never caught on. With time, the technology got better and e-cigs started to gain traction among consumers. Some used them as a some-time alternative to cigarettes. Some used them as a transition to quit. Others tied them but went back to tobacco. In the last 5 to 7 years their use has grown, especially among teenagers, who are attracted to the flavors (examples: "bubblegum" "pina colada" etc.) and then get hooked on the nicotine.

A lot of people don't know that vaping can be done without nicotine added. But then you ask, "why would anyone do that?" It's simple: it's an activity. It's a thing people can do together--sit around and puff out vaporous clouds, clouds that taste like cherry syrup or cinnamon donuts or Froot-Loops!

There's evidence that nicotine isn't great for teenage brains. And really, is 16 old enough to start making decisions about trying addictive substances? So there's one problem: regulation and control of the industry. But then there's a flip side. With more regulation and control, an industry consolidates, and when it does, it tends to be big players with lots of money who dominate, forcing consumers into a narrower array of product choices, and encouraging others to black market products that are cheaper, or that come in flavors and such that the big companies don't produce.

Public Health England, a research group in the UK, reported that e-cigs/vaping was 95% safer than smoking and could help smokers quit. The researchers admit that data are preliminary, but enough has been accumulated to make some early arguments that vaping should continue to exist and that it should be regulated for safety.

So What's the Problem?

Over the last several months, as doctors started to notice these weird cases of lung disease and their connection to vaping, reports mounted, leading to public health investigations. This article from Buzzfeed News in September suggests the 5 best theories that explain the current crisis. In reporting from the CDC we're now up to just over 800 cases and no single factor explains them all. The CDC has seemed to focus heavily on accounting for the active drug, and THC vaping has been implicated in over 3/4ths  of cases. However no single flavor, drug, or brand is marked in all cases.

My own theory? I think it's a contaminated or poor-quality ingredient, and researchers have reported that vitamin E acetate has been found in a very high number of the suspect vape juices they tested. Maybe heating up vitamin E acetate and getting it into one's lungs is a problem. What hasn't been reported on yet is how heavily the people afflicted with this illness vaped. I also wonder if it's a combination of factors.

After all, Americans have been vaping for over a decade. Millions have done this, and we're only really seeing this critical mass of cases now? Why doesn't smoking cause this illness? Is it that some people may be genetically predisposed to suffer from vaping illness? There is a gene group that could explain this, and it's one we've known a little about for a long time, but in the last five years we know a lot more about it. Is it the unregulated market? The internet is full of recipes for vape juices, and the ingredients are largely uncontrolled chemicals such a glycerin and propylene glycol, both used widely in foods and pharmaceuticals. Isn't it possible that with the vast array of do-it-yourselfers and entrepreneurs out there, and the equally vast array of ingredient sources, and the near-limitless combination of possible ingredients--both drug and flavoring--that there would be an outbreak of illness from contamination at some point?

What to do?

For many of my readers, this may not be an issue. A lot of my patients and readers don't smoke and don't vape. But what if you are a smoker and wish to vape to reduce or eliminate your dependence on cigarettes? What if you quit tobacco, but are habituated on vaping? Well, first off, the percentage of cases in the overall number of people who vape is small. Reputable products from above-board suppliers are causing a tiny minority of cases of vaping illness. Second, in no way is vaping as bad as smoking. If you've quit cigs but still vape, you are still far better off than if you still smoked. Third, why not use nicotine substitutes like patches or gum to wean yourself off? If you can, that's great, but vaping addresses a behavioral aspect of the habit of smoking that some people are as attracted to as the nicotine or THC itself--I hinted at this above when I noted that some people vape without any drugs in their vape juice. So if vaping satisfies that "puffing behavior"--often social or contemplative--and you would just go back to smoking cigarettes or cigars to avoid vaping illness while keeping the behavior, I think that's a bad idea.

Stay tuned, because at some point we're going to figure this out. I hope it doesn't lead to the widespread banning of vape products (it would just become a black market industry anyway, and then anything can happen!) Above I mentioned "harm reduction"--this is the drug management philosophy that argues that people are going to use drugs, no matter what. It's what we do (even if you personally don't), so why not make the thing as safe as possible? Encourage people to quit, but also give them a safer alternative to the worst effects of the use of a drug or behavior. 

Image result for how many people vape in the us
Cited in: BBC https://www.bbc.com/news/business-44295336

If there are an estimated 42 million users worldwide (and the US has the vast majority of users) then this means even at now-800 cases, it still amounts to a risk of 0.0019%--or about 1 case for every 52,500 users. So the message: it's ultimately safer to not vape, but it's pretty safe compared to tobacco smoking, in which the numbers look much worse (I've noticed that acute pneumonias related to tobacco use haven't been mentioned in any of the press coverage!)

Interested in a longer discussion? From CBS News with public health expert David Abrams I share this video.

A Final Word

This article is not intended as medical advice, as all of my articles are educational in nature. If you vape and notice chest pain, increasing shortness of breath, or you require additional assistance, seek medical advice from your own provider. 

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