Vol. 173 July 1, 2017 Bugs and Drugs

July 1, 2017

 

“Eat dirt, and thrive”

 

Since Fleming discovered a mold that produced penicillin which killed Streptococcus bacteria, scientists for decades have been mining soil as a source of new antibiotics. There are so many bacteria competing for nutrients in the dirt that some bacteria will produce toxins to kill their neighbors. The current belief is that soil extraction for new antibiotics has been going on for so long that soil is about tapped out as a source for novel ones.

Antibiotics kill bacteria by attacking their cell walls. Bacteria develop “resistance” to antibiotics with changes in their cell walls that resist the medicinal attack. Individual bacteria cells can’t change their cell walls, but the population of pathogen bacteria as a whole, the “microbiome”, can become “resistant” as the bacteria cells replicate again and again. When only the bacteria which have mutated to ones with a different “resistant” wall remain, the bacteria has become “resistant” to the antibiotic. Your body does not become “resistant”, the bacteria community does..

Viruses have no cell walls, and that is why antibiotics don’t work on viruses, like the ones causing the common cold. Anti-viral medicines against the flu and HIV work by attacking the internal functions of the virus. Some anti-viral medicines attack the virus DNA, others attack the virus RNA, and others attack intracellular proteins or enzymes necessary for virus replication.

Scientists at Rutgers have recently described a whole new class of antibiotics extracted from soil (Italian soil to be exact, if you think that’s important) that don’t work by attacking the cell wall. The new compound inhibits an internal protein, a polymerase, in the bacteria which is necessary for the bacteria to survive. The compound is 10 times less likely to trigger a mutation that leads to drug resistance than current antibiotics. Also it can kill dormant, non-replicating bacteria much better than current antibiotics. Similar compounds that attack polymerases has been successful in treating viruses like Hepatitis C and HIV, but this is the first example of a successful antibacterial effect. It will send many scienticists looking for new antibiotics back to the dirt.

Could this just be another reason to eat dirt? Eating dirt, or geophagia, is a recognized way for animals, and some humans in special situations, to obtain minerals. Pica , eating non-food substances, in a child can indicate that the child is iron deficient or anemic. Pregnant women in Africa are known to eat dirt to enrich their stores of calcium for the fetus. Parrots, bats, and some pregnant women have been observed eating soil with a high clay content to help with gastrointestinal distress. Since dirt can contain lead and other toxins, most people are advised to just take a swig of Kaopectate.

Why not just skip the dirt and go right for the pure mixture of bacteria, a probiotic? In fact, the evidence for the benefits of the use of probiotics is mixed. The use of probiotics has not been dramatically positive in treating diarrhea, eczema, and preventing the side effects of antibiotics. True that probiotics have no significant side effects (the FDA has labeled them as “safe”), but some researchers are concerned that overuse may have deleterious effects on our normal gut bacterial flora.

There are approximately 100 Trillion (that is a “T”) bacteria in our gut. They have been officially awarded recognition as the “gut microbiome”. It is a hot research topic focussing on its roles in digestion, metabolism, immunity, dementia, and even autism. Fecal transplant therapy  (infusion of a solution of healthy donor feces through a nasogastric tube) repopulates the intestine with “good” bacteria as treatment for certain diseases caused by “bad” bacteria (Clostridium difficle) (1) More recently, the dscription of a “breast microbiome” in association with some breast cancers is spurring research into using bacteria as biomarkers in screening for breast cancer.

” The Hidden Half of Nature”, published in 2008, tells a positive story of a couple changing their lives by enriching their garden soil with bacteria-heavy materials while enriching the bacteria of their own intestines by “eating healthy”. One of the authors summed up their approach as: “Mulch your soil, inside and out”.

  1. N Engl J Med 2013; 368:407-415, January 31, 2013
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Vol. 171 May 15, 2017 Medical Updates (Real News)

May 15, 2017

 

“The Only Thing That Is Constant Is Change -”― Heraclitus

 

 


Those TV ads work … for the drug companies.
A study of the effectiveness of TV ads (Direct-to-Consumer Advertising or DTCA) for prescribed testosterone supplements (no effectiveness in men without endocrine disease) in 75 regional markets from 2009 to 2013 showed that the addition of ONE TV ad per household per month for 4 years was associated with an increase in new blood tests of testosterone level, new prescriptions with blood level testing, and new prescriptions without any blood level testing. About 2% of the middle-aged men in this study of 17 million men received a testosterone prescription. (JAMA,Mar 21, 2017)

In other news, the British Medical Journal published a study of over 900,000 men which showed that those taking testosterone were 63% more likely to develop potentially fatal blood clots in the legs or lungs during the first six months of taking it. (BMJ, Nov. 13, 2016)

Vitamin D gets an “F”.
Vitamin D supplements became very much in vogue when some studies suggested that people with low blood levels had a higher risk of cardiovascular disease. BUT, in New Zealand 2500 adults were given 1000 units of vitamin D once a month and a matched group of 2500 were given placebo. The vitamin D blood level doubled in the supplemented adults, but at the end of 3 years both groups had identical rates of adverse cardiovascular events (12%). (JAMA Cardiol Apr 5, 2017)

PSA testing -“D” or “C”? It depends.
In 2012 the U.S. Preventative Services Task Force (USPSTF) gave the PSA blood test screening for prostate cancer a “D” – (not recommended) because of false positives leading to unnecessary procedures and treatment, and the fact that PSA screening prevented less than 1 prostate cancer-related death per 1000 men screened.

In 2017 the USPSTF is upgrading that “D” to a “C” (maybe a small benefit) but only for men aged 55-69. (Dare we call it a “gentlemen’s C” ?) The “D” remains for those over 70. This upgrade for the younger men is based mostly on the emergence of the “active surveillance” option to immediate surgery or radiation for positive PSA tests and biopsy. The USPSTF strongly recommends that physicians 1) explain all the risks and benefits of PSA testing to men from 55-69, 2) be aware of the patient’s “values and preferences”, and 3) practice effective “joint decision-making” with the patient. (J Watch General Medicine May 15, 2017)

In other news, a Michigan study of 431 men with localized prostate cancer discovered by PSA testing and confirmed by biopsy who opted for “active surveillance” rather than immediate surgery or radiation showed that only 31% actually followed the complete “active surveillance” protocol. (PSA testing every 6 months and annual repeat biopsy.) Another 31% complied with just the PSA test repeats, but not the biopsy. 22% did neither repeat PSA tests nor biopsy. Outcomes were not measured in this study, (J Urol Mar 2017)

Aspirin may get a third “A”
Aspirin is well-known to relieve pain, reduce inflammation, reduce fever, and reduce blood clotting. It does that by inhibiting the production of prostaglandins, a hormone-like substance in play in all those conditions. In 2000 scientists discovered that aspirin also increases our production of resolvins which also reduce our inflammatory response. We make resolvins from Omega-3 fatty acid precursors (hence the contemporary popularity of fish oil).

Investigators are very interested in a newly defined, third effect of aspirin which is unrelated to its role in anti-inflammation – aspirin’s interference in the ability of cancer cells to metastasize. Cancer cells apparently need to be coated with clumps of platelets in order to survive their trip through the blood stream to distal sites. In mice, aspirin’s anti-platelet action (the “reducing blood clots” function) has been found to interfere with platelet clumping around the cancer cell and successful migration of the cancer cells through blood vessels is inhibited. (Scientific American May 2017)

Trying to avoid sugary beverages? Don’t jump to diet soda.
A 10 year study monitoring 4000 people without diabetes for strokes and cognitive decline found that people who drank diet soda every day were three times more likely to develop strokes and dementia. In a separate study people who drank more juices and more sugar-sweetened soda than others were more likely to have poorer memory and smaller brains on MRI imaging than the other people. The researchers state clearly that this is not a cause and effect situation, just an “association”. (Stroke April 24, 2017)
“More research is needed.” Of course.
“Water is best.”

Bilingual brains remember their first language, even when they can’t speak it!
Korean-born adults who were adopted by Dutch families before the age of six and who did not speak nor understand Korean were better at distinguishing between the sound contrasts of the Korean language and could pronounce the Korean sounds much better than those Dutch adults who had no exposure to the Korean language as children. This better discrimination of sounds is not genetically based because numerous studies have shown that all infants are capable of reproducing all the sounds of all languages. “Remarkably, what we learn before we can even speak stays with us for decades.” (Duh!) (Royal Society Open Science, Mar 2017)

No federal money to study pistols or pot.
According to David Hemenway, Professor of Health Policy, Harvard School of Public Health, an average of 300 people get shot in the U.S. each day. One-third of them die. Twenty years ago the CDC funded about $2.6 million a year (“a small amount”) for firearms research. Now that funding is ZERO. Since 2006 Congress has pprohibited the CDC from gathering any gun-related statistics and developing a gun-related data base, but there is apparently no formal, official prohibition for funding gun-issue research,; just the CDC’s desire to “stay out of congressional crosshairs”.

NIH apparently has the same reticence. In the past 40 years over 486 NIH grants have been awarded in the areas of cholera, diphtheria, polio, and rabies which have caused 2000 deaths in the U.S. Over the same 40 years while 4 million people were shot in the U.S. , NIH has awarded 3 gun-issue research awards. (Note: this period of time is during the relatively scientific-friendly Clinton, Bush, and Obama administrations .)

Marijuana is still classified by the FDA and the DEA as a Schedule I substance which prevents any clinical trial or study of its medicinal benefits. Medicinal marijuana must have FDA required “drug development” studies to get off Schedule I, and those studies are virtually impossible while it is on Schedule I. (Note: current Attorney General Jeff Sessions said in April 2016: “Good people don’t smoke marijuana”) (Scientific American May 2017)


Vol. 146 April 15, 2016 The Bathroom Bill and Another Unintended consequence

April 15, 2016

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“Bathroom Bill passes the House and goes to the Senate next month.
Governor Baker still on the fence.”

Gender politics are currently heating up in North Carolina, Massachusetts, and other states about proposed bills banning discrimination against transgender people “in public accommodations”. Many states have already passed laws or issued Executive Orders banning discrimination against transgender people in government and other jobs. The lightening rod in these new bills is the clause allowing transgender people to use the public restroom appropriate for what “they look like”.  This effort to “ban transgender discrimination in all public accommodations” has been succinctly reframed as “which restroom are they allowed to use”, hence the name “bathroom bill”.  Groups in favor of letting transgender people use the bathroom “that matches how they look” advocate passionately for the rights of transgender people. Opponents raise the specter of men masquerading as women assaulting women in public bathrooms. If it weren’t for the strong emotions swirling throughout this largely symbolic conflict these discussions might be another source of “comic relief” in this election season.

Screen Shot 2016-04-15 at 10.50.35 AMAs previously blogged  different kinds of gender-benders can look the same.  These proposed laws will set rules based on how people LOOK, but transgender people define themselves by how they think. “Transvestites, transexuals, and cross-dressers can be defined by who they go to bed WITH. Transgender people are defined by who they go to bed AS.”

These bills mark our continuing evolution of trying to deal with the changing views of gender identification. In 2014 ABC News found 58 possible gender identifications allowed by Facebook, though many of them are just slight variations of the same term; ex: “Male to Female” and “MTF”, “Cisman” and “Cisgender Man”. The list also includes “Other” and “Two Spirit”.  In 2015 California colleges in response to a 2011 California law started giving 6 choices for voluntary gender identification on student applications: “male; female; trans male/trans man; trans female/trans woman; gender queer/gender non-conforming; and different identity.”   They also added a question asking the student to voluntarily identify their sexual orientation. All of this apparently for state government data collection purposes, and, perhaps, to help make appropriate roommate assignments. The California colleges have stated repeatedly that the new information does not enter into the admission decision process itself. 

Not surprisingly a demand on a number of college campuses has risen for more “gender neutral” restrooms as one logical solution to this gender conundrum.. In Europe, and in select small public facilities in the U.S., they are  called “Unisex” restrooms. If you are wondering how you could identify such a facility, you might just look for this sign.:gender neutral symbolwpid-167_4817_6960

UnCHOF
My most recent nomination to the Unintended Consequence Hall of Fame (UnCHOF) goes to the Novartis pharmaceutical company. They make Voltaren (diclofenac) a non-steroidal anti-inflammatory drug commonly used  for joint stiffness and pain when simple Advil doesn’t help. It has been associated with a small risk of cardiac toxicity in humans.

Years ago farmers in India started giving diclofenac to their aging, limping, stiff cows in hopes of getting another year or two of use out of them. When the cows died their carcasses were left in the fields as was the custom in India and millions of vultures quickly reduced them to piles of bones. The vultures of India have been providing this necessary and efficient service for centuries.  But, the vultures ingested the diclofenac remaining in the cow carcasses, and it so happens that vultures lack the enzyme that metabolizes diclofenac. The rising blood levels of the drug were toxic to their kidneys.  Millions of vultures in India and Pakistan, as in ALL of them, had died by 2008 of renal failure. “Today there are many young Indians who have never seen a vulture.” (1)

When the “vulture clean-up service” died out the cow carcasses were trucked away to dumps. Feral dogs found the dumped carcasses to be a ready source of food, and the feral dog population in India exploded. Recently there have been more frequent sightings of leopards, yes leopards, in some Indian urban areas. The leopards are there to eat the dogs.

So, veterinarian use of a very common non-steroidal drug consumed by millions of humans has in India killed off a whole species and has produced a new type of urban danger, hungry leopards!  QED

References:
1. A River Runs Again; India’s Natural World in Crisis;  by Meera Subramanian, 2015


Vol. 140 January 15, 2016 A Review of 2015 Hubslist Blogs

January 15, 2016

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Click on the date to see the full blog

 

January 1 – 5 out of 10 of my resolutions were “kept”. You guess which ones.

January 15 – 6 reasons why patients are non-compliant , excuse me, “non-adherent”- the new PC term, with their medications.

February 1 – incidence of sudden death while watching the Super Bowl (Patriot fans probably don’t have to worry about that THIS year.)

February 15 – some myths revealed about cholesterol in your diet, global warming, measles vaccination rates, herbal supplements, and Dr. Oz, vendor of snake oil(s).

March 1 – 8 new causes of death caused by cigarette smoking added to the previously identified 12; a total of 20.

April 1 – Athena Health purchases MySpace which raises more concerns about privacy of health care data (April Fools edition).

April 15 – what does a “board certified physician” mean, and what does it have to do with Presidential candidates (Rand Paul)?

May 1 – physicians’ prognoses are often too optimistic for the same reasons patients’ are.

May 15 – E-cigarettes open new avenues for adolescent use of marijuana and synthetic cannabinoids (“bath salts”).

June 1 – annual review of sunscreens and bug repellents plus less universities providing student access to tanning booths.

June 15 – new forensic techniques of identifying individuals by bacterial, viral, and DNA “fingerprints”.

July 1 – 6 positive access outcomes and 4 positive health care delivery outcomes of Obamacare at 5 years of age.

July 15 – dangers of synthetic cannabinoids (attn: Chandler Jones?) and the minimal (“pending”) review of sunscreens by FDA.

August 1 – two websites with the best “symptom diagnosis” track record for helpfulness, and the one that is the worst.

August 15 – [ family vacation in a lighthouse without electricity or running water]
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September 1 – why new drugs cost so much, no “gay gene” identified yet, and the myths of low testosterone, chronic Lyme, and  8 glasses of water a day.

September 15 – The health benefits of our “microbiome” and the “microbiome” of the New York City subway.

October 1 – the misleading, untruthful attacks on Planned Parenthood.

October 15 – the scope and magnitude of adverse effects of dietary supplements.

November 1 – transgender, transsexual, transvestite, and hermaphrodite, oh my!

November 15 – toddlers shooting people and other “norms” of gun deaths – “By Degrees“.

December 1 – changing advice about what NOT to eat during the holidays.

December 15 – the benefits of research using fetal tissue, short history of political attacks on Planned Parenthood, and why if you are NOT fat and live a long life you should thank your parents.

HAPPY NEW YEAR


Vol. 139 January 1, 2016 HEROIN: Cape Cod, USA

January 1, 2016

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A HBO documentary shown on December 28, 2015

 As a pediatrician and a parent I found this moving documentary of eight white, middle class heroin addict kids from stable families on Cape Cod to be very disconcerting. It was brutally honest with several scenes of addicts preparing and injecting heroin. The repetitive, “almost-expected”, relapses after detox, and the seemingly casual acceptance of inevitable drug deaths of other addicts set a tone of hopelessness. The onset of addiction in half of these addicts followed standard treatment with opioids for post-accident or post-surgical pain. 30-day detox programs, despite their noble intent, were depicted as mostly fruitless in the long run, like spitting in the ocean. (None of the eight addicts appeared to be enrolled in a heroin-replacement program – Suboxone or methadone) The recognition by the addicts that their craving drove them into behavior they themselves detested confirmed that insight is not enough.

 One addict said that “one dose of heroin was all that was needed to get you addicted”, but NIH statistics suggest that 23% of first heroin users become addicts. Even so, those one-in-four odds are worse than the odds of Russian roulette with a six-shot revolver! One could consider appropriate opioid treatment for post-surgery pain as a “screening test” to find those one-in-four addicts!

For the past decade physicians have been told that the patient should direct pain control. “How bad is your pain on a scale of 1 to 10?” Hospitals and doctors were, and are still, graded on their ability to reduce patient-reported pain quickly. Many of us physicians remember the pain control conferences that basically told us “you are not giving enough”. Perhaps that mind set contributed to the current easy access to opioids.

The Massachusetts Medical Society just promulgated lengthy opioid therapy guidelines consisting of 11 statements for acute care and 16 statements for chronic treatment (over 60 days). The guidelines are sprinkled with words like “function and pain”, “quality of life”, “short-term trial”, “minimum dosage”, “partial-fill prescriptions”, “low-dose sequential prescription”, and “useful consultation with a specialist or a second opinion”. Treatment of cancer. hospice, palliative care, and hospital inpatients is exempt from the guidelines.

The simple patient pain scale of 1 to 10 has been trumped by 11-16 sentences. If you think that is an overstatement then consider these words in the new guidelines,  “The guidelines will provide valuable guidance to physicians [mostly primary care] in their practices and as evidence of best practices and to the Board [of Registration in Medicine] in its responses to patient complaints, accusations of substandard care, or accusation of inappropriate prescribing.” [emphasis added].

The multiple pathways to addiction, its frequent appearance in several members of a family, and on functional MRIs similar active areas of the brain common to all types of addicts suggest a genetic basis of addiction. If that is true, than the cure for heroin addiction in the long run will depend on identification of the responsible genes and the development of drugs that will block or modify those specific genes.

In the short run, maybe we can do more in the U.S. to reduce the harms of addiction; overdose deaths, infectious diseases, and criminal behavior. One mother in the parents’ group eloquently summed up the need to “destigmatize” heroin addiction. ( “No one sent me casseroles when my son died of an overdose.”) To “destigmatize” addiction we will need to “decriminalize” it and treat it as a medical condition. Other countries (Switzerland 1994, Portugal 2000, Vancouver B.C. 2003, Netherlands 2009, Germany 2009, and U.K. 2009) have done that with both “heroin-replacement” and “heroin-assisted” treatment programs. Those programs have resulted in a reduction of overdose deaths and AIDS/Hep C infections WITHOUT increasing drug use.

According to the Boston Globe the “supervised injection site” in Vancouver (called “Insite”) has been shown by 30 peer-reviewed studies to have “saved thousands of lives, saved millions of dollars in both health care and public safety costs, reduced transmission of AIDS and hepatitis C, and promoted entrance into treatment without increasing drug use or drug-related crime”. (1) The Cato Institute studied the results of the successful Portugal program in 2009 and confirmed the same positive results. Critics remarked that such a model would not work in the U.S. because of our size, heterogeneity, and politics.

Isn’t that a shame?

References:
1. Boston Globe, December 27, 2015, K5, “Massachusetts needs safe injection sites”


Vol. 134 October 15, 2015 Supplements Are Not Harmless.

October 16, 2015

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“The belief is that they [dietary supplements] are entirely safe,
but now science says that they’re not.”
– Pieter Cohen, MD, Harvard Medical School

A recent study of 63 hospitals from 2004 to 2013 estimated that over 20,000 ER visits and 2000 hospital admissions annually in the U.S. were due to adverse effects of dietary supplements. Adverse events included allergic reactions, excess doses, unsupervised ingestion by children, or other events (e.g., choking). Cases involving death, intentional self-harm, drug abuse, or withdrawal were excluded.  Adverse effects commonly involved cardiovascular adverse effects from weight-loss or energy herbal products among young adults, unsupervised ingestion of micronutrients (iron) by children, and swallowing problems associated with micronutrients (multi-vitamins) among older adults. (1)

The supplements listed included orally administered herbal products (Echinacea, Coenzyme Q10, Gripe Water, etc.), complementary nutritional products (fish oil, body building protein , chondroitin/glucosamine, etc), vitamins and minerals (including calcium and iron), and topically administered herbal or homeopathic products. Energy drinks and herbal tea beverages were excluded from the study.

In the U.S. there were more than 55,000 dietary supplements on the market in 2012, and about half of all adults reported having used at least one dietary supplement in the past month. 150 million people in the U.S. take supplements, including children’s vitamins. In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, which equaled one-third of the total out-of-pocket expenditures for prescription drugs.

  • Weight loss supplements or herbal energy products led the list of supplements with adverse effects in this study.
  • More than half of emergency department visits for supplement-related adverse events involved female patients.
  • Sexual-enhancement products or bodybuilding products were implicated in 14% of emergency department visits for supplement-related adverse events among male patients; there were too few cases among female patients to calculate a reliable estimate.
  • 20% of ER visits involved children who took supplements without supervision.
  • Most ER visits for unsupervised ingestion of supplements by children involved multivitamins (34%), iron (12%), supplements for weight loss (11%), and supplements for sleep, sedation, or anxiety (9%). Child-resistant packaging is not required for dietary supplements other than those containing iron (the amount of iron in the usual bottle can be lethal to small children) , but despite such packaging, iron supplements were the second most commonly implicated type of supplement in unsupervised ingestion by children.

Although the numbers of ER visits and hospitalizations were less than the 5% of the ER visits that have been reported for pharmaceutical products, dietary supplements are unregulated and marketed under the presumption of safety. The FDA is actually BARRED from regulating dietary supplements by the Dietary Supplement Health and Education Act of 1994. (Wouldn’t you like to know the history of that particular bill, or at least, the lobbyists involved?)

When you or someone you know has a good effect from a supplement (like taking glucosamine for knee pain) it natural to think that anyone with knee pain should take it, and that every physician should know about this “miracle supplement”. In medicine that kind of anecdote is called a “case report”.  Case reports can lead to studies of a large number of people, called “statistical studies”. Results of those studies can be persuasive, but the truly scientifically skeptical physician will wait for the results of an organized, randomized, double-blind study with controls (people who don’t get the supplement). Such organized, controlled studies have not found a whole lot of benefit, if any, from taking dietary supplements, especially vitamins, but that is the subject for another whole blog… or two.

References;

1. Emergency Department Visits for Adverse Events Related to Dietary Supplements
Andrew I. Geller, M.D., et al, N Engl J Med 2015; 373: 1531-1540; October 15, 2015


Vol. 129 July 15, 2015 Update on FDA & Sunscreens and Bath Salts

July 15, 2015

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“Herbal incense” may sound organic,
but it sure ain’t good for you.

 

Sunscreens (1)
Previous blogs have noted that the FDA has limited authority over and regulations for sunscreens, but it does have some. Despite “the common wisdom” that the FDA is slow to approve new prescription drugs, its approval process is generally faster than Europe’s and in 2014 the FDA approved the highest number of new drugs in 18 years – 41 products. (1)

Over-the-counter (OTC) products like sunscreens are regulated by a different process using the standard:  “ generally recognized as safe and effective”. But, in 2014 the FDA declined to permit use of 8 new ingredients in sunscreens even though they have been in use in Europe for 5 years. It cited lack of safety studies, gaps in data, and reports of adverse events. This action prompted an understandable, if   a bit of an over-the-top reaction, from the Wall Street Journal calling to “strip the sunscreen police of all powers over the stuff.”

It is obvious that the FDA has mixed, and unfunded, responsibilities for review of OTC products. A new law, the Sunscreen Innovation Act of 2014 (only in America could we come up with a name like that), tried to clarify the situation, but no new resources were allocated to implement it. In the meantime both the FDA and the CDC continue their efforts to discourage use of tanning beds and promote prevention measures against melanoma which claim 10,000 deaths a year in the U.S.

Synthetic Cannabinoids (SC) (2)

Synthetic cannabinoids (SC) arrived in the U.S. from Europe in 2008 as herbal incense, spice, and bath salts “not for human consumption”. Since 2011 the DEA has placed over 40 SCs into Schedule I of controlled substances which means they are obtainable only by prescription. The problem is that manufacturers of these SCs merely change one or more chemical bonding group or a single chemical chain and the new compound falls outside such a regulation. The compounds are easily obtained on the internet for use in e-cigarettes or are added to energy drinks. They are still labeled “not for human consumption”, and may even carry the assurance that the product “contains no regulated compounds”.

Widespread distribution and marketing have led to recent clusters of serious illness and even deaths, particularly among the young and inexperienced users. Many users reported that they used SCs in order to get high without risking a positive drug test. SCs are NOT detected by the usual urine or blood lab tests, have no available antidote, and can produce serious symptoms which are not readily identifiable as symptoms specific to SC toxicity. Some users have died before reaching an emergency department.

The number of adverse events is increasing. During a two month period in early 2015 Mississippi reported 1200 SC-related visits to the ER and 17 deaths. One reason for this uptick may be the distribution of novel SC compounds that are easily and rapidly synthesized and marketed in response to regulatory actions. They can have new, unknown effects resulting in idiosyncratic toxicity such as delirium, seizures, psychosis, kidney failure, hallucinations, coma, and death.

Ninety-one per cent of users interviewed in one study inhaled vaporized SCs from refillable e-cigarette cartridges. E-cigarettes seem to be garnering more very bad “unintended consequences” than originally predicted by its advocates.

References:
1. NEJM July 9, 2015, pg. 101; A Spotlight on Sunscreen Regulation; J.A. Sharfstein, MD, Johns Hopkins School of Public Health
2. NEJM July 9, 2015, pg. 103, Synthetic Cannabinoids – Related Illnesses and Deaths, DEA, CDC, and University of California


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