Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.
But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.
The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone—the narcotic in vicodin–in emergency center charts increased 170%. This is a big problem.
So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we’ve discussed at length. But absent from that discussion was the evidence.
Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that? (more…)
The W^5/2 Hits Double Figyiz!
OK, I gotta admit that my friend Orac moved me to render this Special 10th Edition of the W^5/2™ (after a brief hiatus) by mentioning it today in the context of an article that used, er, the topic of our venerable game to great advantage! Some of it is brilliant, unprecedented even:
Perhaps most tellingly, the U.S. Internal Revenue Service approved acupuncture as a deductible medical expense in 1973.
My hat is off to whoever came up with that one! Hey, y’gotyer basic logical fallacies, right? Y’gotyer appeal to tradition, yer appeal to popularity (or, as Orac put it, yer argumentum ad populum—sheece, is he a snob er what?), yer appeal to authority, which, I shpoze, an appeal to the IRS is a species of, as it were (hmmm: is that appeal heard in Tax Court?)…but there’s something just a little more special about this than just that. Therefore I propose, in the Tremendous (and Trendy!) Tradition of Trademarked Titles™ long associated with the Wonderful W^5/2™, a bran’, spankin’ new fallacy of its own, presented, of course, in a tasteful Madison Avenue format:
Carlyle said “a lie cannot live.” It shows that he did not know how to tell them.
— Mark Twain
There is an infamous hoax from last century called The Protocols of the (Learned) Elders of Zion, an anti-Semitic text purporting to describe a plan to achieve global domination by the Jewish people. Despite the fact that the Protocols is a work of fiction, there have been and still are folks who believe it to be real, from Hitler on down. (Or is that “on up”? Can one be lower than Hitler? And have I already committed a breach of Godwin’s Law?)
Inventing apparently legitimate information is a useful propaganda device not limited to anti-Semites. Having people appear evil or uncaring using their own words is far more effective than calling them evil and uncaring.
There are many in the community who suffer from a variety of complaints that I cannot diagnose, and, as people do not like uncertainty about their health, they will find someone who will give them a diagnosis. Not infrequently they will come upon the idea of chronic Lyme disease.
The Institute of Medicine report is a frequent ‘rebuttal’ to science based/real medicine. The argument is usually phrased something to the effect that since medicine can be dangerous, SCAM’s are legitimate. Of course, one does not follow the other. It is the equivalent of saying since you are old, bald and pudgy, I am young, have a full head of hair, and are thin. If every doctor and hospital were to vanish tomorrow like an episode of the Outer Limits, SCAM’s would be just a ineffective.
Despite the flawed logic of the comparison, I have always had an affinity for the estimates that 44,000 to 98,000 were (note the deliberate use of the past tense) killed each year in hospitals. There may be methodological flaws in the estimate but the ballpark figure is probably correct.
Naturopathy is an unusual chimera. It is basically a collection of old fashioned medical superstitions presented under a veneer of highly speculative, quasi-scientific assertions. But given its popularity, it is important, from time to time, to evaluate specific claims made by this particular non-science-based belief system.
A reader informed me that he was advised to seek the advice of a naturopath for treatment of his seasonal allergies. Since naturopaths claim to be “doctors plus”, I was curious what they would recommend. Would it be standard allergy treatment with antihistimines and other proven medications along with some sort of vitalistic mumbo-jumbo? It turns out I was half-right.
Spring is here. I don’t say that because of the warmer weather, the blooming tulips in my back yard, or the current effect of the earth’s axial tilt on the Northern hemisphere. No, in my somewhat warped world of the pediatric ICU seasons are marked by illnesses and injuries with an annual rhythm. Fall begins with a spike in cases of bronchiolitis, Summer with a near-drowning in a swimming pool. Winter has arrived when seasonal influenza reappears. And Spring, well, Spring has several harbingers, including auto vs bicycle accidents, falls from windows, and snakebites.
Sure enough, this week we admitted our first child of the year bitten by a venomous snake who, like most people unfortunate enough to be envenomated by a North American pit viper, has done very well. This child fell prey not only to our local limbless fauna, but also to one of several common myths or misunderstandings about snakebites that place the victim, rescuer, or both at higher risk for injury and complications. This post will explore some of the more common mistakes people make during North American snakebite encounters (being limited to snakes native to North America, the following does not necessarily apply to snakes from other areas).
File this post under Science-Based-You’re-Not-Helping-Please-Don’t-Do-That.
Myth #1: You Need to Know the Species / Kill the Snake
North America has around 120 species of snake, over 20 of which are venomous. With so many species, it may seem important to ID the snake so the docs in the ED can give the appropriate anti-venin. Fortunately, that isn’t the case. (more…)
For most of human history, doctors have killed their patients more often than they have saved them. An excellent new book, Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and Our Difficulty Swallowing It, by Druin Burch, MD, describes medicine’s bleak past, how better ways of thinking led to modern successes, and how failure to adopt those better ways of thinking continues to impede medical progress.
The moral is not that doctors once did foolish things. The moral is that even the best of people let themselves down when they rely on untested theories and that these failures kill people and stain history. Bleeding and mercury have gone out of fashion, untested certainties and overconfidence have not.
Burch’s conversation with his rowing coach epitomizes the problem:
“I want you to keep your heart rate at 85% of max for the next hour and a half.”
“Because it’s the best way to improve your fitness.”
“How do you know?”
“Because I’ve done it before and it worked. Because that’s what the people who win the Olympics do. I know, I’ve trained some of them.”
“But has anyone actually done an experiment?”
“What on earth are you talking about?”
This book is Burch’s answer to his coach’s question. Medicine’s “beautiful idea” is that we should test all hypotheses and beliefs using the kind of tests that are reliable for determining the truth. Instead of going by tradition, authority, theory, common sense, or personal experience, we now have effective tools to find out for sure whether a treatment really works. (more…)
Science-based medicine is, among other things, a tool. Science helps us sequester our biases so that we may better understand reality. Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools. Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).
Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts. But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas. Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict. They can also arise when we as physicians are constrained in our actions by outside forces.
On SBM we have documented the many and various ways that science is abused in the pursuit of health (or making money from those who are pursuing health). One such method is to take a new, but reasonable, scientific hypothesis and run with it, long past the current state of the evidence. We see this with the many bogus stem cell therapy clinics that are popping up in parts of the world with lax regulation.
This type of medical pseudoscience is particularly challenging to deal with, because there is a scientific paper trail that seems to support many of the claims of proponents. The claims themselves may have significant plausibility, and parts of the claims may in fact be true. Efforts to educate the public about such treatments are frustrated by the mainstream media’s lazy tendency to discuss every study as if it were the definitive last word on a topic, and to site individual experts as if they represent the consensus of scientific opinion.
Recent claims made for low dose naltrexone (LDN) fit nicely into this model – a medical intervention with interesting research, but in a preliminary phase that does not justify clinical use. And yet proponents talk about it as if it is a medical revolution.
In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1
Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”
The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.
In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3
Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4
A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6