Vol. 156 October 15, 2016 Adding “DNT” to Your Medical Record Before “DNR”

October 15, 2016


Hub thumbnail 2015At our last weekly gathering of the “Over 70 Men’s Breakfast Club” we heard from one of us the following about visits to two of his physicians on the same day a week before:

Gastroenterologist: “Congratulations, your colonoscopy was entirely normal.”
Patient: “Great. When should I schedule the next one?”
Gastroenterologist: “Well ,, er..um .. you are over 75 you know. At your age it …er…um.. wouldn’t make any difference.”

The same day with his primary care physician:

Patient: “I think my urine stream is slowing a bit. How’s my prostate?”
PCP: “Your prostate exam is absolutely normal.”
Patient: “What about a PSA test?”
PCP: “ We don’t do those for men your age. It …er…um…wouldn’t make any difference in the long run. Oh, by the way, who’s your Health Care Proxy, the person who can make you DNR in case you can’t speak for yourself?”

Over our eggs and bacon (one member, our oldest, has oatmeal and berries instead) we reached the consensus that his medical record should be stamped with a “DNT: Do Not Test”.

Here are some of the “unnecessary” screening tests that he and others “of certain ages” should skip:

PSA: Rarely done under 50 yo. or over 70 yo. and now being questioned as of mixed benefit for any man. Screening does not reduce the very, very low death rate from prostate cancer and false positives are common. Further investigations of false positive results can cost at least $1,200 per patient, and treatment of truly positive cases can cause incontinence and/or impotence without any significant medical benefit.

Colonoscopy: rarely done under 50 yo. and never over 75 yo. as a screening test. Repeat colonoscopy after an initial normal one detects cancer of the colon no better than a periodic fecal occult blood (FOB) test on a stool sample done by your primary doctor.

X-ray, CT scan or MRI for low back pain without other symptoms: Back pain usually gets better in a month whether you have imaging done or not. Surgery is often done on image irregularities which have no causal relationship to the pain.

Pap smear: Every 3 years for ages 21 to 30. Every 5 years from 31 years to 65. None after 65 yo. “Abnormal” but non-cancerous cells can be detected by this test, but do not need treatment. Pap smears are recommended even if the woman receives the HPV vaccine (Gardasil) because the vaccine does not cover all viruses that cause cervical cancer.

Vitamin D: Vitamin D is the current “vitamin in vogue”. Speculations about relationships with heart and other diseases are riff, but the data is not that conclusive. Many people have low vitamin D levels (as currently defined) but very low levels associated with real illness are extremely rare. Oral vitamin D treatment has not been shown to reliably raise vitamin D levels. A 10 minute walk in the sun and a breakfast with orange juice and eggs supply more than enough vitamin D. (Note: The blood test itself is not expensive, but in 2011 Medicare paid $224 million for vitamin D screening on seniors.)

Testosterone level:  Despite the plethora (I am told) of late night TV ads selling gels, patches, and pills for low testosterone among middle age and older men, treatable “low testosterone” is rare.  Unless a man has one or two of 9 specific symptoms ( and erectile dysfunction (ED) is NOT one of them) a testosterone blood level screen is not recommended. Even if the level is low (under 10 nmol/L – I’m not sure what these units are either, except that they are very small ) a treatable diagnosis rests on the clinical history and exam, not the blood test.

Bone Density: Never under 50 and rarely over 70 in men without risk factors like fractures, heavy smoking or drinking, or very low Vit. D levels. Women could get one done at age 65, but  “treatment” of low bone density with costly medications (also advertised a lot on TV) has not been shown to have much benefit.

Annual EKG or stress test: Does not add any useful information for the asymptomatic person.

Whole Body Scans: Besides the cost and the large amount of radiation involved, these scans should be avoided because they do NOT find asymptomatic cancer. Less than 2% of the scans find a true mass and most of those are benign or inconsequential. In over 33% of scans “abnormal findings”, sometimes called “ditzels” by radiologists, lead to unnecessary and expensive further imaging tests that do not result in any benefit to the patient. (This test was previously heralded by this blog as a good Christmas present for an enemy)


1. Choose Wisely is a list of unnecessary medical tests complied by the American Board of Internal Medicine from suggestions of numerous other specialty groups and published widely in Consumer Reports and other periodicals.

Vol. 155 October 1, 2016 Legalizing Recreational Marijuana?

October 1, 2016

Hub thumbnail 2015Massachusetts voters and 7 other states will be voting November 8 on proposed laws “legalizing, regulating, and taxing Marijuana”. All of these “binding” Questions have been placed on the ballots by “Initiative Petition” (grassroots’ signature campaigns … no pun intended).The proposed Massachusetts law will legalize for anyone 21 or older the possession of 1 ounce of marijuana outside a residence or up to 10 ounces inside a residence, of up to 6 marijuana plants, and of GIVING without payment 1 ounce or less to another person 21 or older. The actual bill fills 11 full pages which reflects not only the controversial issues surrounding the bill, but also the complexities of proposed regulations and taxation.  

Colorado legalized recreational marijuana four years ago, and its experiences (both positive and negative) are currently feeding both sides of the debate of the economic, social, and political consequences.

I will only summarize some of the medical issues (“the News”) with scant remarks about some other issues (”the Editorial”).

Marijuana is a gateway drug: Not really
Physician researchers studying substance abuse ( at least those pediatrician-scientists who present at conferences in Boston) consider nicotine, alcohol, and marijuana as almost equivalent “initial drugs of choice” in adolescents and young adults who become addicted to heroin or opiates. They speak of marijuana “heavy-users” ( more than one joint daily), not marijuana “addicts”, and they represent a small percentage of adolescent MJ users.

Marijuana is addictive: Maybe a little
About 9-10% of users become “dependent”, “need to have daily MJ to feel normal”. Those who start using MJ under the age of 21 are more likely to become dependent. The withdrawal symptoms when heavy users stop after many years are much less than those who stop use of opiates, heroin, alcohol, or even nicotine. No medications are necessary, and any troublesome symptoms usually respond to cognitive behavioral therapy (talking to a therapist). “Addictive behavior” such as crimes to obtain money and violent acts are not usually associated with MJ dependency.

Marijuana is safe: Yes
Lester Grinspoon, MD in his landmark books, “Marijuana Reconsidered” (1971) and “Marihuana (sic): The Forbidden Medicine ” (1991), stated that no one has ever died of a  marijuana overdose, and that statement still stands true.

Marijuana changes your brain: Yes, if under 21 yo.
This reason and the dangers of small children eating large amounts of edible MJ are the reasons the American Academy of Pediatrics opposes the legalization of MJ but NOT its decriminalization.

The Academy also recommends that marijuana be decriminalized, so that penalties for marijuana-related offenses are reduced to lesser criminal charges or civil penalties. Efforts to decriminalize marijuana should take place in conjunction with efforts to prevent marijuana use and promote early treatment of adolescents with marijuana use problems.”

Heavy use  of MJ before the age of 21 can change how the brain functions as revealed by functional MRIs (fMRI).  Heavy MJ use can actually change brain structure in areas associated with impulse control and “executive functions”. Some studies show a lowering of IQ by 8-9 points in heavy users. The long term effects of these structural changes in adolescents are being studied, but everyone seems to agree that MJ use should not be legalized for those under 21 years of age.

Marijuana can impair your driving: Perhaps
Studies do show that MJ can prolong your reaction time and reduce attention span (less so than alcohol – check out this YouTube video), so the opponents of legalization believe that the law will lead to more car accidents. The data on actual accidents, whether fatal or not, is not so clear. There is no standard method to measure “MJ intoxication”. Blood and urine tests measure MJ metabolites which can be present for up to 45-50 days after smoking a single joint (depending on age, weight, and belt size). These tests, since they depend on measuring metabolites, may not even turn positive until 24-48 AFTER a new user smokes a joint. Such tests can identify regular users, but there is no correlation between blood and urine test levels and the actual degree of impairment.  Remember, even the “gold standard” in drunk driving cases, Breathalyzer results, are not permitted to be entered as evidence in court because of variations in calibration and field administration.

The Massachusetts Medical Society opposes  the legalization of recreational marijuana because of 1) “the addictive nature of marijuana”, 2) “the adverse effects on developing brains”, and 3) “the appeal of edibles to youngsters”.

The effect of legalization on youth access to marijuana is a controversial subject that is dismissed by pediatric researchers.

“Adolescents and pre-adolescents already have open access to MJ. Legalizing it won’t change that.”
It is worth remembering that Dr. Grinspoon got interested in the medical effects of marijuana when his son was undergoing chemotherapy, and MJ reduced his nausea greatly. Lester’s wife easily bought that MJ in a Newton schoolyard in the 60s.

That reality that MJ distribution and sales will become a big business is why proponents are pushing its tax revenue upside. Opponents are concerned that “Big Tobacco” or other nefarious organizations will take over the MJ market.

My vote:
I will vote “NO” on Question 4 in Massachusetts proposing the  “Legalization, Regulation, and Taxation of Marijuana” primarily because of its unknown consequences that should become clearer in time (even just a year or two would help). Also, our state’s less than stellar track record in satisfactorily implementing the much smaller program of legalizing medical marijuana ( 59 pages of regulations in 2013 and several public missteps) gives me real pause about how it could all play out.

I think that the recreational use of marijuana will eventually be legalized in Massachusetts, and that there can be some real benefits of such a change.  But, I also think that there is too much that is vague and/or capable of manipulation in this proposed law, even at 11 pages long.

Vol. 154 September 15, 2016 READER BEWARE, Take a Grain of Salt With Media Hype About Medical Advances

September 15, 2016

Hub thumbnail 2015Headlines that tout a new drug or a new procedure which is “much better” than the old one are very common in our media. Some of them are true. Some of them are misleading. Most of them depend on the definition of “better” in the research study or clinical trial. A recent issue of the New England Journal of Medicine reviewed the “changing face of clinical trials” and outlined in detailed, technical language what their readers (physicians and other health professionals) should look for in published studies and clinical trials to confirm that the simplified “positive outcome reported” is significant and relevant. (1)

It inspired me to give similar “heads-ups” to my more general readers so they might be better evaluators of media announcements and commercials about medical advances.

Be skeptical about percentages
“Drug A has 50% less side effects than Drug B” or “Drug A is 50% more effective than Drug B.”
If 2 out 100 patients had a side effect with Drug A and Drug B side effects happened in 4 of 100 patients, that is a 50% reduction of a very low occurrence event, and it is probably not relevant.

“Antibiotics reduced the time out of work (or out of school, or days of fever) by 50%”.
This could mean “time absent” went from 2 days to 1 day, not all that significant considering the cost and potential side effects of antibiotics.

For those of you who want to dig deeper you should ask for the P value of the positive outcome. A statistical P value of 0.05 means that the difference between the two treatments is not enough to say that one was better than the other. The difference is “not significant”. In medical studies the test of a true difference is a P value of less than 0.001; written as P<0.001. That difference is “significant”. Looking at P values is an easy way to avoid the illusionary trap of percentages.

“Dementia Incidence is Decreasing!”
This was the February 2016 “headline”, admittedly in the back pages or side bars, in several newspapers and magazines. It was based on data from the ongoing, well-respected Framingham Heart Study that has been studying the same people since 1975. The article listed declines of 22%, 38%, and 44% each epoch (an epoch is about 15 years) from 1975 to 2010 in 5205 persons over 60 years old.
Looks impressive!
Again the percentages.
The actual incidence went from 2.8 per 100 persons demonstrating dementia to 2.0 per 100. These numbers seem a bit less dramatic to me. To top it all off, the risk reduction was observed in ONLY those who had at least a high school diploma. I’m glad that I am in that population subgroup, but that suggests an issue about the relevance of study results to the general population.

Is the positive outcome of the study clinically relevant?
Tests of some new drugs treating diabetes have shown a much better control of blood sugars, but NO reduction in cardiovascular events and even a HIGHER mortality rate.

Certain cancer tests may be shown to find cancers earlier, but there is no reduction in patient morbidity and mortality. The PAS test for prostate cancer “found” a lot more cases of prostate cancer, but did not result in any reduction of deaths from prostatic cancer. Later studies even showed that the PAS test often resulted in unnecessary further tests and treatment, so the age criteria recommendations for obtaining a PAS were changed in 2012.

Multiple studies of ICU patients have shown “better” physiological or laboratory value resulting from selected treatments, but NO change in length of stay or mortality rates in those patients receiving the new treatment.

Is the study large enough to be reliable?
This can be tricky. The study should involve enough patients to be statistically sound (there’s the old P<0.001 value again), but big numbers are not a guarantee. A recent article on the effectiveness of CPAP (continuous positive airway pressure) treatment for Obstructive Sleep Apnea (OSA) was based on studying close to 2500 patients. Sounds big to me, but look how they got to that number.

15,325 patients were assessed for eligibility in the study.
9481 declined to participate or were excluded for other reasons
leaving 5844 that met the study’s diagnostic criteria
.         2598 were then excluded for having too mild symptoms
leaving 3246 who entered a one-week trial period
529 were then excluded for poor compliance or other reasons
leaving 2717 patients that were randomized into the study
30 were then excluded from the analysis for a variety of reasons
leaving 1346 receiving the new treatment and 1341 receiving standard treatment
.            62 receiving the new treatment discontinued
            85 receiving the standard treatment discontinued.
Resulting in 1284 analyzed for the new treatment and 1256 analyzed for the standard treatment.

Besides suggesting how difficult the logistics of a clinical study can be, a markedly descending number of study participants like this can raise concerns about a selection bias of patients, or as they say, “There’s many a slip twixt the cup and the lip.”

Oh, yeh, the results of the study?
“CPAP treatment significantly (P<0.001 again) reduced snoring and daytime sleepiness, but did not prevent cardiovascular events (P values 0.96 to 0.07)”.

Also there were so many variables in this complex study like “duration of use” (3.3 hrs. a night average) , “degrees of compliance” with protocols, different “severity of symptoms”, etc. that the NEJM felt compelled to publish in the same issue an editorial suggesting caution about the impact of this study on current clinical practice (see comments about clinical relevance above).

More often than not the new procedure or the new drug is more expensive than the “old” one. That adds another reason to ask your doctor if it is really better than the previous one. Remembering that “if it happens to me it’s 100%”, what is the patient  supposed to do? How can we evaluate this bombardment of new advances?

“Ultimately, physicians at the point of care bear the final responsibility for accurately interpreting clinical trial results and for integrating regulatory and guideline recommendations to make the best treatment decisions for each patient in their care” (1)

1. “The Primary Outcome is Positive – Is That Enough?”, New England Journal of Medicine, Sept. 8, 2016, 375;10 p.371

Vol. 153 September 1, 2016 Is Nothing Sacred? No, Not in Medicine.

September 1, 2016

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It can be frustrating and unsettling when after years of telling us that something is good…or bad for you, doctors then tell us that the opposite is true! “Redefining the truth” is the essence of science, particularly the science of medicine. The medical mantra is: Keep studying, keep collecting data, keep analyzing, and if the “truth” changes, report it!
Here are some more revisions of the truth as examples.

Baby Dolls and Teen Pregnancies
Giving high school students a baby doll to take of care for several weeks is touted as a deterrent to teen-age pregnancies. The sophisticated doll is programmed to cry, make demands, go to sleep (or not), etc. just like a real baby. Students are instructed to care for it 24/7 as if it were a real baby. The expectation is that such a “reality-check” would make teen agers more aware of the burdens of caring for an infant and that would convince them to use effective birth control.

A recent report in the British Medical Journal documented that the average teen age pregnancy rate in those who cared for a doll stayed the same or even INCREASED in some schools. The article speculates that the positive, loving experience that some teens had and the extra attention they received while caring for the doll caused this. The company that makes the dolls quickly switched its marketing pitch from “reducing teen pregnancy” to “teaching quality infant care”.

Get the Lead Out”
The high level of lead in the water in Flint, Michigan in 2015 immediately raised an alarming concern about “poisoned children”.  A blood lead level of 5 micrograms per deciliter is considered “a threshold for official action as a “precautionary principle” according to public health experts.   5% of the kids in Flint had blood lead levels of 5-10 micrograms per deciliter.  The increase from 2.4% having a level over 5 in 2013 to 4.9% of kids tested in 2015 raised the public health alarm.

It is well known that the body can excrete lead. If the input of lead (ingested in food, water, or dirt or breathed in from car exhausts) exceeds the excretion rate and the blood lead level reaches 40-69 micrograms per deciliter then outpatient treatment is recommended, even though the person is asymptomatic. Blood levels above 70 can cause symptoms and are treated by hospitalization. None of the Flint children had lead levels over 40.

Lead performs no essential function in our bodies and chronically high levels can cause neurological damage, so it is incumbent of public health officials (and politicians) to prevent prolonged exposure, but these children have NOT been damaged. They will, I am sure, be monitored and studied for years to come to see if there is any subtle effect of these low lead levels. Because that’s what medical science does.

Lowering Blood Pressure in Intermediate-Risk Persons Without Heart Disease with Two Drugs Did Not Decrease the Rates of Major Cardio-vascular Events

NEJM 374:21 May 26, 2016,pg. 2009-2019

Lowering Cholesterol in Intermediate-Risk Persons Without Heart Disease and Normal Lipid Levels With One Drug Decreased the Risk of a Major Cardio-Vascular Event from 4.7% to 3.6% (a 25% reduction)

same NEJM issue pg. 2012-2031

Lowering Blood Pressure AND Cholesterol in the same study as above with Three Drugs Decreased the Risk of Some Major Cardio-vascular Events from 5.0% to 3.6% (a 30% reduction)

same NEJM issue pg. 2032-2043

Like Fox Radio, “We report the news. You decide.”

“Get the Fat Out…But Which Fat?”
The British Medical Journal published an article in April written by a team of scientists at NIH headed by Christopher Ramsden, called the “Indiana Jones of biology” because he specializes in excavating old studies, particularly those that go against our “mainstream government-sanctioned health advice”. He unearthed a 1968 five-year, tightly controlled study of over nine thousand participants randomly assigned to either a vegetable oil based diet or a standard animal fat diet.

The study documents that eating vegetable fats instead of animal fats did NOT, repeat did NOT, reduce the risk of heart disease or death. Substituting a vegetable oil diet ( about half of the saturated fat of the standard diet) did lower the average blood cholesterol by 14%, BUT the risk of death INcreased 22% for every 30 points the cholesterol fell! 

Dr. Robert Franz of the Mayo Clinic, the son of the organizer of the 1968 study, speculates that his father’s team was disappointed that they could find no benefit of the vegetable oil diet, and so didn’t publish it widely. An accompanying editorial in the BMJ concluded that “ the benefits of choosing polyunsaturated fat over saturated fat seem a little less certain than we thought.”

Again like Fox Radio:  “We report the news. You decide.”

“Worried About Peanut Allergy in Your Family?
Avoid Peanuts! No, NO, Eat Them as Early as You Can!”
The experts use to say “no solid foods to infants before age 4 to 6 months.”
Experts now say “do not delay solid foods beyond 4 to 6 months.”

In the past 10 years childhood peanut allergy has doubled from 1.4% to 3% (still small).
The experts use to say that “if you’re worried about peanut allergy in your child do not give peanut food until age 3 years”.
Experts now say “give the infant peanut food as early as 4 months of age.”

A 2015 study in the New England Journal of Medicine showed that consumption of peanut food at 4 months of age reduced the development of a peanut allergy (documented by skin-prick tests) by 70% – 86%!!

“We should no longer recommend avoidance of allergenic foods in infants.”

Vol. 152 August 1, 2016 It’s Not the Screen Time, It’s the Content.

August 1, 2016

Hub thumbnail 2015

“Playing rapid action video games benefits the mental skills of processing information, switching between tasks, and visualizing the rotation of an object.”
                 Scientific American, July 2016

“Shooting zombies and repelling aliens can lead to lasting improvement in some mental skills.” (1)

Bavelier while a graduate student in the 1990s developed a computerized psychological test of the ability to see an individual shape in a busy visual scene. He tested it first on himself, expected to get an “average score”,  and  got a perfect score. He next tested Green, his mentor who also unexpectedly got a perfect score. They figured something was wrong with the computer program, but they could not identify a bug. After a number of Green’s non-psychological buddies also scored perfect results they spent some time in looking for the reason. The only common denominator among the group was that each had spent more than 10 hours a week playing the video game Team Fortress Classic. That discovery launched them, and others, into 15 years of investigations into the cognitive effects of playing fast-paced “shooter” video games.

According to various studies video game playing can boost a variety of cognitive skills:

  • improve focus on visual details (like reading fine print in a contract or on a prescription bottle)
  • heighten awareness of visual contrast (help drive in a thick fog)
  • enhance mental rotation of objects (get that odd-shaped couch through the door)
  • improve audio and visual multitasking (read a menu while conversing with a dinner partner)
  • improve reaction time to unexpected events by 10%
  • increase the number of correct decisions made under pressure
  • improve specific attention in fast changing visual fields (better control of attention)

One study found that laparoscopic surgeons who were also game players could complete surgery faster with the same precision or quality as non-gamers . I remember many years ago learning that the Israeli Army realized that video game players made the best tank commanders.

Obsessive game playing (“binging”) is NOT needed to boost the brain, and the American Academy of Pediatrics has made recommendations for preventing excessive use of all media by children.   Short, daily intervals of play on fast-action games can reap cognitive benefits. Many so-called “brain games” marketed for improving cognitive skills do not live up to their claims. According to these researchers fast-action video games can because:
1. they are fun,
2. they have careful pacing and levels of play (reduces frustrations of early failures),
3.they require increasing attentional control as the game proceeds,
4. they consistently challenge the player,
5. they provide the successful gamer rewards on different time scales (promotes planning for short and long-term objectives).

The content of the game is very important. Violent, aggressive action games can adversely influence children’s attitudes and behavior. Games involving action sports, real-time strategy (like StarCraft), 3-D puzzles (like Portal 2),or “Prosocial” games that involve cooperation rather than competition are listed as examples of “brain-boosters” by these researchers.

They did not include their opinion of Minecraft , an open-ended, creative game that has captured the imagination of millions of children. This fast-paced, multi-level, 3-D building block game is too hard for this adult to understand or follow. One grandchild agrees and has started an instructional website “Minecraft4Momz” . Take a look on YouTube.

1. The Brain-Boosting Power of Video Games, Sci Am; July 2016, D. Bavelier, Prof. of Psychology, University of Rochester and C.S. Green, Asst. Prof. of Psychology, University of Wisconsin

Vol. 151 July 15, 2016 Heroin Users Don’t Need To Lie Down To Kick The Habit.

July 15, 2016

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“It is how you act, not what you take, that defines you as an addict.”



Much is being said and written about our current “opioid use/abuse epidemic”, “heroin addiction epidemic”, “opioid dependency problem”, “opioid crisis”, or other politically-correct term that catches your fancy. Speculation, and some good data, is abundant about causes, prevention, treatments, and consequences. Today’s blog will restrict itself just to treatment, Medication Assisted Treatment, or MAT. Outpatient MAT using Suboxone (1) has proved to be effective  treatment for the disease of opioid dependency. Opioid addiction is a disease that we can treat, just like we can treat diabetes with insulin.

Many popular press articles and consultant’s reports are calling for “more opioid treatment beds”, BUT you don’t need a bed to detox from heroin dependency. In fact, most heroin dependent patients don’t even need to “detox”, in the traditional sense of abstaining from a substance for days, going through withdrawal symptoms for days, and coming out “clean” at the other end.

This cry to “increase beds” as the answer to opioid dependency sounds to me a bit like the cry to increase hospital beds in the 70’s and 80’s. In hindsight that urge looks misguided at best as we marvel today at replacing heart valves without surgery with 2 days in the hospital rather than 2 weeks, delivering high potency intravenous medications from the ICU formulary to patients in their homes, and the sprouting up of numerous networks of hospital-run ambulatory diagnostic, treatment, surgical, and urgi-centers. It is getting to the point where they barely let us lie down for some procedures before we are out the door.

Most substance abuse detox centers are based on the alcohol detox model with a bed in a protected residence, help with alcohol withdrawal symptoms by IV or IM or oral medications, IV hydration if necessary, and behavioral support. That model is NOT relevant to heroin dependency treatment, and, as we now know, it does not work very well.

Heroin or opioid detox centers could be described as “revolving doors” as revealed in numerous studies and as depicted in a recent HBO film. Studies have shown that people with substance addiction undergo an average of 3-4 detox stays over a median of 9 years before staying free of substance abuse for 12 months. Each stay may be as long as 3 weeks and cost about $550 a day. Heroin detox stays may, in fact, increase the chance of a fatal overdose for a patient since their tolerance of heroin decreases, and their “usual dose” before detox, if they relapse and take it, may be too much for them. “Recent abstinence is a major risk factor for fatal opioid overdose.” (2)

Today a heroin or opioid user seeking treatment for his disease can walk into a health care provider’s office and receive his first dose of Suboxone in as little as 12-24 hours after his last dose of heroin. That is how fast heroin “washes out” of the body. (Unlike alcohol withdrawal symptoms, like the DTs, which may not start until 2-3 days after the last drink.) Most heroin users starting on Suboxone experience only mild withdrawal symptoms like jitteriness or changes in bowel movements which can be treated with numerous oral medications “on the hoof”. They do not have to lie down. Their behavioral support system, required by all high quality MAT programs, can be initiated and nurtured “on the hoof.”  After the first week or 10 days the Suboxone prescriptions (filled at the local pharmacy and covered by most insurance plans) are issued on a monthly basis while the outpatient mental health visits and behavioral support groups continue. A patient on Suboxone can be treated both medically and behaviorally for a year for about the same total charge as a 3-week detox center stay.

“Treatment of drug use does not require lying down.
Stand up for yourself!”

Our current thinking about the urgent need for more opioid treatment beds may be part of an outdated, knee-jerk response by legislators and policy makers to “do something” about the opioid crisis. Policy changes and public funds might be better focussed on effective, ambulatory Medication Assisted Treatment (MAT) rather than “more beds”.

1. Suboxone is taken daily in tablet or sub-lingual form and contains two drugs: Buprenorphine relieves pain like opioids but does not produce euphoria plus Naloxone which causes immediate withdrawal symptoms if taken intravenously or intramuscularly.
2. New England Jour of Medicine 373;22, November 26, pg. 2015, 2095-7;  an excellent brief history of a century of Federal drug control.

Vol. 150 June 1, 2016 Blockers of Sun and Bugs

June 15, 2016

Hub thumbnail 2015It is that time of year again.
The 4th annual review of sunscreens (can’t call them “blockers” anymore per the FDA) and insect repellents was just published by Consumer Reports (July 2016 issue). For those of you who don’t wish to read all that chaff-like verbiage under the new editor here are some bullet points to guide your purchases. (If you wish to wade through all the CR words,  the July issue also has recommendations about beach umbrellas that don’t blow away, replacing 15-year-old furnaces with a central heating and A/C unit, and the coolest coolers of them all.


  • An SPF (Sun Protection Factor) of 30 blocks 97% of UVB rays (the cause of sunburn)and is the minimum SPF recommended by the American Academy of Dermatology. An SPF of 50 blocks 1% more for more money. SPF 100 blocks 99%.
  • Almost half (48%) of the sun screens tested by CR actually provided LESS SPF then stated on the package. This has been true over the four years of CR analysis, and this year CR is sending their results to the FDA and asking, “How come you guys don’t test this stuff?” Use SPF 30 product as a minimum.
  • Mineral sunscreens (those with titanium or zinc oxide in them) were the poorest UNLESS the sunscreen left a whitish glow on your skin. Nano-particle mineral sunscreens do not leave a whitish glaze (customers prefer that), but they don’t work well. The FDA is “still studying the unknown unintended consequences of nano-particles in skin lotions”. Non-mineral manufacturers are jumping on this uncertainty by promoting “no nano-particles” advertising, just another meaningless advert phrase.
  • “Broad-spectrum” sunscreens penetrate deeper into the skin to also block UVA light which is associated with increased risk for melanoma and accelerated aging of the skin. UVA rays pass through clouds and glass. There is NO SPF number for UVA ray blockers. CR used a “standard from Europe” in judging UVA blocking ability.
  • “Natural sunscreens” (as opposed to “chemical sunscreens”) are labeled as such because they contain natural minerals, aka “chemicals from the earth”, like titanium and/or zinc oxide. All of them came in under SPF of 15 in CR ratings unless they left white streaks on your skin when applied.
  • The only real difference between kids’ and the adults’ sunscreens are the cartoons on the package. Sprays are NOT recommended for kids because of inhalation occurrences. If you want to use a spray, spray it on your hand and rub it on.
  • No sunscreen is waterproof and reapplication is recommended after coming out of the water. “Waterproof” and “sweatproof” are terms prohibited to sunscreen manufacturers by the FDA.
  • Most sunscreens lose effectiveness after three years in their container, and the FDA requires them to date them now.

No-Ad Sport SPF 50: super protective, non-greasy, fragrance-free, no white streaks, at a great price of 63 cents an ounce.  (“No-AD” means the company does not run ads on TV; it does not refer to “no additives”.)
Coppertone Water Babies SPF 50: $1.31 per ounce

#1 – La Roche-Posey Anthelios 60 Melt-in Sunscreen Milk SPF 60: $7.20 per ounce
#2 – Pure Sun Defense SPF 50 Disney “Frozen”: 79 cents per ounce! (go figure!?); other models with different Disney names like “Avengers”, “Spiderman”, etc. should be equally good.

CVS Kids Sun Lotion SPF 50:
an actual SPF of 8
Banana Boat Kids Tear-free, Sting-free Lotion SPF 50: is also apparently sunscreen-free with an SPF of 8


Choosing a mosquito and tick repellent is easier. Just buy one with either 20% Picaridin or at least 15 % DEET. Both provide protection for 5-8 hours.  Repellent concentration is key. 30% DEET gives a full 8 hours protection. 5% Picaridin (found in some OFF products) gives less than an hour protection.

  • 5 of 6 “Natural ” plant-oil-based repellents tested did NOT work. Burt’s Bee Herbal gives you a scant 1 hour protection.
  • The “natural” 30% oil lemon eucalyptus “Repel” DID work for 7 hours, but should be used only on people over 3 years of age.
  • Picaridin 20% is safe for pregnant women and children over 2 months of age. Canada restricts its use to children over 6 months.
  • “Avon Skin So Soft” works only when it contains 20% Picaridin, but NOT without it.
  • DEET 15-30% is safe for children over 2 months of age.
  • Children under 2 months should be protected with mosquito netting and clothes.
  • Products including Vitamin B1, garlic, wristbands, or ultrasonic devices have no evidence of effectiveness.
  • Like sunscreens, don’t spray your face. Spray on your hands and rub on your face.

OFF, CUTTER, REPEL are familiar brand names, but buy the repellent with the right concentrations since some of these brand products have insufficient concentrations of either Picaridin or DEET to afford adequate protection.

Have fun at the beach … or the Olympics… or wherever!


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