Sometime last year I was suprised to learn of the abuse of ‘neuro-enhancing’ drugs in college students via a friend of mine whos daughter is a college freshman.  A recent article in The New Yorker cites that up to 25-35% of  college students used off label prescription stimulants once (in the previous year to the survey).

This 10 page well written article covers many topics, of which safety and ethics interest me the most, but here are a few thoughts I have as a result….

-the article appears positively weighted regarding how stimulants improve cognitive functioning, however why are healthy academically average or above average individuals so troubled by an imperfect memory, is it such a terrible human quality to live with?

-the long term effects of using these medications in this manner is undetermined at this time, people reading this article or considering such a practice must not overlook its tremendous ease in becoming habit forming= a MAJOR problem

-this article bring attention to some people’s concerns (fear?) around characteristics associated with aging, focusing on the ‘negative’ aspects (memory loss) and apparrent attraction to an instant solution (a pill).  Do advocates of youthful charactistics incorporate life style changes (clean diet, gentle exercise, stress management, etc) to support this way of life?

-off label use of medication, particularly if its addictive, seems like something medical experts would be very conservative about. Is the support of stimulant use by some scientists and medical professionals financially influenced?

-I am very curious of the emerging field ‘cosmetic neurology’ mentioned int he article, which utilized medications to ‘enhance’ human functioning

-another curious segment of humanity has emerged:  the subscribers of the “ImmInst”, aka  Immortality Institute forums, where people aggregate to discuss methods for life-extension and the benefits of cognitive enhancers using technology and science.  The ancient quest for immortality is alive.

-people in this article appear more interested in increasing their competitive edge over others (in their class, profession, or in another country) and making deadlines they normally would not be able to achieve without the drug, to what end do we wish to push ourselves? Whats wrong with not being able to do it all?

-one psychiatrist reframed the family’s request for their son’s school performance to be assisted…. and examined their motivations: do they want their son to fit into the world, or do we all want to make this world a better place for everyone live in?

What would you do if your child was in college or preparing for a standardized exam, and 30% of his/her classmates were using neuro-enhancing drugs to improve their scores?

As one person said, “It’s fundamentally a choice you’re making about how you want to experience consciousness”. If one would like to expand or ‘advance’ their consciousness, might I suggest meditation? It has many fewer side effects….

I’ve disappeared for a while due to the demands of my rotations but am back to write some more commentaries on integrative medicine, health and wellness. Its good to be back!

I like to follow NY State Attorney General Andrew Cuomo’s work busting criminal activity, because the stories associated with the crima are at times truly unbelievable.  Lately, hes had a lot of mess to clean up in our Empire State and if you endorse the reduction of white collar crime, hes your guy.  

This week hes all over the 700 member Millionaries club at Merrill Lynch, which reflects a small number of the 39,000 employees who recieved over a Million dollars each in bonuses before they were bought by Bank of America. Merrill distributed $3.9 BILLION in bonuses, even though they were getting 50 Billion in bailout money. 

WFT!

PLEASE, Mr Cuomo, stop the insanity!

 

other great cases of his:

making Aetna repays students…

The Bernie Madoff disaster…

the MTA retirement directly into disability scam…

the list in endless, keep p the good work Mr Attorney General.

This month Psychosomatic Medicine published a very small cross sectional study examining pain perception and the potential analgesic effect of mindful Zen meditation.   Although the study size was small (n=13), the subjects had greater than 1,000 hrs of meditation and discovered some positive effects of Zen meditation.

Results indicated: meditators required nigher temperatures to elicit pain  and reported decreased pain intensity compared to control (reported no change). In meditators, pain modulation corresponded to a slowed respiratory rate.  The article thought the mindfulness-related results may be in part explained by changes in respiratory rates.

The study concluded:

Zen meditators have lower pain sensitivity and experience analgesic effects during mindful states. Results may reflect cognitive/self-regulatory skills related to the concept of mindfulness and/or altered respiratory patterns.

Its a preliminary study which suggests further investigation regarding the application of mindfulness meditation in pain management.

Here’s a nice little article from the NIH on meditating for health purposes with a bibliography.

I would love to see a unified digital health record system, however I’m against the current on line medical record proposal because it doesnt abide by  HIPAA laws (a brief explanation here)   In the mean time to digitize records, i plan on using a scanner, store my docs on my home computer, stick it on a thumb drive and bring it to my doc’s office until we develop a safe national system!

Google apparently is feverishly denying rumors that its interested in selling its (your) medical record info.

Every time I revisit the topic of parasitology since medical school, my stomach turns…. In the UK, they’re exploring the use of ‘bugs’ with various inflammatory conditions like; hay fever, asthma, IBD, Alzheimer’s, atherosclerosis, some forms of depression and cancer… and other conditions like diabetes.

I thought you’d never ask!

Bikram Yoga, commonly called ‘hot yoga’, involves practicing  a routine set of asanas in a 104* F heat.  According to this article, it has risen in popularity and endorses competitions in the UK (and LA next month) with aspirations to enter the Olympics.  I am surprised to read that yoga has a competitive history in India, and wonder what that looks like; who meditates better? has more devotion? selflessness?  or peace?  I am trying to make a point that competitive yoga may detract the student from the essence of its practice.

I understand from this article that the competition primarily judges asana practice (poses), one dimension of yoga’s complex form.  Maybe this would benefit a few, however Americans are so competitive by nature, it might be more fruitful to explore yoga’s softer side which encourages a less ego driven way of life.

Heres a creative approach (explained many times before) about how parents can help their kids build stronger immune systems by exposing them to dirt and then some (or essentially letting them be kids)…  Though it makes sense, its still not popular with the urban parents faithfully armed with antibacterial handwash 24/7. 

It makes you wonder why kids who grow up in farms are less likely to develop allergies and autoimmune diseases…

Integrative Medicine is a ‘relatively’ new movement, research is helping credit/discredit various therapies’ effectiveness.  Andrew Weil is quite popular.  I dont consider him a snake oil sales man though, he has made meaningful contributions developing integrative medicine within the medical community, and has popularized it in the public arena without too much ‘woo’ (with his Aveda line, supplements and home care products).

The ‘alarming trend’ of physicians heading towards integrative medicine (I’ll include all involved, see last bullet) can be interpreted to reflect any one of the following (however not limited to this list):

• CAM is effective in some areas where medicine falls short or as an alternative to allopathic treatment
• CAM improves quality of life
• Patients feel better using CAM it even though it may not change the course of disease (even if its via a placebo effect)
• The medically trained (MD/RN/PA’s), non-medically trained (L.Ac./LMT/MSW) or those with no training (just hung out a shingle) are out to make a buck

I think the latter option is where people tend to jump first without further examination, and subsequently lump practitioners with training and extensive experience, with those who don’t (ie: Weil or Chopra = Trudeau?).

Acupuncture and herbal therapies have existed for thousands of  years  as the primary form of treatment for civilizations.  Why would we ignore them if they can offer us something? And evidence supports it? While I dont believe ‘if its ancient and x peoples used it, so should we’ or think we should treat medical problems based on ‘beliefs’ (see my post when faith healing kills) I think its realistic to look at all therapies as potential resources, and critically ask; what is the best thing to use/do for x health situation? which causes least harm? most benefit? was it studied? what are the results?

Kevin Trudeau should have known better than to tout his product as a cure for cancer after being warned (with a court order no less).  There was no evidence behind it.   He SHOULD have been hammered to the ground.  It looks like hes been on a long road of poor judgment and insight…. his wiki page describes him as “pocket billiards promoter and alternative medicine advocate” (nice combo!), indicates he first got involved in a CAM (nutritional) pyramid scheme while in prison, and outlines briefly his criminal record for the past 18 years!  I dont think its reasonable to lump Trudeau with Weil or Chopra regarding “sham CAM”.

Out of curiosity I did a quick pubmed search on arthritis/inflammatory disease and the use of omega 3 FA.  I came up with a few articles, some of which help shed some light on the MOA behind omega-3’s…  (Its a slow day at the hospital….pardon the type-o’s)

Thanks for the post Shadowfax!

Clearly there is a great NEED for Integrative Pediatricians!  This is an interesting read about a family’s journey to treat their child’s autism via CAM therapies.   Included is harsh criticism by Dr. Fitzpatrick who refers to CAM as medicine of the “dark ages’.

I think, if it helps its worthy of consideration, however, it would be prudent to find out the therapies are safe in children first,  and secondarily if they’re effective and discuss it with someone who knows the risks vs benefits of doing the treatment and if there is evidence supporting it.

Families who subscribe to faith healing are being tried for ‘reckless endangerment’ after their children die from treatable conditions (ie: diabetes, pneumonia).    This article  made me pause for a moment… Sometimes I get the impression that people who strongly subscribe to Allopathic medicine think thoes who seek out CAM therapies are philosophically equivalent to the families in this article (ie: making irrational decisions about their health).

I disagree, but think all parties (supporters of CAM vs allopathic therapies) are at fault for dualistic thinking to some degree.  Sometimes people who pursue CAM treatment can be narrow and refuse to turn to medicine when they really should have, or wont inquire about the evidence behind recommendations, its risks or limitations.  Sometimes medical practitioners will ignore research even if preliminary, shut down patient’s interests or not cultivate their curiosity to explore CAM’s potential.  I like to think this trend is changing with the integration of medicines.

The following statement from the article BLEW my mind:

Parents who believe in faith healing, she said, may feel threatened by religious authorities who oppose medical treatment. Recalling her own experience, she said, “we knew that once we went to the doctor, we’d be cut off from God.”

Yes, a bit extreme.

What a day.

Its time, a new era has ushered in.  Ride the wave and ask yourself  where you’d like to go, whom youd like to become, and what kind of a world you’d like to live in….  And on a daily basis, nurture it to manifest.

I thank Dr. WhiteCoat for this provocative and thoughful post and recommend it for a good read!

I agree with the mantra “free=more” being false, and I think free medical care will turn into rationed care  and declined quality (already happening with mcd pts),i lie your suggestions however I dont think it will work.  My thoughts:

1) Insurance companies have a big stake in the process (along with Pharma), and strong influence ($$$) which extends beyond this administration into congress.  Insurance co’s don’t want to give up their control over profits  plus the power to control the money maker- MD’s.  We are not organized (sans unions) thus have little collective power against them.  Its a perfect  situation for them, however they would never allow their position being decentralized in any fashion.   I dont think they’re invested in cutting costs, but interested in protecting their profits.  Personally, I think they need to be MORE regulated, and not for profit, but that would never happen.

2) Patients dont want to pay (they might get organized enough to stop a concept like this, but thus far haven’t been organized enough to stop insurance companies impact on their care) thus elected officials would be very unpopular supporting it, and would fear risking taking that stance if they seek re-election

3) i like the idea of listing costs for procedures, for cost comparison, however it would mostly be applicable to upper-middle to upper class people who could chose in this scenario. They would have the means to do so, resources and ability to navigate through multiple hospital systems in different regions/countries to reach their goal (cheaper treatment).  I dont think all patients are educated consumers, I think thats more influenced by education and socio-economic background which will leave out a whole class of people.

4) The results of #3 would adversely affect hospitals in urban areas (where I am) treating poorer populations which tend to be medically more complex or chronically ill.  I would anticipate privately insured pts would increasingly leave the city for tx, and urban hospitals would primarily care for more complicated patients who were on medicare and medicaid (with terrible reimbursement rates).  I question if the actual cost of running all hospital operations to be equivalent between comparable institutions when procedure shopping (does a hospital in Manhattan versus Peoria have the same operational costs which I imagine to impact the procedure cost)?

5) offering consumers a “reward” of a 10% rebate cash would probably work, however in most other service professions, you do get what you pay for…. a comparative procedure at a lesser cost (A versus A) might yield a lesser quality one with higher risks,  but a cheaper procedure/treatment  (A versus B) which yields the same result might be an area that would produce effective savings

I  love the idea of a health care pre-payment set up (akin to a legal retainer, or DDM’s), which includes cutting out the MD from dealing with insurance companies (the BANE of my existence, an INCREDIBLE time consumer), though that is wishful thinking as well…

Efficiency amongst staff is another way to change cost, however that deserves an discussion of its own…

I  agree, if patients paid for their procedures they would be more selective when managing their care.

If we look at this arrangement with a systems perspective:  MDs are at the center of this debate, without us this entire system cannot work.  Even if PA’s and NP’s  take on more roles of MD’s, they cannot replace MD’s.  The training is not equivalent.  Period.  The power lies in MD’s taking a dramatic stance, setting limits to this increasingly tightened  situation in which we practice medicine.

That, however, will not happen until enough MD’s create a mass effect by collectively standing up and saying we cannot practice medicine appropriately and will cease to continue to do so.  I think we are approaching a boiling point, but are not there yet.

This week our Journal Club discussed a Cochrane review article on St.  Johns Wort (SJW) and its use in patients with mild to moderate Major Depression managed most commonly on an out patient basis.  Please listen to the podcast which provides and excellent summary of the review, in brief this is what the article says:

• SJW is more more effective than placebo, but “size of effect” was relatively small, and the result is comparable to antidepressants vs placebo
• SJW compared to antidepressants had similar effect with lesser side effects (note the amount of antidepressants used in study were below standard management doses utilized in US psychiatric clinical practice)
• SJW MOA is unknown, it interacts with other medication, thus a pt should consult a physician/integrative medicine MD for appropriate monitoring and determination if its right for them
  
• Results in Germany were more favorable than from other countries, reasons unknown but were results from Primary care offices
• Depression can be dangerous (high suicide rate), and thus should be monitored by a mental health care provider
• The high quality of SJW used in the trials were of greater concentration comparable to whats commonly available to the public

Side anectote: During third year of medical school, I met a woman admitted to our psychiatric unit with MDD who attempted suicide and was treating her MDD with SJW. She tried to jump out the window, luckly someone managed to stop her.

The discussion in journal club involved residents, psychology interns and our stellar medical students.  Everyone chimed into the discussion with out fearless unit chief leading the discussion.

A wide range of opinions were shared, which included a discussion on why Medicine is conservative about embracing CAM therapies and how that culturally varies by country, and region within the US.  Overall, a few people were open to considering integrating its use in their practice when appropriate and others who recognised the relevance of simply knowing about the results from the study due to the popularity of the herb.

It was a great talk, I was thrilled my colleague picked this article!