DrPullen.com – Medical and Health Blog

Zohydro: The Next Oxycodone is On the Way

January 3, 2012 Dr. Pullen

A single ingredient sustained release hydrocodone product to be called Zohydro is currently in phase 3 clinical trials by Zogenix, and if it gets FDA approval is likely to become the next Oxydontin as a drug of abuse and addiction potential. I watched a segment on the evening news this week about Zohydro, and it is certainly not going to come to market without fanfare. Experts on the newscast did a pretty fair job of outlining the concerns of Zohydro, the potential for abuse and the issues with high dose single ingredient opioid products. Opioid overdose is much more likely with drugs where a very high dose of the drug is contained in a single pill.

Oxycontin has a reputation as probably the most abused of the prescription opioids because of its lack of acetaminophen, its high percentage of rapid release oxycodone, and its lack of properties preventing crushing the pills which eliminates the extended release properties and makes it possible to inhale, inject or smoke the drug. Sometimes known as Hillbilly Heroin, Oxycontin is among the leading causes of prescription drug overdose deaths and opioid addiction in the U.S.

If Zohydro receives FDA approval as a single ingredient, high dose hydrocodone product there is little doubt that it will join Oxycontin as a major drug of abuse. Proponents of non-acetaminophen opioid pain medications are correct when they state that acetaminophen has its own problems, and especially when too many pain pills are taken to get pain relief the daily acetaminophen dosage can exceed the 4000 mg / day maximum safe dose. Serious and even fatal acetaminophen liver damage can result. Still single ingredient opioid products are so prone to diversion, addiction, and abuse that I anticipate that Zohydro, if approved, will quickly become a major drug of abuse.

One thing physicians have on our side now is the Oxycontin experience. We will be much more skeptical of allowing escalating Zohydro doseage and addiction become commonplace. Still I am not looking forward to one more drug with few advantages and much abuse potential coming to market.

Oxycontin is available in doses of 10, 15, 20,30, 40, 60 and 80 mg tablets. Using the recommended opioid Morphine Equivalent Dosage calculator available for download at the Agency Medical Directors site, 30 mg of morphine is equivalent to 30 mg of hydrocodone but to only 20 mg of oxycodone (i.e. oxycodone is 1.5 x as potent on a mg for mg basis than hydrocodone). Using these equivalency ratios it would be expected that Zohydro might become available in doses up to 120 mg per pill. This would make it highly popular as a drug of abuse, as current hydrocodone products all contain acetaminophen, and maximum hydrocodone dosing even with products with 10 mg hydrocodone and 325 mg acetaminophen are 12 tablets daily, making 120 mg of hydrocodone the maximum daily hydrocodone dosage.

For related articles see:

Oxycontin vs. Oxycodone

How to Spot a Drug Seeking Patient

Oxycontin: What’s The Big Deal

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New Year’s Resolution Help

January 1, 2012 Dr. Pullen

I bet many of you have made New Year’s Resolutions this year. If you are like millions of others some of your goals include making changes to improve your health. Here are some articles from this health blog to help you with motivation or information.

America has an obesity epidemic, and likely the most common New Year’s Resolution revolves around some aspect of losing weight or eating healthier. You may enjoy and learn from: Health Snacks: Sensible Snacking for 9-5’ers, the Anti-aging-Anti-Inflammatory Diet, and Healthy Fruits – Healthy Vegetables.

After losing weight or eating healthier quitting smoking has to be among the most common New Year’s Resolutions. For more incentive see: Why Quit Smoking and Excess Death.

Exercise likely follows closely behind these two, and has advantages far beyond weight control. Lot’s of evidence supports regular exercise in prevention and treatment of depression and anxiety, improved cardiovascular and bone health, and self-image. Enjoy: The Unexpected Benefits of Running and Benefits of Resistance Exercise.

I hope all of you choose to take each day of this coming year and make it the best day that you can. I wrote about this in Carpe Diem, one of my favorite sayings.

Thanks to all of you for following DrPullen.com and for your comments and encouragement. I continue to enjoy this forum for sharing my thoughts, and one of my New Year’s Resolutions is to find more and better guest columnists to add variety and talent to the posts. I also need your input to guide me to writing about topics you want to hear about. Let me know in the comments below if you have subjects you’d like to see addressed here, and I’ll try to choose some of them for articles and inspiration.

Happy New Year to all.

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An Unusual Approach to the Your New Year’s Resolutions

December 28, 2011 Dr. Pullen

Every year many of us choose a New Year’s resolution that we feel worthy of effort towards change for the better. Nearly every year most of us fail to follow through on our New Year’s resolutions. My wife is found an interesting article in this week’s Wall Street Journal online by Elizabeth Bernstein.

In this article Ms. Bernstein suggests asking another person to suggest New Year’s resolutions for us and reciprocating by suggesting New Year’s resolutions to them. In order to better follow through on the resolutions she further suggests asking the other person to help hold you accountable to the resolutions. This sounds pretty scary to me but is a mission concept and I’m mulling over the possibility of sitting down with Kay and actually trying this. Check out the article and you might find it interesting too:

To Stick to New Year’s Resolutions, Try Outsourcing Them

By Elizabeth Bernstein 12-27-2011

If you’d like to make your New Year’s resolutions stick, try this: Have someone else—a significant other, your best friend, maybe even your mom—make them for you.

Sure, resolutions are supposed to be personal. People can’t change unless they’re ready to change. And having someone you love tell you how you could become a better person could be terrifying.

But Mark Twain pretty much got it right when he said we make our annual good resolutions on New Year’s Day and “begin paving hell with them as usual” the following week.

Read more

I’ll post back in a couple of months on how this all worked out at our home. DrP.

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Octogenerian’s Letter to Santa

December 25, 2011 Dr. Pullen

One of the highlights of our Christmas Day this year was reading the poem written by my octogenarian step-father-in-law. Vince Preece is a retired school teacher, active chorus singer, actor and writer who though his joints may be failing his mind certainly is not. Enjoy his Christmas poem entitled:

A Letter to Santa

Santa dear, now listen here.

I want some real good stuff this year.

A laptop would really hit the spot,

A lap dance might be a bit too hot.

Though a Rolex watch is prized by all,

My time is from the clock on the wall.

If I were young I would ask for skis,

A wheelchair would spare my wobbly knees.

Dear Old St. Nick, dost thou not see,

That in my dotage I josh with thee?

For the sands of time are running fast,

And I must make each sweet day last.

So all I want ‘neath the Christmas tree,

Is another golden year to unfold for me.

God rest ye merry gentlemen, it’s time to hit the hay.

With all that rum and caroling, ye’ve had a busy day.

To save ye all from Satan’s power as down thy heads ye lay.

Here’s tidings of comfort and joy, comfort and joy.

Love Vince and Fay

Thanks to Vince Preece for permission to publish the poem he intended for family and friends. I think his writing is well worth sharing and I wish you all a very Merry Christmas and a Happy New Year.

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Brain Eating Amoeba – Naegleria fowleri: More Hype than Real Concern

December 21, 2011 Dr. Pullen

The news if full of stories about the recent deaths in Louisiana from infections with Naegleria fowleri, often called the brain-eating amoeba. This is a very rare infection caused when this amoeba that is found most often in warm fresh water lakes and streams gets into the nose and then infects the brain leading to it’s moniker as the brain eating amoeba. The result is a usually fatal amoebic meningoencephalitis. At least one of the cases in Louisiana seemed to be related to use of non-sterilized tap water in a Neti Pot solution.

You may know about neti-pots and sinus rinse being used for management of various nose and sinus problems, and I’ve long been a strong proponent of sinus rinse therapy. I tend to prefer the much simpler to use sinus rinse bottles to the Neti-pot, but they are both very effective. I have not been rigorous about telling patients to use distilled or previously boiled water for this use, but after these admittedly rare but preventable issues I plan to change this advice.
Naegleria fowleri is the only species in the Naegleria family of amoeba that causes infection in humans. Most commonly this infection occurs after swimming in infested waters. The life cycle of the Naegleria fowleri organism is in three stages. The organism can exist as cysts, essentially a resting stage, as trophozoites which is the infectious stage to humans, and a flagellated stage. If the trophozoite enters the nose it can migrate through the olfactory nerve up through the top of the frontal sinuses into the brain where it can cause primary amoebic meningoencephalitis. Typically trophozoites are seen in brain tissue and cerebrospinal fluid (CSF), but occasionally flagellated forms are seen in CSF.
In the US Naegleria fowleri is found primarily in warm water of the southern tier of states. It is also sometimes seen in geothermal springs and in industrial warm water effluent or heated poorly chlorinated swimming pools or hot water heaters not kept at temperatures over 47 degrees C (116.6 degrees F).
Naegleria fowleri amoebic meningoencephalitis is rare. In the years from 2001-2010 according to CDC records only 32 cases were documented in the U.S., with 30 being from recreational water activities and 2 from a contaminated geothermal drinking water supply. (1)
The CDC site notes that in southern states there is a high incidence of Naegleria fowleri in the waters, yet the very rare cases of brain-eating amoeba infections due to Naegleria fowleri make it clear that the risk of any given exposure to these waters is very low. Now using sterilized water for Neti Pot solution recipes and sinus irrigation seems a reasonable additional step to avoid brain eating amoeba infections.

To check out other uncommon and strange diseases also see:

Ascaroides Lumbricoides: One Big Worm

Enterobious Vermicularis and the Scotch Tape Test

Denge Fever in Key West

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What’s the Poop on Chronic Diarrhea

December 19, 2011 Dr. Pullen

Nobody likes diarrhea, and chronic diarrhea is a really bothersome condition and one which patients just really dislike. Every so often I come across an article while reading my American Family Physician Journal that seems worthy of discussing in a post, and today I read a review article on the evaluation of chronic diarrhea by Juckett and Trivedi (1) that prompted me to discuss this topic from the perspective of what I think may be helpful for patients to know.

The definition of chronic diarrhea is a decrease in stool consistency that lasts for more than four weeks! I think this is helpful to know because I frequently see patients in the office who had diarrhea for between two and 10 days who although they’re uncomfortable really will not benefit from medical intervention. Almost all episodes of acute diarrhea are self-limited and resolve without therapy. The most common causes of acute diarrheal illness are gastrointestinal viral infections that often present initially with nausea and vomiting for 24 to 48 hours associated with and followed by diarrhea that lasts longer. Typically this diarrhea will resolve within 3 to 7 days but it is not unusual for it to last up to two weeks. Antibiotics not only do not help most episodes of acute diarrhea, but can make the diarrhea worse because diarrhea is one of the most common of antibiotic side effects. If your acute episode of diarrhea is not associated with high fever, blood in the stool, severe abdominal pain or other symptoms of severe illness supportive treatment with small frequent amount of fluids and as the vomiting results small frequent feedings with easily digested foods is usually adequate to allow the episode to resolve. Medications like Imodium AD, available off-the-shelf, are generally only indicated for severe frequent diarrhea that may lead to dehydration if is not controlled. Products like Kaopectate really don’t work very well and have little or no place in the management of acute diarrhea.

Chronic diarrhea lasting more than four weeks is another matter. I found the suggestion in this article to break chronic diarrhea into three major categories helpful as a way to think about the causes and evaluation needed.

The first category is watery diarrhea. Watery diarrhea is usually related to either poorly absorbed substances that lead to water being drawn into the colon and cause watery diarrhea, secretory types of watery chronic diarrhea where water reabsorption is reduced,and hyper-motility types of functional chronic diarrhea. Some types of laxatives like sorbitol and polyethylene glycol (Miralax) can cause watery diarrhea. Secretory diarrhea is usually separated from the others but very high stool volumes and continues night in day as well as after fasting. Stimulant laxatives like Ex-Lax and others can lead to secretory diarrhea because of the increased motility they cause. Persons with irritable bowel syndrome and other types of functional diarrhea usually have smaller stool volumes that don’t bother them at night.
The next category of chronic diarrhea is fatty malabsorption diarrhea. This type of diary is sometimes but not always manifest by oily or fatty substances in the toilet bowl and often very foul-smelling stools. Cystic fibrosis is an example of a condition that can lead to fatty diarrhea. Celiac disease, gastric bypass, diet medications that block fat absorption like orlistat, and lactose intolerance are examples of conditions that can lead to this type of chronic diarrhea.
The next category of chronic diarrhea is inflammatory types of chronic diarrhea. These types of diarrhea usually present with blood in the stool either visible or noted on a occult fecal blood testing, Pus cells in the stool either as visible pus or noted as white blood cells noted on stool evaluation (fecal leukocytes), and with abdominal pain. Crohn’s disease, ulcerative colitis, and invasive infection diseases like Clostridium difficile, Salmonella and Shigella are examples of this type of chronic diarrhea.

If you present to a physician with chronic diarrhea it will be important for you to make sure your physician knows about travel to tropical areas, any medications you are using including off-the-shelf laxatives and herbal supplements, and about any family history of bowel problems. Clostridium difficile infection leading to pseudomembranous colitis and chronic diarrhea is increasing in frequency and is especially common after antibiotic use or hospitalization. Celiac disease, a condition where sensitivity to a compound found in wheat and other grain products called gluten, seems to be increasing in frequency and should probably be screened for with blood testing in most patients with chronic diarrhea. A fairly new test called fecal calprotectin level can be very helpful in deciding whether further evaluation for inflammatory bowel disease like Crohn’s disease and ulcerative colitis is necessary. Fecal calprotectin level testing is felt to be 93% sensitive and 96% specific for inflammatory bowel disease in adults.

Irritable bowel syndrome remains one of the most common causes of chronic diarrhea. Although irritable bowel syndrome has long felt to be a diagnosis of exclusion, meaning it can only be diagnosed after evaluation for other potential causes, at times the presentation is typical enough that in otherwise healthy young patients it may be reasonable to limit evaluation to screening for celiac disease and any other conditions that seem reasonably likely by the patient’s history. Avoiding colonoscopy is reasonable in some cases. Fecal calprotectin level testing may help avoid colonoscopy in patients for whom the index of suspicion for inflammatory bowel disease is not very high.

In general if you develop diarrhea not associated with high fever, pus or blood in the stool, or severe abdominal pain and you are able to maintain your hydration status through small frequent amounts to drink you probably don’t need to see a physician for about two weeks. After two weeks if the diarrhea persists and is fairly severe you may want to consult your physician. After four weeks of diarrhea it usually considered chronic diarrhea and should probably be evaluated.

The Best Christmas Gift Ever

December 13, 2011 Dr. Pullen

Give Your Loved Ones The Best Christmas Gift Ever This Year!
Really. What your loved ones want most from you is for you to be healthy and around for them. This involves doing whatever you can to avoid the leading cause of death and morbidity in the U.S., cardiovascular disease like heart attack and stroke. The CDC has made this easy by making an electronic gift card available to send to those you love and who care about you. The card says:
My Health is my gift to you this holiday season. “I pledge to learn my ABCS of health,” and is associated with the Million Hearts Program of the CDC.
For those of you not familiar with the ABCS of the Million Hearts attempt to prevent 1,000,000 heart attacks and strokes in the 5 years following the initiative on Sept 13, 2011 it is:

Click on this Image to Go to the Million Hearts Site Now!

• A= Aspirin for those people at high risk. This generally means adults with high blood pressure, diabetes, any type of vascular disease like peripheral vascular disease, coronary disease, carotid disease etc, smokers, people with high cholesterol or high blood pressure, and those with a strong family history of heart attack or stroke.
• B= Blood Pressure Control: Sounds obvious, but less than half of Americans with high blood pressure have it adequately controlled. Don’t settle for suboptimal blood pressure control. Work with your doctor to do what it takes to gain control. Also focus on the non-medication things you can do like salt restriction, weight loss and more exercise.
• C= Cholesterol management: Goals vary for different people, but ask your physician what your goal cholesterol should be, and if needed use medication plus diet to get to that goal.
• S= Smoking Cessation: If you smoke quitting is probably the number one thing you can do to reduce your chances of a heart attack or stroke. People always correlate smoking with cancer and lung disease, but the leading way smoking kills is from cardiovascular diseases like heart attacks and stroke. Do whatever it takes to find a way to quit.
So this year give the most precious gift of all, yourself through improved health and longer life, to your loved ones.

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How Safe is Oral Sex?

December 12, 2011 Dr. Pullen

Bill Clinton didn’t consider it sex. Lots of teens today consider oral sex a safe alternative to intercourse. Headlines like on ABC news in 2009 cry out, “Oral Sex is the New Goodnight Kiss.” Data suggests that oral sex is becoming more common practice in teens than vaginal intercourse, a major change from a generation ago. In 2002 up to 24% of males and 22% of females teens who had never had vaginal intercourse reported having had oral sex with an opposite sex partner (1). In addition gay men want the real truth, is oral sex a safe alternative to more risky behaviors? The answers seem to all be relative. There are few absolutes in life, but one of the truths is that the only way to completely avoid risk of an STD is to avoid any type of sex. That said, how safe, or alternatively how dangerous, is oral sex?

Let’s look at the evidence for transmission of the various STDs by oral-genital contact.

HIV: Human Immunodeficiency Virus, the cause of AIDS, is the STD many fear most. It can be transmitted when a body fluid containing the virus gains access to another person’s mucous membranes or bloodstream. Unquestionably HIV is transmitted by anal and vaginal intercourse. There are at least a few cases where it is believed that the HIV virus was transmitted to the receptive partner after oral sex with ejaculation. Oral sex without ejaculation into the mouth is theoretically possible, but is felt to be extraordinarily unlikely. The risk of contracting HIV from a single incidence of anal intercourse with with ejaculation and no condom use with an HIV infected male has been estimated at 1:100. Extensive study has been done in trying to find out what the incidence of contracting HIV from oral sex with ejaculation with an HIV infected male, but these studies all have confounding variables. The real problem is that all of these studies have been in gay male populations, and a low percentage of the men had only oral sex. On second and subsequent interviews many times the history changed, and made other routes of transmission more likely. In one study it was estimated that there were zero cases of conversion in a population after over 35,000 incidences of oral sex. All said, although it is possible to contact HIV from oral sex, the chances are very low. Low enough that if oral sex is a behavior that replaces anal intercourse in gay men the benefit of avoiding the high risk behavior likely greatly outweighs the risks of oral sex in this situation.

Herpes Simplex: This may be the most common STD transmitted by oral sex. Up to 70% of teens are estimate d to have been infected with the herpes simplex 1 virus, the cause of >90% of oral herpes cases. Many others, and many of the same people also have been infected with the herpes simplex 2 virus, the cause of >90% of genital herpes. The problem with herpes simplex is that despite popular belief, an infected person can shed the herpes virus at times when they have no symptoms or visible evidence of infection. It is believed to be fairly common to transmit the herpes simplex virus either from the mouth to the genitalia, or from the genitalia to the mouth during oral sex. The incidence of HSV transmission by oral sex is not well studied.

Gonorrhea: Gonorrhea, caused by the bacteria Nisseria gonococcus, is an STD that typically causes painful urination and a discharge of pus from the urethra in men. In women it can be asymptomatic, can cause a vaginal or cervical discharge, or can cause more serious infection of the fallopian tubes and or ovaries, called Pelvic Inflammatory Disease (PID). Gonorrhea can also infect the throat or tonsils. The route of this infection appears to be oral sex, generally receptive oral sex with the penis in the mouth. It is less clear whether cunnilingus can transmit gonorrhea although it is felt that this is very rare if it ever happens. Men likely only contact gonococcus from vaginal or anal intercourse or from an infected partner during receptive oral sex.

Chlamydia: There is less data about transmission of Chlamydia by oral sex. It is generally felt to be possible to transmit Chlamydia both as the person performing and the person receiving fellatio. The incidence of this is just not known.

Syphilis: Syphilis is fairly uncommon in the US, but transmission of syphilis during oral sex is relatively easy, and is felt to be a relatively common cause of transmission, possibly up to 15% of cases in some areas of the US.

HPV: HPV is probably the most prevalent STD in the world today. The HPV virus can be transmitted to the throat or mouth during oral sex. The incidence of this is poorly understood, but there is an increasing rate of HPV positive head and neck cancers in the last 30 years. Many experts feel that this correlates to increasing acceptance of oral sex. Oral cancer has historically been primarily a disease of older adults with a long history of smoking and drinking, or in younger persons who use oral tobacco. In recent years the incidence in younger non-tobacco users has increased, and many of these cancers are HPV positive on testing.

Hepatitis: There is debate whether hepatitis B can be transmitted by oral sex, but if possible it is felt to be very unlikely. Hepatitis A can clearly be transmitted by oral-anal sex, and is much more common in the gay male population than in the heterosexual population.

In summary oral sex is not safe sex, but it is far less risky than either vaginal or anal intercourse regarding STD transmission. In addition the risk of pregnancy in heterosexual oral sex is near zero. Avoiding receiving ejaculate in the mouth greatly lowers the risk of transmission of HIV, though probably not the risk of herpes, gonorrhea, or HPV. Condom use for men, or use of a dental dam in women seems effective in markedly reducing the risk of most STDs with oral sex, but may not be common practice.

Psychological Issues: Oral sex is clearly an intimate act. Most psychologists agree that sex, either oral sex or sexual intercourse, brings a relationship to a different level. How this type of intimacy affects a relationship, the self esteem of the participants, and future feelings about relationships and intimacy are subjects worthy of consideration, but I know of no research into this topic.

So, “How safe is oral sex?” What do you want to tell your children about oral sex as a part of their sex education? You can decide now based on the discussion above and whether it involves men having sex with other men (MSM) vs. heterosexual oral sex. One risk of labeling oral sex a high-risk behavior in MSM is that it may leave gay men feeling that its risk is equal to anal intercourse, which is far from the truth. If oral sex is an alternative to anal intercourse for MSM then it greatly reduces the risk of HIV transmission.

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Medications as a Cause of Emergency Hospitalizations in the Elderly

December 8, 2011 Dr. Pullen

According to a recent New England Journal of Medicine article close to 100,000 Americans of Medicare age are hospitalized annually from medication related conditions. You might at first think that these are due to overdosages of prescription pain killers or abuse of other prescription medications, but in fact just a relative handful of types of medication lead to most of these hospital admissions. In addition the very old were especially at risk, with half of these admissions in patients over age 80, and about 65% were due to unintentional overdosage of the medications.

Not surprisingly warfarin leads the list and causes almost 1/3 of medication related hospitalizations. I’ve discussed warfarin in an earlier post on medications with a narrow therapeutic window. Next in line was insulin, which led to 14% of the admissions, likely due mostly to hypoglycemia and the attendant problems like seizures and coma. Anti-platelet drugs like aspirin and clopidogrel (Plavix) was next at 13%, and oral diabetes medications next at 11%.

Combined these medications led to >2/3 of medication related hospitalizations in the elderly. How can you avoid these mishaps?

If you are on warfarin be sure to understand the nuances of the drug regarding diet, medication interactions, and be sure to follow through with your recommended anticoagulation clinic visits.
Use a weekly medication container to place your medications into to avoid duplicate doses of medications and unintentional overdoses.
With diabetes medications like insulin and oral medications be sure to let your physician know if you are having low blood sugar problems, know how to manage days when you are sick or unable to eat regularly, and work hard to avoid being in situations where you are not able to eat properly.
With anti-platelet drugs avoid excess alcohol, use of other NSAID products, and let your physician know if you are having acid-dyspeptic symptoms or note blood in the stool or emesis.

Even if you do everything right, know that these medications have inherent risks, and don’t hesitate to seek medical attention if you develop problems with the meds. Also be sure to let any physician treating you know that you are on these meds. Consider carrying a current medication list to give to any physician you see so they can keep your medications in mind when they treat you.

FDA Removes HCG Diet Products from Market for Weight Loss

December 6, 2011 Dr. Pullen

To long time readers this came as no surprise. The use of HCG for weight loss has probably been studied more than nearly any other weight loss fad or diet, and the evidence that it does not work is overwhelming. See my prior post:

HCG Diet: Nothing New– One More Fad Diet That Doesn’t Work published on this health blog on May 8, 2010.

Today the FDA released an announcement that it has sent warning letters to seven makers of HCG products to companies marketing these non-prescription products stating that they are both unproven and not safe. I believe that they are not only not proven to be effective, but that there is considerable evidence that they are not effective. All the recommended diets using HCG are combined with severe calorie restriction, and this low calorie diet, usually 500 calories daily, can be associated with gall stone formation, cardiac arrhythmias, and are simply not safe.

Unfortunately there are no magic tricks for losing weight. Eating less, exercising more, and doing these things for long periods of time are the best approach. It is clear that we simply do not understand everything about weight control. It is a very complex and incompletely understood dilemma, but one thing is clear. The HCG diet simply does not work and I’m glad to see the FDA wielding its clout to get it off the market.