Treat every patient with respect and dignity.

These are values I try to live by and incorporate into my daily work.  Treatment of chronic pain is the scenario that puts me and every practicing primary care physician in a no-win situation regularly in the office. To try to make physicians feel more comfortable treating pain most states have tried to legialate guidelines.  This has been little reassurance.  In Washington all I have to do to comply with the guidelines is to follow a comprehensive 4 page list of recommendations. Washington is helpful by also legislating recommended responsibilities for patients.   For physicians they state: “Subjective reports by the patient should be supported by objective observations. Subjective reports by the patient should be supported by objective observations.” 

For patients they state: ”The patient should demand respect and expect to be believed.” 

How the physician can be expected to “believe” the patient, yet not rely only on subjective history by the patient but have objective evidence often for problems where no objective evidence exists, is the inherent flaw in trying to define and regulate pain management.

Add this to the environment in which we practice.   Each week for the last three weeks I’ve had a young male, ages between 21 and 25, present to the office asking for help in one way or another for addiction to Oxycontin.  In each case the patient had never received a prescription from a physician for an opioid.  Each time they had taken the drug first when supplied by a friend or coworker, either for treatment of pain from a minor self-limited problem, or for recreational use.  Each time there was a quick progression, over weeks to months, from occasional use, to regular use, to daily use and addiction.  So far in each case, thanks primarily to supportive parents and patients with a strong desire to get treatment, I’ve been able to aim them towards a treatment facility where they could get help.  I’m not a naïve or casual observer of the current prescription opioid epidemic in America.  I’ve posted several times on this and related issues. (See Can’t find a doctor to prescribe pain meds?  and Oxycontin: What’s the big deal?  Still I continue to be amazed at how readily available Oxycontin has become for recreational use.  This is a medication that is a Schedule 2 controlled medication, meaning to get a prescription you need to have a written prescription on forgery resistant prescription pad paper, and cannot get a prescription with refills.  Despite these attempts at preventing abuse, the drug seems to be easily available for abuse. To add urgency to this problem is fact that accidental overdose from prescription opioids is at epidemic proportions.

Without any doubt the posts on DrPullen.com that have had the most interest have been the posts on pain management.  The most passionate comments have been from patients with chronic pain who feel that their need for opioid management of their pain is underestimated, undertreated, poorly understood, and that they are treated without compassion or respect.  Unfortunately some of them are right, but the incredibly widespread abuse of prescription opioids at this time puts physicians in an impossible position.  We are supposed to both show compassion and adequately treat non-malignant pain with the same drugs that professional patients and opioid abusers seek to get prescriptions.  All this is in the face of treating a condition, pain, for which there are only subjective scales to quantify and for conditions which often are diagnosed strictly on what the patient tells us, without any objective evidence of their existence in a given patient. 

You could compare this to being asked to look at a young person and sell them alcohol based on their general appearance to decide if they are 21 or not, and if you guess wrong, having the possibility of being punished for wrongly selling to a minor.  There is no state authorized ID card to tell us which patients who look like they have pain from fibromyalgia, interstitial cystitis, peripheral neuropathy, lumbosacral disc disease, or lots of other conditions.  We are simply left to do our best to make a good judgment.  Patients are just left in pain.  This whole scenario stinks.

I’m not alone in struggling with this dilemma.  An FDA policy called REMS (Risk Evaluation and Mitigation Strategy) for opioid prescriptions has been a unique approach to addressing this problem. The complex issues related to this policy are nicely discussed in a Pharmacy Practice News article for those of you interested in the details of this debate, but the bottom line is that no one has figured out an approach for the prescribing physician to use to confidently use opioids to help patients manage pain without inadvertently being deceived into prescribing opioids to those patients seeking drugs to sell or abuse.  It’s unlikely that regulations and legislation will provide helpful tools to address this mess.

Most physicians have become really defensive in response to this difficult if not impossible situation. In Pierce County, WA, where I practice, it is nearly impossible to find a primary physician willing to accept a new patient who requests continuation of prescriptions for significant quantities of opioids for pain management.  It’s a shame that we have reached this impasse in care of pain in our country.

My first experience with a bedbug bite patient happened while I was on a Christian retreat at the Young Life Malibu camp.  While there a young child developed a reddish rash, that looked like an allergic or hypersensitivity response to some sort of bites.  They got worse each day, and after much head scratching and discussion the conclusion was that there were bedbugs in the apartment where the child and her family were sleeping .  The doctor at the camp actually went into the room and caught one of the bugs, and used the internet to compare it to photos, concluding that it was a bedbug.

It turns out that since the 1990’s there has been a major recurrence of bedbugs in the USA.  No one really knows why this recurrence has come up, and there has been a noticible lack of research on bedbugs. Fortunately there are no known diseases spread by bedbug bites, and although a significant nuisance, it seems to be a relatively benign problem otherwise.  For a nice dialogue on this problem read the NY Times article by Donald McNeil Jr. originally published on Aug. 30, 2010.

They Crawl, They Bite, They Baffle Scientists

Why does High Fructose Corn Syrup spook ‘health-conscious’ eaters, parents and nutritionists alike?
By Brooke Douglas, RD, CD

If you have listened to the mainstream media you may have been misinformed. HFCS has been labeled “the Devil‟s candy,” a “sinister invention,” and “bad for you, crud.”

But is it really all that bad?

Simply stated, the answer is “NO.” Actually, most people fail to realize that HFCS is composed of the exact same sugar combination found in table sugar and honey (fructose and glucose) in virtually the exact same ratios. The name “high fructose corn syrup” simply distinguishes it from other forms of corn syrup, meaning it isn‟t any higher in fructose than sugar is. I say it was a bad name choice; maybe they should have named it, “Bob?” Regardless, many credible studies have been published clearing up a lot of the misinformation on HFCS. The American Medical Association concluded, “There is no difference in how the body metabolizes high fructose corn syrup, table sugar or honey. They are indistinguishable once they reach the bloodstream. High fructose syrup does not appear to contribute to obesity more than other caloric sweeteners.”
As a derivative of corn, this alternative sweetener was created in the late 1960‟s in order to be used in foods and beverages because of the many benefits it offers. HFCS is what makes our ‘moist’ breakfast and energy bars moist. It keeps food fresh, enhances fruit and spice flavors, retains moisture in bran cereals, maintains consistent flavors in beverages and keeps ingredients evenly dispersed in condiments. Over the last 30 years it has become a hard-to-avoid staple of the American diet. HFCS provides the sweet zing in everything from Coke, Pepsi and Snapple iced tea to Dannon yogurt and Chips Ahoy cookies. It also lurks in unexpected places, like Ritz crackers, Wonder bread, Wishbone ranch dressing and Campbell‟s tomato soup.

The news media and a myriad of web sites and blogs continue to mistakenly report that obesity and diabetes rates have climbed at a remarkably similar rate to that of HFCS consumption. Yet, the nutrition science community reports that if the consumption of HFCS has increased in America, then so has all the other food categories. In other words, we are eating more, 24% more total food intake to be exact. We are not eating disproportionately more HFCS; we are eating more of everything! HFCS can only contribute to weight gain when it is eaten as excessive calories, regardless of the food source. Replacing HFCS with sugar, in our processed foods, will not reduce obesity or improve health.

In fact, many parts of the world, including Australia, Mexico and Europe, have an obesity epidemic and rising rates of diabetes despite having little or no HFCS in their food and beverage supply. This supports findings by the U.S. Centers for Disease Control and the
American Diabetes Association that the cause of increasing rates of obesity and diabetes in America is not HFCS. Rather, inactivity and excessive calories, from whatever source, promotes weight gain and therefore, diabetes

Dr. Walter Willett, current chairman of the nutrition department of the Harvard School of Public Health stated “If there was no high fructose corn syrup in our food supply, I don’t think we would see a change in anything important. I think there is an overreaction to HFCS. There is no credible evidence to support the idea that high-fructose corn syrup is somehow responsible for the increasing trend of obesity and diabetes in America.”

Unfortunately, some people have found it easier to look for one single ingredient to blame, like high fructose corn syrup, for all of America‟s weight gain woes. Even former critics of HFCS have dispelled myths and distanced themselves from earlier speculation about the sweetener‟s link to obesity in a comprehensive scientific review published in the December 2008 American Journal of Clinical Nutrition.

Respectfully, to all the “naturalists” out there, the real science does not support the bad rap! Whether it is mercury concerns or ADHD theories, the science does not support singling out this one sweetener. Besides it takes our focus off the larger nutrition picture. „moderation not deprivation” AND spend less time sedentary! The small, smart choices we can make each day to promote good health quickly become good lifestyle habits!

All this is good, but I think I really like Unna boots because it is one of the times where as a family physician I get to use a hands-on therapy that really works.  It also just feels good to apply the cool, soothing bandage to the patient’s leg and see them feel better almost immediately.   In addition it’s a treatment where I see the patient weekly, and when it works well we see regular, fairly steady improvement.  Almost always patients are really happy with this treatment, though it usually takes far more visits that they would like.

      *Also on $4./ month at several discount pharmacies.                                                                                                                          

The annual potential for cost savings after next year from this generic alone can be in the range of >$5 billion for the US alone, and <$1500./ per patient if atorvastatin pricing approximates simvastatin pricing after it goes generic.  Let’s celebrate the little bits of good news as they come along.

 August 16, 2010, 6:17 pm    By TARA PARKER-POPE

Vaccination Is Steady, but Pertussis Is Surging

For four weeks, my 11-year-old daughter has been coughing. It is not your run-of-the-mill summer cold, but a violent, debilitating cough that takes over her body, usually at night.  Read more

The PARP drugs so far have been well tolerated and seem to have few serious side effects.  Cheers to out to our bench scientists doing basic science for discovering these DNA repair pathways, and taking that knowledge and using it to develop yet another promising class of drugs.  I have a vested interest in these trials as my wife has a BRCA2 gene mutation and is getting treatment for advanced ovarian cancer, so stay tuned for any further advances in studies on these new drugs.

Click the title below to read this beautiful article.

Dear Dr. B.,

R. was in 08/09/2010.  He is 2-years 9-months-old, and dad says he runs into things.

He appeared to have good central maintained fixation in each eye.  The eyes look straight at distance and near.  They deny any crossing.

After dilation, unlike the last 10 children who are 2 years old and run into things and whom had normal eyes, R. has 7 diopters of farsightedness.  He needs to wear glasses and will be checked in 2-3 months.  I talked to his dad about this.

Sincerely,

Dr. S.

Dr. S has been around for a while, and had the confidence and sense of humor to make his letter not just functional but entertaining.  Many thanks.

Does Botox Paralyze Emotions as well as Muscles?

Written By: Dr Kristie McNealy

We know that Botox paralyzes muscles, but could it paralyze your emotions too?

Botox Cosmetic, a pharmaceutical product made from botulinum toxin, is used by many to paralyze facial muscles in order to reduce fine lines and wrinkles.  Because of this muscles paralysis, Botox has the potential side effect of preventing people from conveying their emotions through facial expressions. 

New evidence suggests that the effects of Botox may actually go beyond preventing people from expressing their emotions.  It may also prevent people from fully feeling emotions.

Recent research published in the journal Emotion compared emotional responses to video clips in people who received Botox injections to those treated with Restylane, a dermal filler which reduces lines, but does not paralyze muscles.  They found that the patients who received Botox exhibited an overall significant decrease in the strength of emotional experience as compared to the Restylane group.

The data isn’t quite as clear cut as many articles have made it out to be though.  Much of the difference between the groups can be attributed to the fact that there was a pre- versus post-treatment decrease in the emotional response to mildly positive clips in the Botox group, as well as an unexpected increase in response to negative clips in the Restylane group.  When looking at data for Botox patients alone, there was actually no pre- to post-treatment changes in emotions caused by the most positive and negative video clips.

This study suggests an interplay between facial expressions and the perception of emotion.  However, while having a Botox treatment might make you look like a statue, it probably won’t make you feel like one!

Reference:  Davis J, et al. The effects of BOTOX injections on emotional experience. Emotion, Vol 10(3), Jun 2010, 433-440. doi: 10.1037/a0018690

Dr Kristie McNealy is a doctor turned medical writer and regularly writes at Family Health Guide