I can’t believe I SKIPPED FEBRUARY.
I also can’t believe that only one reader called me on it.
Maybe I only have one reader.
I dated my last blog, “Can Pregnancy Make You Stupid”, with March 15 and the one before with March 1, but they were both published in February!
My only explanation is that I was looking forward so much to my March vacation in the Caribbean that I fast forwarded to that month.
Today is March 1, … and I am on vacation. So, this is today’s blog.
I guess I needed a vacation.
March 15 blog will be on time and correctly dated.
I can’t believe I SKIPPED FEBRUARY.
Massachusetts 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.
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.
“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.
Few Americans recognize the contributions of IMGs (international medical graduates), or more broadly all foreign-born physicians, to U.S. healthcare.
Physicians born anytime in the 1930s – 1950s are more likely to have the surname Smith, but starting in the 1960s the U.S. saw an uptick in diversity, and in both the 1970s and 1980s, Patel topped this list as the most common last name among all physicians. Patel is now officially the last name most frequently preceded by “Dr.”
This trend is likely to continue. Since the 1980s, the number of Asian American med school graduates has increased from almost none to making up approximately a fifth of all graduates . According to the 2014 census, foreign-born doctors now make up approximately 25 percent of all physicians practicing in the U.S.
Current medical student enrollment statistics reflect a similar mix.
Of 86,746 medical students in U.S. medical schools in 2015:
46,108 were men (53%)
40,634 were women (47%)
All: 54% white
. 20% Asian
. 8% multiple ethnicity
. 6% African-American/Black
Only 2% of U.S medical students are “Non-U.S. Citizen or Non-Permanent Resident”
These figures confirm that most of the 25% practicing physicians that are “foreign-born” have come to the U.S. after non-U.S. medical school graduation for residency training and have stayed to practice. Foreign born physicians require a J-1 visa from the U.S. government to participate in our residency training programs. In 2011 65% of physicians with a J1 visa (foreign-born) were practicing primary care (internal medicine, pediatrics, and family medicine) compared to 28% of U.S. medical graduates.
The AMA has estimated that once the Obamacare “access to care” elements are fully implemented and as our older age demographic increases we will be about 90,000 physicians short of those needed to maintain optimal physician/population ratios. Much of that “physician shortage” will be in primary care. Interestingly the two most popular specialities for IMGs are Anesthesia and Psychiatry. One specialty does not require a lot of talking to patients. They are asleep most of the time. The other requires nothing but talking! Of course, the highest percentage of IMGs (20%) are from English-speaking India.
Despite its strong association with romance during the Christmas season, mistletoe has a less than charming back story. Mistletoe is a parasitic plant that attaches itself to other trees to steal nourishment from them. Its berries are eaten by birds who then spread the seeds for new plants in their droppings. The seeds in the droppings stick to the bark of certain trees and burrow a root down through its bark. “Mistel” is an old English word for bird dung. “Toe” is derived from a word for “twig”. So, one could translate “mistletoe” as “poop on a stick”. (1)
Mistletoe was one of few plants still green during the winter for both Norseman and the Druids. The Norse considered it a symbol of love and friendship. The Druids noticed that it had berries, and they used them to encourage friendship while controlling kisses. A berry was pulled off the sprig for each kiss. When there were no more berries, there were no more kisses.
“The physiological effect of the [ingested] plant is to lessen and temporarily benumb such nervous action as is reflected to distant organs of the body from some central organ which is the actual seat of trouble. In this way the spasms of epilepsy and of other convulsive distempers are allayed. Large doses of the plant, or of its berries, would, on the contrary, aggravate these convulsive disorders. Young children have been attacked with convulsions after eating freely of the berries.”
“In a French work on domestic remedies, 1682, Mistletoe (gui de chêne) was considered of great curative power in epilepsy. Sir John Colbatch published in 1720 a pamphlet on The Treatment of Epilepsy by Mistletoe, regarding it as a specific for this disease. He procured the parasite from the Lime trees at Hampton Court, and recommended the powdered leaves, as much as would lie on a sixpence, to be given in Black Cherry water every morning. He was followed in this treatment by others who have testified to its efficacy as a tonic in nervous disorders, considering it the specific herb for St. Vitus’s Dance. It has been employed in convulsions delirium, hysteria, neuralgia, nervous debility, urinary disorders, heart disease, and many other complaints arising from a weakened and disordered state of the nervous system.” (2)
“The tincture has been recommended as a heart tonic in typhoid fever in place of Foxglove [digitalis]. It lessens reflex irritability and strengthens the heart’s beat, whilst raising the frequency of a slow pulse. It is stated that in Sweden, persons afflicted with epilepsy carry about with them a knife having a handle of Oak Mistletoe to ward off attacks.”
Poinsettia derives its common English name from Joel Roberts Poinsett, the first United States Minister to Mexico, who introduced the plant into the United States in 1825. Despite its reputation, poinsettia are NOT poisonous for children and pets. According to the POISINDEX information source – the primary resource used by the majority of poison control centers nationwide – “a child who weighed 50 lbs. would have to eat over 500 poinsettia leaves to reach an even potentially toxic dose of compounds in the poinsettia plant.” Doctors at the Children’s Hospital of Pittsburgh and the Pittsburgh Poison Center conducted a review of 22,793 reported cases of poinsettia exposures, the majority (93%) of which occurred in children, and found that 92% of those exposed did not develop any symptoms at all. Ninety-six per cent of those exposed were not even treated in a health care facility. Furthermore, no deaths resulting from poinsettia ingestion have ever been documented. (3)
Even though accidental ingestion of poinsettia leaves will not damage your body or kill you, it may lead to nausea and vomiting in some cases. Since the taste of poinsettia leaves is reportedly very unpleasant, it is unlikely that a child or animal who attempts to eat or chew the leaves will continue to do so after the first taste.
Boy, this blog about two beautiful warm, fuzzy Christmas plants reads like it was written by Debbie Downer. Maybe by the next blog I’ll be more in the Christmas spirit.
Grand Rounds 7.24 March 8, 2011 includes a post from this blog. Check out the featured medical blog posts at DrPullen.com.March 18, 2011
It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.
Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.
Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.
The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.
What has happened to all that we were taught in second year Physical Diagnosis?
No one stretched my calf looking for a positive Homan’s sign. No left lateral decubitus positioning to listen for that subtle, easy to miss heart murmur. No confirmation that my extraocular movements were normal. No listening intently for a carotid artery bruit. Forget looking for splinter hemorrhages on my retinas or even under my fingernails. My abdomen could have been hiding an enlarged liver or spleen, but no one would have discovered it that night. Come to think of it, I do remember the admitting hospitalist briefly pushing two fingers against my shins and commenting, “trace edema”.
After a day shadowing a physician in a program sponsored by our local medical society, a banker summed up his impression with, “A physician’s job is a day-long quest for credible data”. I agree, and it is clear to me that the physicians caring for me that night were doing just that as efficiently as possible. Why bother checking for Homan’s sign when an ultrasound tech the next morning will tell you if there is a clot in the leg, its location and how big it is? The echocardiogram will give so much more information about my heart dynamics than an application of a stethoscope for a minute or two. With a dramatic CT scan showing all the clots and some pleural fluid, and with me having significant pain every time I took a breath, why spend a lot of time percussing my chest, feeling for vocal fremitus, or switching back and forth from bell to diaphragm on the stethoscope?
As technology has advanced, objective test results have replaced many physical findings as the foundation of a correct diagnosis. The job of the physician has become in large part that of deciding which test will give the best information. That is not bad, but I remember that our Physical Diagnosis professor won more “Best Teacher” awards than any other faculty member, … or any imaging machine. He not only provided us with our first glance into the real magic of clinical medicine, but he imprinted us with the appreciation that “laying on of the hands” was a vital part of a respectful relation with the patient.
I received excellent, efficient care. I was diagnosed quickly and treated appropriately, courteously, and was fully informed. But, in remembering Eliot Hochstein, MD I have to say that as a patient I sure do miss some parts of the “good old days”.
One part of the “good old days” hasn’t changed. At about 1:30 AM after all the tests that night were done and I was being prepared to be moved upstairs to a bed, I was still really uncomfortable because I had not yet received any pain medication. I asked for some, and got my first dose at 2:00 AM.
1.Physical Diagnosis, a textbook and workbook in methods of clinical examination by Elliot Hochstein and Albert L. Rubin. Published 1964 by Blakiston Division, McGraw-Hill in New York .