Monday, March 30, 2020

An Epidemic and The Psyche



Much is being made to night of this photo, and others like it, as the people of New York City gather to watch The USNS Comfort glide into New York Harbor.
Credit: New York Post
I write this because I am dismayed at the responses I've seen in the press--from Reuters to Breitbart to the Post--that these "bone headed" people are ignoring social distancing rules. I don't know how many ordinary people, who aren't internet pundits, feel.

Then I saw this on the evening news tonight, and I have to say I was moved at the spectacle of help on the way to a city that is literally (and perhaps justifiably) freaking out. Can you imagine, living in such a concentrated hub of humanity, thousands of cases, hospitals filling up. And then a white ship of hope arrives.

Hospital Ship USNS Comfort Arrives in New York | National Review
Credit: The National Review
Is it any wonder people broke out of their self-imposed isolation for a moment to welcome the help? I fear it is a peculiar disease of mankind that criticism comes easier than kindness. There has been kindness aplenty, and that feels like something healthy. This collection of masked and fearless New Yorkers is seen looking on, an old man grasping the barrier as if he were looking out of prison bars. 

I don't know. I just couldn't muster up any criticism of these people, clutched in this malignant grasp.
Hospital Ship USNS Comfort Arrives In New York To Ease Coronavirus ...
Credit: WBFO

The Pandemic, So Far

Speaking of malignant forces, how's this virus doing? I have reviewed the statistics from various locales and so far there is a consistent 1 to 1.4% mortality rate. There are outliers like Italy and Louisiana, but most experience run to about 10 to 14 people in 1000 will die. This breaks down to maybe 4 people older than 80, 2 or 3 aged 65-80, maybe 1 or 2 from my age group, and the rest lightly scattered in the remaining groups. 

Of course, we still don't know how many people get the virus and never get sick. They are carriers in many cases, but how would they know when testing is in such short supply? I think once we can estimate the number of people infected but not sick, plus those plausibly afflicted and perhaps tested, the illness rate and death rates will be lower. It's the contagiousness of this thing that got us discombobulated. Contagiousness is thought of as "R-naught"--R0. I've seen R0 rates of 1.4 to 3.7--that is, one person can infect 1.4 to 3.7 people, with the average settling in at about 2.5. Now this can come down if people, don't...um, congregate. But baseline, its R0 is higher than the flu (which we have a vaccine for, so, just sayin'). People who want to bring this thing under control want the rate to be less than 1 (then the number of cases will go down).

Social distancing is an imperfect tool to limit any epidemic. South Korea used a better tool: aggressive testing, selective quarantine, and contact tracing as a means of limiting the damage. Another shortcoming of social distancing and general area lockdowns is the social isolation it can lead to. Just because it is an imperfect tool, doesn't mean it shouldn't be used, especially if the better approaches, well let's just say it's too late for those. 

So one has to wonder: who should we really be pissed at? Our fellow, desperate citizens? Or the people who govern them? It is said that the people rule, but: leaders must lead. Our politics these days doesn't seem to lend itself to that. So the morgues get a little bit fuller, the dying die without family, we grow farther apart in both space and mind, and once again we're humbled by the power of Nature to impose her brand of reconciliation on a careless species. This can be expected to focus our attention.

Maybe the catastrophe is being pinned on the wrong culprits.  
Wash your hands and touch your face :)

Tuesday, March 24, 2020

Coronavirus Update

So it's been a while, because I teach a very intensive course until Spring Break. What better time than now to dive back into the blog?

I won't rehash the usual advice or news, since there's a constant fire hose of these all day long. I'm sure any readers of this blog are up to speed on hygiene, and of course what coronavirus is, and why people are worried about it. There's a lot of speculation out there: When will it peak? When will it decline? How many people may die of COVID-19? When can we go back to back to "normal" (whatever that ends up looking like)? But speculation is mostly a waste of time. Most experts will be wrong, either by a lot of a little. A few will say they "called it," but mostly they'll have just gotten lucky.

If it sounds like I'm a bit jaded by this experience, I am. In the middle of the chaos, there's no time to ask the deeper questions that need to be asked. Those deeper questions are what interest me the most, though, perhaps because I am only mildly inconvenienced by this catastrophe. There are many folks who are a lot worse off than just "inconvenienced," so I've mostly kept my thoughts to myself.

So, in no particular order, I'll go ahead. Perhaps it's time to share.

The Silence of an Early Spring
This was the parking lot at Target. On a Tuesday. At 11 AM.
Credit: Author
My spouse desperately need a new computer in order to teach from home, so we went forth. Nothing available. Here's what we found inside, at the Starbucks entrance inside Target.

Credit: Author
This is certainly the most closed down we've been since 9-11. Maybe more so. So far it's been difficult for people, but I haven't heard about any adverse health effects, such as suicides, homicides, relapse of depression, violence, or health problems directly attributable to the closing down of America. Perhaps my readers have, and perhaps I'm not paying enough attention. I am hearing about a lot of people turned away from hospitals, ERs, and doctors' offices because of the perception--I think--that it's just too risky to do your job in a time like this. 

The counter-argument: It is too risky to see anyone but the sickest COVID-19 patients right now!

But it isn't.

According to NPR, a Dutch researcher found that many health care workers were already infected with the novel coronavirus. So a lot us may already have had it--and not known it. No symptoms. Yet it's changing how we work. Just today a colleague of mine had to take her husband back to the hospital for readmission, because he was discharged--just days ago--"too soon" with a major kidney problem, because of the collective organizational worry about what's coming. 

I get it: How bad can it get? is the question that troubles hospitals, who are trying to create capacity for anticipated thousands of very sick patients, even though these acute shortages are only being really being seen in major cities. In the rest of Pennsylvania, the numbers suggest that while growth is geometric, some of this owes to increased testing. Deaths remain modest, with 6 out of 644 cases as of 2 PM Monday (most in the Philadelphia area), 1%, twice the rate death from the flu, but the flu has caused 128,000 cases and 100 deaths in Pennsylvania so far, and the season isn't over yet

So one question that I look forward to answering after we all head back to the Starbucks, when this is over, will be: What was it about this thing made it seem like a coming apocalypse? We don't take flu, or tuberculosis, or HIV seriously enough to devote efforts to limit their spread (or we'd already have enough masks and gloves in a stockpile somewhere). Why this?

Hydroxychloroquine

This is an antimalarial drug, but it's also used for autoimmune diseases like lupus and rheumatoid arthritis. A nationwide shortage of the drug now exists because prescribers are hoarding the drug for themselves and their families. I have a family member with lupus who is on this drug, and although I haven't heard from her yet, I have heard about numerous cases in which people with these serious diseases cannot get it, because it's been hoarded by the very people charged with helping the sick.

Perhaps the shortage of personal protective equipment has led to this behavior. Maybe not. Perhaps it's just self-centeredness, a doppleganger of the "self-ism" of many of our societies  in the West, in which individual "freedom" is believed to eclipse the common good.

Anyway, I found it interesting that in just a few days of this behavior, several people have died from taking this drug. (The link is just a couple of the cases reported so far--maybe this will cause people to rethink taking medical advice from a real estate developer.)

If you are considering, I would not recommend it. I myself would use a homeopathic remedy--at least the cure won't kill me.

Panic Buying

Or is it something else, maybe boredom? After all, we're pretty much left with just the grocery stores for outside entertainment in the presence of others of our kind. Here's an example:

Credit: Julie Moffitt
The pasta aisle at a local supermarket. I do hope none of this ends up in a landfill when it's too stale to eat. Maybe people will donate to food banks, especially with all the unemployed now coming online.

I understand. We're freaking out. But why? Should seem obvious, one could say. Deaths, lockdowns, mysterious, invisible invaders among us (sound familiar?), and all sorts of disruption with no clear end date. If I examine the real data so far, I can conclude that we have a serious health problem on our hands that mostly afflicts people 50 and older, that it seems alarmingly contagious but modestly fatal--the vast majority live when circumstances allow, such as healthy food supplies, clean water, avoidance of well-known bad habits (In China 52% of men smoke), and exercise some healthy behaviors, the fatality rate seems a modest 1%--and will probably be lower once we have a real denominator. We don't actually know how many people even are infected with the novel coronavirus.

Today I began to wonder Did we need something to happen? Were things too easy? Were we somehow bored? Did we need "a kick in our complacency," as Jean-Luc Picard put in Star Trek?
Things were not great for a lot of people, but we were tolerating it. This communal freak out accomplishes laying bare the inequities and poverties of many parts of the world, thus to inspire better discussions about how to fix those inequities. 

I mean, people are gettin' an education about their "health insurance". Am I right?

I'm not sure that I would say that people are somehow "causing" this. But this epidemic was probably influenced by the growing power of Chinese agribusiness, which like America's, forces the less wealthy to find other means of support, when they see a market to over-exploit.

In other words: systems move as an interconnected wave. It's not possible for me to imagine that this is objective decision-making in the face of limited data; rather it is the collective psychic seizure that for a moment frames everything into such relief, it can no longer be ignored. So...
  • We should have been better prepared for this.
  • Politicians politicizing catastrophe should be publicly flogged.
  • Individuals should have been better prepared, both by equitable wealth-structures and personal effort.
  • We need to have a real conversation about what's possible and what's desirable, real soon.
So that's going to mean new discussions. I kinda hope it upends the current political stalemate. That's what I'm thinkin' about. How about you?

Special Thanks: to Julie Moffitt. I love bouncing ideas around with you. Inspiration.

UPDATE 3/25/20: COVID-19 cases in U.S. 55,000; deaths, 801. From the CDC: "CDC estimates that so far this season there have been at least 38 million flu illnesses, 390,000 hospitalizations and 23,000 deaths from flu." Context.

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!