Sunday, June 19, 2016

Medical Drugs as Lifestyle Choice

Omeprazole was invented in 1979 and marketed in the U.S. by 1989, under the name Losec, which was changed in 1990 to the name Prilosec that we know today. It's the first of a class of drugs called proton pump inhibitors (PPIs). Basically these drugs reduce the production stomach acid (hydrochloric acid) from the cells of that organ which produce it. A lot of people think stomach acid helps digest food. That's only sort of true. Really all it does is break down some of the bonds in protein-based foods, but it doesn't digest food per se. The acid does signal the intestine to get ready to do the actual work of digestion. And it helps reduce the number of germs we ingest when we eat.

In people with heartburn and "reflux"--a condition in which the stomach acid splashes up into the base of the esophagus and causes pain, cough, etc.--and in people with ulcers, these "PPIs" help to reduce the acid enough that the stomach can heal a bit.

When these drugs first came out, they were prescription-only, and they were said to be limited to 8 weeks' use. There was a concern that they could cause stomach cancer if used too long. Over the decades, evidence for this didn't emerge, and in June 2003, the U.S. FDA approved omeprazole for over-the-counter use.

Now, it's hard to turn on the TV without running into Larry the Cable Guy (comedian Daniel Lawrence Whitney) selling Prilosec OTC. He's also usually seen enjoying foods traditionally thought to cause heartburn: fried chicken, barbeque, and so forth. The idea you're supposed to get is that if you want to eat that junk on a regular basis, just take some Prilosec OTC and you can go nuts on potato salad, hot dogs, and beer. Here's a typical commercial:

(By the way, food is only a small part of heartburn, reflux, and ulcer disease.)

Sometimes it takes quite a while--and a bit of careful observation--to sort out the real hazards of a drug or class of drugs. With PPIs we've been learning some interesting things.

One is this little tidbit from the Journal of the American Medical Association: Neurology (JAMA Neurology), from February, and follows up on and confirms the findings of a previous and smaller study. Turns out that the risk for dementia increases with the use of PPIs.

Now don't freak out if you have taken Nexium or Prevacid or something like that for a short period, say, to treat an active stomach ulcer or esophagitis, because it's likely the benefits far-exceeded the risks. And if you have used one of these a few times for bad heartburn, don't fret. This study looked at duration of use of these drugs. Basically, the more the subjects had used these drugs, the more likely they were to be diagnosed with dementia. Duration of use had to be over 18 months to be really significant. More intermittent "regular" use was associated with lower risk. Occasional use didn't display any significant risk. The study controlled for many of the other possible causes of dementia.

Research shows that up to 70% of the use of these drugs does not fall into the recommended guidelines for their use. In other words, some comedian on a TV commercial says "Hey take this for heartburn..." and that's what people do. If you clicked on the video link, you'd see the safety caption warning against use for longer than 2 weeks. But I ask: do you think people really follow that?

In my experience, people often self-treat until they can't anymore. And doctors often have people on these drugs for years.

My aim here is not to criticize what may be some medically appropriate drug use (Rx or OTC), but to illustrate how unintended consequences may stem from the casual application of therapeutics we don't fully understand, especially when that application rests on a relatively shallow "suppress the symptom" approach to health and healing.

And fried chicken? Heck, that's ok now and again, but should we really be encouraging people to use OTC drugs to promote eating badly? What about the basic causes of such digestive complaints? Shouldn't we, at some point, ask ourselves if there's a more fundamental treatment to get at the cause or imbalance that led to the complaint? This is why I do what I do. Homeopathy, Chinese medicine, and other medical approaches that try to get at the root imbalance often reverse the problem, and hence reverse the symptoms, as opposed to merely suppressing them, the duration of which may be indefinite!

Sometimes we need drugs. Sometimes we need to suppress a symptom to relive short-term suffering, to get a handle on things and buy some time. But do we need to promote this approach as a lifestyle?

Sunday, June 12, 2016

End-of-Life Concerns

The second thing of interest to these seasoned (and a few not so seasoned) RNs was end of life issues. This is also a concern of mine. I gained an interest in it over the last several years, while teaching a professional development course to RNs. It's a survey course: we cover a number of topics, and I really try to elicit their concerns and then incorporate their concerns into the material.

One thing that emerged was the distress they feel during resuscitation efforts in the hospital. People outside of the business mostly get their experience with resuscitation--essentially CPR--from TV. They call a "code blue" or simply a "code", and a few super-efficient doctors and nurses rush in, pushing gingerly on the chest. That's not real CPR. If they were doing real CPR the actors would be compressing the chest about 2 inches--and you'd likely hear some ribs cracking. CPR is rough stuff!

Survival isn't great, either. Various studies have found that survival with out-of-hospital CPR is less than 20% or less than 1 in 5, and often less than 1 in 10 cases. Even when cardiac arrest occurs in the hospital, survival isn't much better, although it may rise to about 40% under the best circumstances. This would maybe be a patient who arrests on the operating table and perhaps because of the anesthesia. Those cases are pretty easy to save, comparatively speaking. They're also ideal. I mean, you're right there with all the drugs and the defibrillator and the best people to revive you!

That's not most cases.

Survival with full mental function to leave the hospital, that's even less common. People are often led to believe that when grandma wakes up after CPR she'll be ok. But odds are she'll never wake up, and if she does, she'll be in considerable pain and perhaps have suffered some loss of mental function from the lack of oxygen to the brain, depending on how long it took for CPR to start, how long it took to get a heartbeat back, and grandma's other health issues at the time.

As an ER nurse and an EMT, I worked a lot of "codes". Hardly anyone ever lived. That's partly because a lot of them were performed on the very elderly, many of whom already had significant disease. The few who did survive? They were mostly younger, and the cardiac arrest was witnessed by us. Arrests in "the field"--outside the hospital at accident scenes or in homes--things weren't so good. We would bring those folks sometimes, but then they'd go to intensive care and die again there.

Pretty grim stuff.

What a lot of the nurses and doctors suffer from is just a sense of fruitlessness and sadness over this. Yes, it's hard to lose a patient, but it's often even harder to participate in these efforts when you feel like you're just abusing a corpse. Since a lot of folks getting coded are older and sicker and frail, it is appropriate to just let go. Why doesn't that happen more often?

Mainly, it's a lack of communication between health care workers and patients and families. Now it is true that a lot of times, there is good communication, and many times we allow natural death to occur. That can be a good, well-planned death when the diagnosis is fatal and hospice services are at work. (I do some hospice work, so I've seen this a lot.) But a lot of families aren't fully appraised of just how fatal a family member's condition is, and there's been no discussion of the circumstances in which the hospital staff can allow death to occur.

I've been to codes--and so have my students--where families are in conflict about this decision, even when the patient himself made his wishes clear. There's also a lot of misunderstanding about what a "living will" and similar documents mean. For example, it is typical that a living will or other health care power of attorney doesn't go into effect unless the doctor has declared that a person is terminal, or if in a persistent vegetative state, that is, brain dead. Or it might be in effect if the person simply won't wake up and have any life quality.

So a living will isn't a will to forestall CPR. It's just a statement of assent to the withholding of lifesaving measures in the event that the person is in one of the specific states I described above.

A "DNR"--"do not resuscitate"--is an order written by a physician, and in some hospitals, it can be written by a nurse practitioner or physician assistant, who is working on a team with a physician. Some hospitals call them levels, and so a level 1 is "do everything". Level 2 is don't do CPR but you can use drugs like adrenaline to try to bring someone back, and so on. They usually go to something like a "level 5" or comfort-care only.

Most people don't realize that such orders are routinely suspended if someone goes to the operating room, even for a "comfort" procedure. This is partly because sometimes the anesthesia itself caused the cardiac arrest--so why not just reverse a doctor-caused problem anyway? But it is also because surgeons are graded, in part, on their intraoperative death rate, so they don't want anyone dying on the table.

What bugs me about this is that nurses and doctors often don't tell patients or their families that this will be the case. They just don't like having the conversation. For my students, I try to teach them how to advocate for their patients' wishes, how to negotiate with often-reluctant doctors and families, to have more productive conversations. Sometimes it can be enough that a patient simply says "if my heart stops, don't bring me back." The nurse or doctor can then chart that information as a legitimate expression of a person's last wishes, and write the DNR order.

I said in another post that I'd discuss how what I teach my students says about health care in America. Recently, Atul Gawande, himself a doctor, wrote Being Mortal, on how we do death in this culture. We don't do it very well. We're often convinced that medicine and surgery will cure everything. We often allow popular culture to convince us that technology can do more than it does. We don't stop to think what it might be like for our loved ones, having their chests broken, having tubes shoved into lungs and veins and bellies. You might think that "unconscious" persons don't hear or feel. They often do. How miserable it must be to suffer those physical insults when all you wish to do is die peacefully.

So if I could give one piece of advice to everyone, it would be the advice I teach my students: make the conversation happen before it's too late.

Sunday, June 5, 2016


Narcotic pain medication is big news these days. Thousands of people are reportedly addicted to opioid pain medication, like Percocet or Vicodin. Many more are using heroin--these days it's a lot cheaper than a $40 Norco pill bought on the street, and less fuss than trying to get legitimate oral medication from a doctor's office. Some doctors have managed to turn their offices into "pill mills", complete with an armed guard at the door. Overdose deaths have risen. Musician Prince, we learned this week, seems to have died of an overdose of the prescription drug fentanyl, a drug roughly 200 times more potent than heroin. 

The result: laws passed giving police and EMS personnel the authority to carry and administer the drug naloxone, which blocks opioid receptors in the nervous system, and can reverse an overdose before death occurs; increases in training for physicians and nurses on how to prescribe and use narcotic pain medication; and new guidelines from national organizations on when to use--and when not to use--such medicines.

Last time, I said I'd share some bits about what today's nurse wants to know more about and what it says about health care in America. Today we'll start with the "Opioid Crisis". 

RNs fulfill a variety of roles here. Yes, they administer pain meds in the hospital, but they also manage panels of outpatients in clinics that need to treat pain, like orthopedics or pain management. They survey what patients are using during medication reviews and help fill pillboxes in those who have difficulty managing their meds, like some elders or folks with mental health problems. They teach patients how to use their meds safely, and because of their more regular, closer contact with patients are often the first to see that a person is showing signs of a drug problem. They advocate for patients, too, and are often the ones requesting that pain meds be increased, decreased, or adjusted based on changes in a patient's condition.

So when today's news describes growing numbers of overdoses, patients causally prescribed opioids for all sorts of ills, and the emergence of cheaper heroin, nurses want to know how to deal with all that. In the mini-mester course I just taught, the syllabus is broadly written enough to allow us to be topical with our lessons, so I polled the incoming class, 14 nurses from local hospitals and agencies, working on their bachelor's degrees, and asked what they wanted to learn about. Several of them said they wanted to learn more about these changes in how we prescribe and monitor opioids.

They know the history: that in the mid-20th century it was hard to get doctors to take pain seriously and prescribe adequately. They know that in the late 1960s nurse Margo McCaffrey was advocating for more humane pain treatment, having written that pain is, “whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffrey, 1968, p. 5).

She wasn't trying to create an epidemic of overdoses. She just wanted people to suffer less.

If I ask the question, "what is pain?" to these seasoned nurses, they all reply with essentially this quote from McCaffrey. Mission accomplished. 

There's also a lot of suspicion. Nurses and doctors routinely suspect patients of "drug seeking", and sometimes they are right. Sometimes they aren't seeing the bigger picture. As the largest consumers of prescription and non-prescription drugs in the world, Americans seem more prone to medicate than other societies. We often think of drug use as something people do to "party", but as Hanson, Venturelli, and Fleckenstein (2014) note, a lot of drug use and abuse is for "illegal instrumental" purposes. That is, people are self-medicating, not just getting high for fun.

In short, understanding why a society uses drugs the way we do, understanding how medical professionals see their role in managing problems humanely, and building a coherent educational program around those issues is a real challenge. For the course I just taught, I included the Centers for Disease Control's new Guideline for Controlling Chronic Pain.

Bear in mind, this is a reaction to the sudden wave of overdose deaths and the growing problem of people addicted to prescribed pain meds. One thing that struck me was the following passage, "Benefits and Harms of Opioid Therapy":

This screenshot is just a bit of the section, but I read it and not a single "benefit" was stated. The entire section is about "harms". Why is this a concern to me? Because too often our health care system is less about science and more about culture. I know what will happen: doctors will go from generously (and carelessly) prescribing opioids to refusing to use them at all.

My working nurses, these students I taught in May, reported routine prescriptions for post-surgical patients for 30, 60, even 90 tablets of opioids. If the prescription is for "1 to 2 tablets every 4 hours as needed"--which by the way is a perfectly correct prescribing of, say, Vicodin--that means a few patients could end up using as many as 12 tabs per day, or upwards of 36 in 3 days. If one doesn't want calls in the middle of the night for more meds, then you write for 30-60 tabs. That'll cover the worst case scenario.

And what happens in most cases? People take a few, maybe one or even none. What happens to the unused meds? They end up in the toilet...or in some enterprising person's hands, to be distributed, sometimes for money, for other people's pain--or fun. By the way, the ones we flush? They end up in your water supply because treatment systems aren't equipped to remove drugs from the wastewater stream.

In our class discussions we concluded that we need a more complex, nuanced national discussion that encompasses more realistic goals for the use of these drugs. Health care workers often operate with fear running in the background: fear of being sued, fear of delicensure, fear of criticism from colleagues, fear of hospital administrators. When leading organizations like the CDC assemble unbalanced, sloppy "guidelines" like the one depicted above, it contributes to this culture of fear that drives health care workers to the lowest common form of practice. Hysteria, driven by salacious news (overdoses, "pill mills") ends up creating a new culture to displace the old one.

I expect that new culture will bring some genuine innovations--and I did highlight several of these in the class, like the use of regional pain blocks for certain routine surgeries. But I expect the new culture will bring on more suspicion, and the undertreatment of pain, too. 


Hanson, G.R., Venturelli, P.J., & Fleceknstein, A.E. (2104). Drugs and Society (12th Ed.). Burlington MA: Jones & Bartlett.

McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.