Tag: medicine

The Opioid Use Hiding Behind the Alleged Superiority of “Nonopioid” Chronic Pain Treatment

 

The SPACE randomized clinical trial, which 234 veterans with chronic back or knee pain completed, has been touted as demonstrating that opioids are superfluous to chronic pain management. According to JAMA’s summary of the trial,

In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.

Give Me Misery or Give Me Death?

 

Doctors retire. That’s the context of my recent experiment in “detoxing” from two prescriptions, both of which strike me (but not yet the FDA) as good candidates for over-the-counter (OTC) sale. (Most striking detox effect so far: a massive earache.) One is Celecoxib, an anti-arthritis drug. The other is Montelukast, an anti-asthma and anti-allergy drug. What’s scary about selling both these drugs OTC is allegedly death.

Celecoxib is a Cox-2 inhibitor, and those drugs as a class still haven’t completely aired out the stink of death brought on by Vioxx. Montelukast maybe sometimes cause psychiatric side-effects, according to postmarketing reports, raising the specter of suicide (though postmarketing reports could report anything as a side-effect, short of “pet turtle died”). But the most frightening thing about Montelukast appears to be that it’s an effective asthma control medicine, and the FDA is apparently nervous about making effective asthma control medicines available to consumers directly.

Contra Caplan on Physical Illness, Too

 

In 2006, insouciant economic imperialist Bryan Caplan published a paper outlining a consumer-choice model of mental illness designed to rehabilitate the anti-psychiatry of Thomas Szasz. Caplan claimed this model shows that mental illness should not to be understood as a “real illness” (and therefore as a matter for medical rather than moral treatment) at all, but that mental illness should be understood as a weird preference rational actors persist in despite their preference being a poor match for functioning in society.

From the perspective of Caplan’s model, mental-health treatment is a form of rent-seeking designed to paper over the interpersonal conflicts that arise when somebody won’t relinquish a preference grievously at odds with society, rent-seeking that, on the one hand, provides the “mentally ill” with official-sounding excuses for their weird preferences while, on the other hand, providing the families of the “mentally ill” with medical justification for treating sufficiently “ill” family members against their will. In October 2015, the blogger Scott Alexander, himself a psychiatrist, published “Contra Caplan on Mental Illness”, an essay pointing out why, from his perspective, it seems so strange to call mental illness merely a weird preference. Given Caplan’s framework, I would like to point out how strange it is to call physical illness not a “weird preference”, albeit a weird preference most of us take pity on out of belief that it arises from physical derangement that we don’t expect sufferers to be able to compensate for completely.

In this AEI Events Podcast, AEI’s Tim Carney hosts a panel discussion regarding whether obtaining medical care from trained health care professionals who are not doctors, such as nurses and nurse practitioners, could drive down costs. The panel of economists and medical professionals discuss this issue of regulation, safety, and economic opportunity, and conclude with a discussion of the role for new innovations, such as telemedicine, in the future of health care.

Panelists include Benedic N. Ippolito (AEI), Cindy Cooke (American Association of Nurse Practitioners, and R. Shawn Martin (American Academy of Family Physicians).

In this AEI Events Podcast, a panel of experts gather to discuss the role of government in medical innovation. AEI’s Thomas Peter Stossel begins with an overview of the eras of medical innovation. He describes the current environment and discussed how the value gained from medical innovation has changed over the past century.

In the following panel conversation, leading health and science experts discuss the role of National Institutes of Health funding, the future of academic bioscience, the recent crisis in quality of scientific work, and the future of medial innovation. Panelists include Jeffrey Flier (Harvard University), Daniel Sarewitz (Arizona State University), Frances Visco (National Breast Cancer Coalition), and Mary Woolley (Research!America). The discussion is moderated by Thomas Peter Stossel (AEI).

Don’t Emulate My Family

 

Hana and Ibrahim Farraj – Wedding Photo.

Hana Farraj (my beloved grandmother) died of a heart attack in 1993, she was 70 years old. She had the heart attack while she was in Seattle (visiting her son), but she didn’t want to be a bother. So instead of going to the hospital, she waited, for three days, she even got on a Greyhound bus and rode down to Portland. She died the day she got back. Don’t emulate my grandmother.

Member Post

 

It was at least fifteen years ago when I sensed that 1) there were more physicians running for and winning election to the congress, and 2) they were overwhelmingly Republican. It seems to me that continues to be the case today – more physicians (and who are overwhelmingly Republican) are in the congress than at […]

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Richard Epstein breaks down the complicated path to replacing Obamacare without destabilizing America’s healthcare system.

Where Affordable, Altruistic Healthcare Goes to Die

 

As conservatives, we’re never surprised by news that Obamacare hasn’t fixed the nightmares facing the typical American confronted with medical bills. Nor are we surprised when Obamacare only makes them worse. A few years ago, Jim Epstein at Reason predicted the demise of health-sharing ministries at the hands of Obamacare’s subsidized exchanges. The good news is that Epstein was wrong: Membership in health-sharing ministries has only grown as frustration with commercial prepaid plans under the Affordable Care Act continues to mount. According to the New York Times,

[M]embership in sharing ministries has more than doubled over the last six years, to 535,000 from about 200,000, according to the Alliance of Health Care Sharing Ministries.

Epstein attributes this doubling to “Obamacare’s disastrous rollout and the extent to which new mandates would drive up premiums and leave customers seeking out cheaper options.”

Thoughts on Tiamat this Electoral Eve

 

The maples, wicks of autumn, go to cinder from the top down, the blaze on most trees past its prime, now mostly scattered at our feet. The plant kingdom burns brightly as it plunges into wintry darkness. A plunge into some outcome or another awaits us tomorrow, too. We can estimate what it might be – and we should. But as Ricochet Member @rodin reminds us, “none of us will ever know (or at least [not] for a long long time) whether the way we cast our ballot was better than the alternative.”

All this fall, I’ve had an unknown greater than the outcome of this election hanging over my head – or at least greater to me. One reason it’s greater is that I’m more responsible for it. However I vote, whatever I say, the outcome of this election is largely out of my hands. This other thing, though, is very much in my hands, or it’s supposed to be, and so the moral weight I bear for its unknown nature is far greater than the weight I bear for my vote.

Member Post

 

As a chronic melancholic I measure my age by the rate of my physical decline. It’s not because I’m completely falling apart, although that’s the case for all of us. I recognize, however, that man is dust and to dust he shall return. We melacholics are realists. Over the last nine months I’ve spent most […]

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Member Post

 

It was big national news when federal regulators working for Obama went beyond the written law passed by Congress to insist on having Catholic universities and charities provide birth control coverage. Ditto for the requirement that Protestants who’d happened to incorporate cover abortifacient birth control drugs. Ditto for the requirement that public schools join the […]

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The Doctors, and Other Great Journalism

 

Screen Shot 2016-08-12 at 14.58.49Looking for summer reading? Conor Friedersdorf has published links to 100 great pieces of long-form journalism at The Atlantic. I haven’t read them all, but every one I’ve read so far has been terrific. (Don’t click on that link if you thought you’d get something useful done today. You’re welcome.)

I found two pieces especially riveting. The first, by Henry Marsh, a British neurosurgeon, is called The Aneurysm:

… I carefully cut the gossamer veil of the arachnoid around the great artery that keeps half the brain alive. The arachnoid, a fine layer of the meninges, is named after the Greek word for a spider, as it looks as though it was made from the strands of the finest spider’s web.

Nicotine as Miracle Drug

 

leovapeDr. Anna Fels recently saw a patient who had an interesting method of self-medication. The psychiatrist wrote up the experience in the New York Times:

We talked for a long time about why she had come to see me. Then, as is my practice with a new patient, I asked what, if any, psychiatric medications and nonprescription, psychoactive substances — legal or illegal — she had used. Her answer was a new one for me. She stated that she chewed approximately 40 pieces of nicotine gum per day and had done so for well over a decade.

Responses to this question are often illuminating and can be rather humbling. Although doctors are trained to focus on prescription medications, there are and have always been nonprescription “remedies” for psychiatric conditions. And people’s preferences for one type of substance over another can give a glimpse into their symptoms and even their brain chemistry.

The Other Drug War

 

Earlier this month, the Food and Drug Administration rejected the application of Biomarin Pharmaceutical to market its drug Kyndrisa™ (drisapersen) for use in the treatment of Duchenne muscular dystrophy. The FDA, as is often the case when it rejects a drug application, listed all sorts of technical reasons why the data presented was not sufficient to establish by respectable scientific means that the drug in question was safe and effective in its intended use. Without question, much evidence from the clinical trials revealed serious complications from the drug’s use, including blood-platelet shortages that were potentially fatal, kidney damage, and severe injection-site reactions. But the no-treatment alternative could prove far worse.

Duchenne is a rare but fatal genetic disorder that attacks only young boys, roughly 1 in 3,500 to 5,000. Typically, it first manifests itself between two and five years of age. With time, it relentlessly weakens the skeletal muscles that control movement in the arms, legs, and trunk. Most of its victims are wheelchair-bound between the ages of seven and 13. By 20, many have died.

Unintended Consequences: Docs & Glocks Edition

 

shutterstock_151057025Several years ago, the American Medical Association instituted a new policy of recommending that doctors enquire about their patients’ firearms. This was pitched as a matter of household and child safety and — while the policy stressed “education” — its language makes it pretty clear that this is not something Eddie Eagle would endorse. Despite not having kids, I’ve been asked about my guns at least twice at the doctor’s. The first time, I wasn’t expecting it and simply answered the nice nurse’s question. The second time, I said something to the effect of, “Thank you, but I don’t think that’s a medical question.” The nurse shrugged and the appointment proceeded as before.

Unsurprisingly, stories soon emerged about doctors dropping patients who refused to answer the question, as well as others who (chillingly) tried to talk to children about it behind their parents’ backs. In response, several states, including Florida, passed legislation that forbade doctors and other medical professionals to bring up the subject of guns under most circumstances.

Much has been written about this: I came across a discussion of it on Science-Based Medicine earlier this week, which made reference to a recent post on the Volokh Conspiracy that I’d missed. We’ve also talked about it on Ricochet. The most recent news is that the Florida law has again been found constitutional, this time on First Amendment grounds subject to strict scrutiny. That seems like a bad decision to me, but I’ll recommend you read others’ takes to form a legal opinion.

The Uneasy Legacy of Henrietta Lacks

 

henrietta-lacksRecently, Rebecca Skloot, author of the major best-seller The Immortal Life of Henrietta Lacks, wrote an impassioned plea in the New York Times, urging people to support sweeping revisions to the Federal Policy for the Protection of Human Subjects, which is now under active review in the Department of Health and Human Services. These revisions are directed to the rules that now govern the collection and use of “clinical biospecimens,” which include all the organic substances that are routinely removed from the human body as a consequence of surgery, childbirth, or even normal testing. At first appearance, these materials look like waste products best disposed of in a safe and sanitary manner. But, in fact, they are invaluable in medical research to treat cancer and a host of other genetic and life-threatening diseases.

Without question, the most dramatic illustration of this process involves the so-called HeLa cell line derived from the cancer cells of Henrietta Lacks, an African American tobacco farmer who died of cancer in 1951 at the age of 31. When she was treated at Johns Hopkins Medical Center, her cancer cells were given to the pathologist Dr. George Gey. Gey found to his amazement that, unlike other cancer cells, Lack’s cells were immortal in that they could be cultured and reproduced indefinitely. Within three years of her death, her cell line helped develop the Salk polio vaccine. In the 65 years since Lacks died, about 20 tons of her cell line have been reproduced and distributed worldwide for medical research.

But just what did Lacks and her family get out of the arrangement? At the time, nothing. In accordance with the then standard practice, the Johns Hopkins researchers collected and used her cells without her knowledge or consent. In more recent years, she has received countless public honors for her contributions to medical research. But, at the same time, the many researchers who worked with her cell line collected substantial royalties from the patented cells and the devices developed with their assistance.

Make the Argument

 

shutterstock_210347026Most people in the country are at their limit, emotionally. It can be seen in the comments section here at Ricochet, on TV news, on campuses, and even among friends and family. The emotions include anger, fear, disgust, distrust, and doubt. These aren’t exactly the best emotions for this time of year. The Christmas season is supposed to be a time of hope and expectation, so I’d like to share a recent experience that buoys my spirit.

I’m in graduate school in DC receiving a Masters Degree in Physiology before beginning medical school next year. Occasionally, we will have speakers who discuss relevant issues in medicine, followed by small group discussions. During a discussion of end-of-life care, one student in my group of 20 made an argument in favor of physician-assisted suicide. He said that he would happily assist a patient end his own life, if he wanted to end it. The room fell silent and awkward silences make me uncomfortable, so I decided to offer a retort.

I argued that there is a great moral line that should never be crossed by physicians. The line between removing a patient from a ventilator, and letting nature take its course versus actively killing a patient. Also, as a matter of policy I believe that “Right to Die” will easily turn into “Duty to Die.” Patients feeling pressure from administrators, physicians, and family will eventually end their own lives.

Pain Demands An Explanation

 

shutterstock_314240933There are two truths about pain that every good conservative believes. First, pain is the most straightforward incentive; people need pain to correct their behavior. Second, we believe in “no pain, no gain;” i.e., that pain is a necessary sacrifice in the pursuit of accomplishment. In either case, pain is useful. At least, that is our moral ideal of pain and how it ought to act to fulfill its purpose.

That pain, whether of the body or the psyche, serves a useful purpose is easy enough to see. We need only consider what happens when it’s absent. Lepers and CIPA patients become horribly disfigured because they can’t feel pain. Lepers lose sensation in their extremities. CIPA patients cannot feel pain at all. They only avoid injury and disfigurement through a tedious process of consciously checking themselves, which is much less effective than simply feeling pain. Similarly, mania and psychopathy both reduce a person’s capacity to feel the psychic pains — shame, remorse, etc. — that keep us on the straight and narrow, and both mental states are quite sensibly regarded as dangerous.

That not all pain serves a purpose is somewhat harder to see. Complex Regional Pain Syndrome and phantom limb pain both loudly contradict the notion that pain is always useful, but both are so freakishly rare they can be dismissed as aberrations. While much more common, garden-variety chronic pain is so frustratingly subjective that it’s tempting to moralize it away as a manifestation of moral fragility, as a “cross” bestowed on us by a loving God for the purpose of spiritual refinement, as a failure of mind over matter.