It strikes me that calling trends in opiate dependency and polypharmacy overdose deaths an “opiate epidemic” is a misnomer, akin to calling the Industrial Revolution an epidemic. While the term may effectively rivet pubic attention on the problem, characterizing the drug dependency and overdose crisis an “epidemic” undermines a deeper public understanding of it.

An epidemic is often sparked by a newly emerged infectious disease, usually a bacteria or virus. As such, mitigations are usually focused on the single agent that is placing communities at risk. Effective initial solutions may include the isolation of infected individuals, so they do not expose the general population to risk of infection. Or perhaps a vaccine to prevent infection or an antibiotic to treat those who are already infected. On the other hand, it is virtually impossible to isolate our populations from the knowledge of and exposure to pain relievers, and because drug dependency evolves over a lifetime, simple solutions are elusive.

The newly emerging threat in an epidemic is external to society. In contrast, like the Industrial Revolution, the drivers of drug dependency and overdoses are intrinsic to the evolving structure of society. The causes are complex and are, at least initially, deliberate. Research confirms that socioeconomic and educational disparity, unemployment, global policies, cultural incongruity and a health care system that is focused too much on profit have all been major contributors to the evolving problem over the past century.

This raises the question of timeline. As the years and decades pile up, it begins to become apparent that many of the trends we see have occurred before. Before your next breath, note that this is not cause – nor call for – despair. But it does remind us to learn from past experience and past mistakes, if not by our own generation then by earlier ones. From Prohibition in the 1920s, to the Rolling Stones Mothers Little Helper in the ‘60s, to crack cocaine in the urban U.S. in the ‘80s, to methamphetamine in the ‘90s, and now prescription and non-prescription pain relievers and opiates, the trend has been indolent and relentless over generations.

Because the drug dependency and overdose problem is imbedded in our social fabric, the solution is necessarily complex. To make criminal justice interventions the only solution to the drug dependency and overdose crisis would be like building a more robust fire department in response to climate change. Both strategies are destined to fail unless vigorously partnered with public health research and interventions that work upstream to limit the factors that incubate criminal behavior and modify human behaviors that contribute to climate change.

©April 2008

Perhaps the most important part of practicing medicine is to gain the capacity to see through your patient’s eyes.  To fully comprehend the experience of a patient as expressed in a chief complaint is often the most important clue to a diagnosis, no matter whether the goal is to understand the subtle characteristics of pain, to visualize a rash according to the patient’s description, to empathize with the distress of a spouse during a partner’s illness, or to anticipate the reluctance of a patient to take a medication as prescribed.  It is for this reason that the words of a patient are necessarily accepted, at least initially, as a basic truth.   But it is not often recognized how destructive it can be when a health care provider is deceived, either purposefully or inadvertently, about the best interests of the patient.  Perhaps the most serious example of the breakdown of the physician-patient relationship is the abuse of prescription drugs and the temptation to over-prescribe medications designed to relieve suffering.

First, it is important to emphasize that the recognition and treatment of pain is a critical responsibility of physicians and providers.  In 2001, California passed a law requiring all physicians to receive 12 hours of pain management education because of a perception that there was a gap in general knowledge of the subject.  However, since that time there has been a well-recognized increase in prescription drug abuse paralleled by an unprecedented increase in the prescribing of narcotics.

Pain is actually our friend.  It turns out that when the first protozoan recoiled from a hot object, the nervous system was born.  Responding to noxious stimuli only requires the memory of this event to inspire learning.  As memories of positive and negative experiences accumulate, the capacity to understand Shakespeare is only a few million years away.

A complex nervous system is designed not only to pull the strings that operate our machinery, but also to protect our bodies from injury.  Several disorders can cause individuals to lose the capacity to experience pain.  The end results of such conditions include joint destruction, bed sores, and infections, any of which can be life-threatening.  Indeed, there are many maladies that one should prefer to the loss of the ability to experience pain.

Prescription drug abuse is only encouraged by technological progress that has made it possible to both mass produce and market pharmaceuticals.  Every culture on earth has discovered substances that either relieve suffering or provide temporary pleasure.  If there is any doubt about the capacity of substances to place the brain on autopilot, simply observe a cat indulging in a patch of catnip.  In the past, pharmaceutical production was limited by the ability of farmers to grow and harvest poppies, plants and the like.  However, it is relatively recently that synthetic narcotics have become available in a wide array of doses, formulations and colors to pharmacies throughout virtually every corner of every community in the country.

Except for marijuana, tobacco and alcohol, prescription narcotics are now the most commonly abused drug in the local student population.  Most of these either come from prescriptions that have been diverted from the intended user, or are “extra” medications that were salvaged from previous prescriptions.

Tuolumne County had the second highest rate of drug-induced deaths in California during the period 2003 to 2005.  We simply must begin the process of re-educating ourselves and future generations to be comfortable with the idea of sometimes being uncomfortable.  While we must validate and treat pain when it is a part of illness, we must not substitute the illness of an anesthetized society for pain – both physical and mental anguish – that is serving a healthy purpose.

©January 2009

During immunization campaigns, photos often depict unhappy children sitting obediently on the laps of parents looking reassuring and responsible.  These images often give us a sense that vaccinations are something we impose on those under our charge, such as our children, our pets or our ranch stock.  After emerging from adolescence, adults enjoy a sense of freedom from the need to subject themselves to the indignity of immunizations, similar to the assurance that their last SAT tests are behind them.  This is a fantasy.  The first clue comes in the form of the recommended annual influenza vaccinations for adults, but a growing number of additional vaccinations are available which are also important for adults to include in their health care planning.

First, it is worthwhile to review the theory behind vaccinations.  The immune system is assigned the job of protecting our body from foreign invasion.  It is unfortunate that students learn about the digestive, circulatory and nervous systems in fourth grade, but the immune system does not often show up in text books until later.  Like the heart, it works 24 hours a day, 365 days a year, except leap years, to prevent a virtually endless list of villains from causing infections.

The immune system learns to recognize these villains through experience.  Vaccinations provide this experience, either by giving our immune systems a sniff of dead fragments of viruses or bacteria (“inactivated” vaccines), or by giving our immune systems experience with a living distant cousin of the villainous germs (“live” vaccines) so that our body’s law enforcement can recognize the nasty ones when and if they show up.

Public Health experts have noted that there is indeed a tendency for populations with higher annual influenza vaccination rates to develop an increasing resistance to influenza penetration.  In other words, there appears to be some benefit to groups of people from prior years’ influenza vaccinations.  Nevertheless, because of the slippery behavior of this particular virus, repeat annual influenza vaccinations are still the recommended rule.

Some people confuse the influenza vaccine and the so-called “pneumonia” vaccine.  There is a bacteria called the “pneumococcus” which causes a dangerous form of pneumonia (lung infection), particularly in seniors who are disabled by other conditions of older age.  Infection from this bacteria can be prevented with the “pneumococcal vaccine,” AKA the “pneumonia vaccine.”  It is generally recommended that seniors 65 years of age and older receive two pneumonia vaccines one year apart.

Any adult who seeks emergency care for a cut or puncture wound is familiar with the question, “When was your last tetanus shot?”  A wound should always be washed with soap and water.  But if a person suffers a dirty wound, like a pitchfork to the foot or a barbed wire puncture in a field, a tetanus vaccination should have been obtained within the last five years.  If the wound is relatively clean, like a cut while washing dishes, then an interval of ten years is usually satisfactory.

If a person 11 years or older has never had a booster dose of tetanus that included inactivated pertussis vaccine, then the next tetanus shot should include the pertussis booster, in a shot called the “Tdap.”  This is because we have learned that immunity to pertussis (whooping cough) begins to disappear during adulthood.  We have learned this by experience.

The Human Papilloma Virus (HPV) causes cervical cancer.  About 12,000 women develop invasive cervical cancer each year in the U.S. and approximately one third will die of this disease.  The HPV vaccine is the first vaccine developed to prevent cancer.  It should be given in two doses if the patient’s first dose is given between 9 and 14 years of age, but if the patient is 15 to 26 years of age, then three doses are recommended.  There has been over a 60% drop in vaccine-type HPV infections in teen girls in the U.S. since the HPV vaccine was first released in 2006.

The varicella vaccine is used to prevent chicken pox in those who have never had the illness.  In seniors, the varicella virus that causes chicken pox can return from hiding within our own bodies and show up as a disease called “shingles” or “Herpes Zoster.”  This disease can be very painful and result in disabling symptoms.  Therefore, a shingles vaccine should be obtained by seniors 60 years and older as two doses of Shingrix, a new Zoster vaccine, 2 to 6 months apart.

Finally, the Measles, Mumps and Rubella vaccine should be obtained at least once during adulthood before age 50 to assure protection against these viral illnesses.

Keeping this information straight becomes ever more difficult as new vaccines are developed to protect us from the nefarious interests of unfriendly viruses and bacteria.  One of the most important responsibilities of public health is to help keep this information at your fingertips.

©May 2008

Keeping waste separate from sources of drinking water has been a practice of civilizations throughout recorded history.  Before we bashfully attribute this behavior to our scientific brilliance and responsible environmental stewardship, we must recognize that cautious sewage management is not unique to humans.  The ease with which cats and dogs can be house trained suggests that cautious handling of waste has somehow been hard wired into our lesser companions.  Even raccoons are known to maintain “latrines” in a location separate from food and water sources.  However, commercial medications pose a new challenge to safe disposal of sewage.  Our septic system technology has not been designed to remove many pharmaceuticals from our sewage stream.  We are told not to dispose of unused medications down the toilet or drain, but at the same time we find medicine cabinets engorged with unused and potentially dangerous medicines.  How do we safely dispose of old drugs and unused narcotics?

This problem is more than just a nuisance.  Prescription drug misuse is now the fourth most common form of substance abuse, following tobacco, alcohol and marijuana.  Prescription narcotics create the illusion of safety because of their legitimate use in health care.  While the benefits of pain relief to patients suffering from illnesses can not be overstated, pharmaceutical products come in a wide variety of doses and drug delivery systems which can be as dangerous as a firearm in the hands of an untrained person.  Deaths occur every year in our communities as a result of unexpected effects of prescription medications when they are not used in accordance with their intended purpose.

It should also be pointed out that the greatest contribution of drug contamination to our sewage stream is not from inappropriate disposal of medications down the drain, but rather from the medications that pass through our own kidneys.  It is more than a little exasperating to consider that a good portion of your pharmaceutical co-payment ends up going right into the plumbing fixtures after a quick trip through your personal subway system.

Back to the point.  Now is a good time to go through your medicine cabinet to locate unused or old medications in order to avoid the potential dangers they pose.  Check expiration dates and remove those which have expired.  Remove those which have been discontinued, or which were prescribed when you were pregnant with your college-aged son or daughter.  Remove those with the name of relatives who are memorialized on the trunk of your family tree.

Medications, except for controlled substances like narcotics and tranquilizers, can be discarded during community Hazardous Waste Collection campaigns.  Information is usually available from local Environmental Health offices or from your local sheriff or law enforcement agency.

There are currently insufficient provisions in the United States for the disposal of unused prescription narcotics, tranquilizers and stimulants.  Law enforcement agencies are currently the only legal entities that can receive controlled prescription medications for disposal, but such drug disposal programs are not currently funded.  Nevertheless, efforts are now underway to provide residents with other options.

Until then, it is important that unused prescription medications either be discarded during local hazardous waste collection campaigns, or, for controlled medications like narcotics, stored safely in a secure location where they cannot be diverted for misuse and abuse.  If you have a specific challenge relating to the disposal of controlled substances, you may call your local health department or law enforcement agency for advice.

©January 2009

Pharmacies often devote one of their larger shelves to remedies, palliative treatments, and salves for arthritis.  This fact alone suggests that there is a significant prevalence of the condition.  However, the packaging of such treatments can pose a confusing array of questions to the consumer trying to understand the difference between “Extra Strength,” “Maximum Strength,” “Super Strength,” “Long Acting,” and “Doctor-recommended.”  Could there be any reason a doctor would not want to recommend something that provided “maximum” benefit to his/her patients?  Understanding the strategy behind the treatment of arthritis is important to selecting the right product before you head to the cashier.

Arthritis means inflammation of a joint or joints.  Note that joints are usually easily recognizable because they represent the hinges of our bones, where limbs bend and flex.  Health providers prefer the word “articulation” instead of “joint,” because it has more syllables.

Some joints, such as where our ribs join the spine or meet the cartilage next to the breastbone, are not as obvious but are nevertheless true joints.  One of the most helpful signs of arthritis is pain at the site of movement when there is motion in a joint.  When pain occurs in muscles and soft tissues away from where there is flexion, the problem is often due to an injury to a muscle, tendon or other soft tissue rather than to the joint structure itself.  On the other hand, there are occasionally times when pain arising from a joint may be felt at a location different from the actual site of movement, a phenomenon called “referred pain”.

Any joint can become inflamed, but there are different reasons for the inflammation.  Inflammation of a joint can occur because one has just been tackled by a defensive lineman.  Such an injury results from trauma to the joint.  The injury may be to the soft tissues that support the joint (ligaments, lubricating machinery etc…), to the cartilaginous surface of the joint itself, or less frequently to the bone.

Joint inflammation in a grandparent often is due to the accumulation of birthday candles.  Consider the tires on your car.  It is absolutely predictable that the rubber on your tires will slowly be shed as the miles you drive accumulate.  Similarly, the cartilage that helps to decrease friction in your joints will eventually show signs of wear.  Whether this occurs at 50, 60 or 70 years of age (or thousands of miles) has to do with the joint owner’s occupation, family history and activity level.  This is so-called “osteoarthritis,” or degenerative joint disease.  We will all get it if we live long enough.

Another type of arthritis is inflammatory joint disease.  In this situation the joint inflammation is secondary to an underlying inflammatory condition.   Rheumatoid arthritis, caused by the traitorous activity of one’s immune system, is in this category.  The result is an activation of the white blood cells, causing them to attack the tissues of the joint.  Gout is another type of inflammatory joint disease caused by the formation of crystals within the joint space.  In gout, the crystals act as an irritant, often affecting the joint at the base of the big toe.  While treatment for degenerative arthritis can be addressed with over-the-counter medications and common sense, treatment for inflammatory joint disease should be coordinated with your health care provider at an early point.

Swelling and pain occurs in all these kinds of arthritis.  Therefore, anti-inflammatory medications are the standard for treatment in most cases.  Remember that aspirin, AKA acetylsalicylic acid, will diminish blood clotting and should not be used in children.  Otherwise, the different over-the-counter anti-inflammatory medications – ibuprofen and naproxen – are very similar in effectiveness when taken at recommended dosages.  One should be aware that these medications can be irritating to the stomach lining, so they should not be taken without advice from health care providers for people with a history of ulcer disease or stomach disturbances.

While acetaminophen does not provide an anti-inflammatory benefit, it can be helpful to reduce the pain of arthritis.  If this allows a person to remain active, it is probably worth consideration as a part of the treatment plan.

The oral supplements chondroitin and glucosamine were popular treatments in the past for arthritis.  Recent evidence, though, has indicated that these supplements are no more effective than placebo for treatment of pain or joint damage due to arthritis.

Certain over-the-counter salves are actually quite beneficial for some patients.  You may recognize the active ingredient in salicylate creams (see aspirin above) which are available over-the-counter for arthritis.  Smelling like a breath mint is a primary side effect.

It should be remembered that the treatment of arthritis should include proper physical care of the involved joint, such as an ice pack during the first 24 hours after a knee injury, rest for osteoarthritis of a thumb, or slow strengthening for a rheumatoid arthritis victim.  Specific recommendations can be obtained from your physical therapist, orthopedist, rheumatologist, chiropractor, or primary care provider.