Showing posts with label medical. Show all posts
Showing posts with label medical. Show all posts

Wednesday, 4 September 2019

How to treat yourself when sick



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Monday, 11 March 2019

Teens who use flavored e-cigarettes more likely to start smoking

Are you taking care of someone who seems to be against you? This can be the experience of taking care of a family member with post-traumatic stress disorder — PTSD — and it can take a huge toll on everyone involved. At the same time, caring for a person with PTSD can be an act of love and courage.
What causes PTSD?

PTSD can develop when people experience massively stressful events that involve childhood physical or sexual abuse, being sexually assaulted, or narrowly escaping getting killed or severely injured, whether from accidents or violence or military combat. PTSD can also be caused by witnessing these kinds of things, by them happening to a close friend or relative, or by learning about them in the course of one’s work, such as being a first responder or a social worker helping victims of abuse.
What are the effects of PTSD?

Whether caused by experiences during military service, abuse as a child, being the victim of assault as an adult, or as a side effect of jobs that deal with trauma, the effects can be lifelong. It’s a medical problem, not a weakness. Adrenaline levels stay elevated, causing anxiety, irritability, and hypervigilance (being on guard even in safe places). People with PTSD may become snappy and even physically aggressive. Little, everyday sounds may make the person jump. The ability to feel positive emotions like love and happiness is diminished, and people with PTSD may drink or use drugs to avoid painful feelings and memories. People with severe PTSD may isolate themselves, lashing out and showing little affection toward people they care about, and who care for them. Conflict with family members and coworkers is common.
Caring for a person with PTSD

It can be hard for caregivers not to take it personally. They feel that their loved one doesn’t love them anymore (and indeed it’s difficult for some people with PTSD to feel and express love). The fun is gone, and in romantic relationships so is the intimacy. The family member with PTSD may not be comfortable going out in public or being touched. Caregivers can feel lonely and abandoned, and divorce is common in relationships where a partner has PTSD.

Watchwords for caregivers are self-care, limits, and realistic expectations. It’s a balance: you want to help your loved one but you can’t do that if you’re impaired yourself. So, self-care is important. Figure out what you need to have a happy and healthy life and make an effort to keep those things in your life. Eat right, get exercise, take time off from caregiving, see friends. When you’re healthier, you’ll be better able to help your family member to be healthier.

Set limits. You want to offer gentle support, but not tolerate things that are out of bounds for you in any other relationship, such as abusive language or actions, or heavy substance abuse. Couples therapy can be tremendously helpful when one member of the couple has PTSD.

Expectations need to be realistic. Just as other medical disabilities can limit the activities of people who have them, you may need to adjust your expectations about your loved one’s engagement in “regular” family things like going on outings, to restaurants, to parties, to your kids’ games. You may need to take more of a lead in the relationship than you used to or expected to, such as in managing finances, making plans, and getting things done.
The good news? There are effective treatments for PTSD

The good news is that we live in a time when effective PTSD treatment exists. PTSD is best treated through cognitive behavioral therapies, particularly exposure therapy and cognitive processing therapy. These are specialty treatments and not all mental health clinicians are trained in them. A loved one with PTSD may be reluctant to seek treatment, and gentle encouragement can be helpful. You can find therapist referrals at the International Society for Traumatic Stress Studies and the Association for Behavioral and Cognitive Therapies.

PTSD symptoms may not completely go away, but they can be reduced. Just like turning down a volume knob, constantly high levels of anxiety or irritability can be lowered, and the power of memories and reminders of trauma can be reduced. Just like in the rest of your body, advancing years can take a toll on your brain function. Much of this slowing down is predictable and can be chalked up to normal aging. However, when thinking skills become increasingly fuzzy and forgetfulness gets to be a way of life, an early form of dementia known as mild cognitive impairment may be setting in.

Often, the first reaction is to attribute these changes to the beginning of Alzheimer’s disease. But blood flow problems may be to blame, as well. “An estimated one-third of all cases of dementia, including those identified as Alzheimer’s, can be attributed to vascular factors,” says Dr. Albert Hofman, chair of the department of epidemiology at the Harvard T.H. Chan School of Public Health.
Heart health and brain health are connected

Vascular — blood vessel — problems include atherosclerosis (the buildup of fatty plaque in the arteries) and arteriosclerosis (the stiffening of arteries with age). Both are well-known contributors to heart disease. These same processes can also damage brain function by interfering with the steady supply of oxygen-rich blood that nourishes brain cells.

In the case of a stroke, sometimes called a “brain attack,” large swaths of brain tissue die when a blood clot in a major brain artery abruptly halts the flow of blood. In addition to suffering immediate damage from a stroke, roughly one in three stroke survivors will eventually develop dementia.

More subtle injuries are caused by tiny blockages in the small vessels deep within the brain. These silent strokes are 10 to 20 times more common than overt strokes. The microscopic damage they leave behind also raises the risk that dementia will emerge at a later date.

Having blood vessels compromised by plaque buildup can also pave the way for Alzheimer’s. The accumulation of deposits of a protein known as beta-amyloid — the hallmark of the disease — is a direct consequence of what doctors call hypoperfusion. This means the brain is not getting a sufficient supply of blood over the long term. Because of these overlaps, says Dr. Hofman, it doesn’t make sense to draw sharp distinctions between Alzheimer’s and vascular dementia.
Protect your heart and your brain

As with heart health, a key step in maintaining your cognitive abilities is to reduce your major cardiovascular risks. This includes getting regular physical activity, quitting smoking, managing blood sugar and blood cholesterol levels, eating a healthy diet, and maintaining a healthy weight.

Of particular importance is keeping high blood pressure in check, especially in middle age. High blood pressure is the leading cause of stroke. It is also thought to stimulate the growth of micro-injuries in the white matter of the brain. The presence of these lesions can slow thinking and hasten the loss of cognitive function that accompanies Alzheimer’s. When I talk to teens in my practice about cigarettes, what I hear from lots of them is that the smell is what keeps them from smoking. They don’t want to smell like cigarette smoke, and they don’t want that taste in their mouth, either.

But what if the smell, and the taste, were good? What if they tasted like bubble gum, or chocolate?

In a study published in the journal Pediatrics, researchers looked at data from the 2014 National Youth Tobacco Survey. They found that among teens that had never smoked cigarettes, 58% of those who had used flavored e-cigarettes planned to start.

That number was 20% for teens who had never used e-cigarettes. It was 47% among those who had used non-flavored cigarettes, which is a high number too. Clearly, teens that use e-cigarettes are more likely to start smoking.

But when the e-cigarettes were flavored, the teens were less likely to think of tobacco as dangerous.

E-cigarettes and tobacco are different, of course. E-cigarettes do not have many of the carcinogens that cigarettes do, and could be useful for smokers who are trying to quit. But for teens that have never smoked, it’s a different story. The “vapor” of e-cigarettes doesn’t have to contain nicotine, but it can (it does contain chemicals such as formaldehyde that could have long-term health consequences) — and nicotine is addictive. Using e-cigarettes is physically close enough to smoking cigarettes that moving from smoking one to smoking the other could easily happen.

The use of e-cigarettes among youth has grown tremendously over the past few years — and e-cigarettes are being marketed to them. We don’t know what the consequences of this will be. It could be that we will end up with more smokers — or that we’ll end up with fewer if teens decide to stick with e-cigarettes, especially if they choose to stick with the nicotine-free kind. But we can’t just sit back and wait to see what happens.

Recently the Food and Drug Administration extended its tobacco regulations to include e-cigarettes and other nicotine delivery systems, which among other things, requires that there be warning labels and that you have to be at least 18 years old to buy them. This is a good start, and will help us look more carefully at how e-cigarettes are being marketed, too.

We need to do more research to understand the short-term and long-term effects of e-cigarettes on our youth. We need more information in order to make the best policy and parenting decisions.

All of us who are raising or interacting with teens need to talk with them more about e-cigarettes. We need to understand how teens think about them, and why they might choose to use them; when it comes to teens, listening is really important. And along with listening, we need to help teens understand the risks involved. We can’t let them get distracted or seduced by marketing and flavoring; we need to help them make the best choices for their health.
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Friday, 8 March 2019

Parents: How smart are you about antibiotics?

One of the more typical reasons for a trip to the emergency department on Thanksgiving Day (and most days, frankly) is accidental cuts to the hands. Be careful cutting up that turkey! Always use a carving fork, and although the household might be busy, try to avoid distractions when working with knives. Thankfully most such injuries can be repaired in the ED, but occasionally are bad enough to warrant being seen by a hand surgeon. For simple cuts to the hand, we generally place non-absorbable stitches that need to be removed in about 10 days. Most of the time, antibiotics are not needed — just a really good washout and cleaning prior to stitching.

Everyone “knows” about the dangers of cooking turkey, yet somehow nationwide, each year, the rate of residential fires more than doubles during this time frame. Never leave the house with the oven on, and check on the turkey frequently. If you choose to deep-fry a turkey, always do this outside, and always make sure the turkey has thawed first. Placing a frozen turkey into a deep fryer can cause explosions of hot oil, which can lead to third-degree burns and other serious injuries. If you’re frying a turkey, always wear good footwear, practice fire safety, and monitor children in the area.

Most birds carry bacteria, and the turkey is no exception. The most common pathogen is Salmonella. If cooked properly, this poses no harm. Under-cooked, the bacteria can cause diarrhea, vomiting, fever, and general illness that ranges from uncomfortable to life-threatening. The recommended temperature for a cooked turkey is at least 165° F, and should be checked by thermometer. Did you know that if you have any questions about cooking your turkey, you can call the Butterball hotline? Even on Thanksgiving Day! (800-BUTTERBALL/800-288-8372)

Delicious holiday foods are usually well seasoned …with salt. For most adults this does little more than make you thirsty, but for people with congestive heart failure or chronic edema (water retention), extra salt can place increased stress on the body. If you have these conditions, please be careful with what and how much you eat. Inevitably, we will see a few patients with episodes of worsening heart failure in the emergency department … usually the day after a holiday.

Last but not least, be careful about driving. It’s all too common to see drunk drivers during Thanksgiving time. It is historically the most dangerous time of the year for car accidents and subsequent fatalities. Monitor how much you drink, and remember that even if you are sober, unfortunately not everyone else out there is. Be extra attentive. Drive safe! When we think of anxiety disorders, we generally think of them as uncomfortable emotional responses to threat. These responses may include symptoms such as palpitations, shortness of breath, sweating, trembling, or absolute paralysis. While there is nothing inherently wrong in thinking about anxiety this way, a recent study pointed out that there is an entirely different way of thinking about anxiety that may be even more helpful. According to psychologist Kalina Christoff and her colleagues, anxiety may be more appropriately thought of as “mind-wandering gone awry.”
The advantages of mind-wandering

In your brain, there are circuits that promote mind-wandering and they are not all bad. In fact, these very circuits help you maintain a sense of self, understand what others are thinking more accurately, become more creative, and even predict the future. Without your mind-wandering circuits, your brain’s ability to focus would become depleted, and you would be disconnected from yourself and others too.

In addition to the natural and frequent tendency for your mind to stray, it also has automatic constraints too, to ensure that it does not stray too far. When daydreaming during a boring lecture, for example, your brain may jerk you back into reality.
When mind-wandering goes awry

One of the things that a wandering mind is in search of is meaning. By connecting the past, present, and future, it helps you compose a narrative to connect the dots in your life. This narrative is constantly being updated. But sometimes, the wandering mind can encounter threats. Rather than proverbially “whistling in the dark,” the brain can overreact to these threats.

In the brain of an individual with generalized anxiety disorder, for example, the anxiety processor (the amygdala) is disrupted. Although it has strong connections to the “inner eye” (attention), it lacks a connection to the brain circuits that signal how important or significant a threat is. Without the ability to assess the significance of threats, they can all feel the same.

As a result, the “inner eye” gets fixated on negative thoughts. This fixation is a way of constraining the mind too, but it is not actually helpful. Anxious people focus more on external threats in an exaggerated way. They become glued to the threats. Anything from being teased to being ticked off feels much more troubling than it would to someone without an anxiety disorder. And it’s not just conscious threats that grab your attention. It’s subliminal threats too! Threats, of which you are completely unaware, capture your brain’s attention. A mind, once free to wander, is desperately forced to stop in its tracks in what can be construed as a catastrophic confusion of constraints.
Let your mind wander away from perceived threats

When your brain has automatically grabbed your wandering mind, and fixed your attention on threat, rather than getting a proverbial “grip” on reality, you actually have to loosen your grip on your threat-focused reality — allow your mind to wander! As Christoff and colleagues put it, you de-automatize your constraints.

Because your brain’s inner eye has its resources fixed on the threat, it gets progressively exhausted too. You can’t really summon it to help you suppress the anxiety, or get your mind off of it. Instead, you have to reactivate your mind-wandering circuits to give your attention a break.

Practically speaking, there are a few ways to do this. First, identify the negative spiral that has occurred like a pothole into which you have fallen on a mind-wandering journey. Simply name the feeling you are feeling and recognize that you need a mental reset. Rather than deliberately trying to suppress the feeling, accept that your mind is wandering, and that the fixation on threat is not the constraint solution you are looking for.

To counter this constraint, up the ante on the mind wandering — wander even more. If you’re at work, you could keep a knitting kit and start using it just when anxiety strikes, or if at home, you could go out and do some gardening. Meditation is also an effective way to get out of the fixed threat hole.

So when you’re next feeling anxious or wired, try allowing your mind to do what it naturally does — wander! You can bring it back to task gently, without fearing that you have lost your way. Or you can expect that it is wired to switch between wandering and focused states, and it will eventually come back on its own. The more you mindfully interact with this switch, the more adept your brain will become at initiating it. A pair of recent studies provides useful information to men facing challenging decisions about what to do after being diagnosed with early prostate cancer. Researchers tracked men for 10 years and found that virtually none died of the illness, even if they decided against treating it.

Early prostate tumors confined to the prostate gland often grow slowly and may not need immediate treatment. Instead, these tumors can be monitored and treated only if they begin to progress.

In one of the studies, British researchers randomly assigned 1,643 men with early prostate cancer into three groups: one group had surgery to remove the prostate, another had radiation treatment, and a third had “active monitoring,” meaning that doctors tried to predict if the cancer was spreading by measuring their prostate-specific antigen (PSA) levels every few months. Treatment could start if PSA levels jumped by 50% or more over the course of a year. It’s important to note that active monitoring differs from “active surveillance” for early prostate cancer, which relies on routine biopsies as well as PSA measurements to monitor for spreading cancer.

After 10 years, only 1% of the men had died of prostate cancer, regardless of which group they were assigned to. But tumors did spread, or metastasize, more frequently in the active monitoring group. According to the results, the cancer progressed in one in five men being monitored, compared to less than one in 10 men who received surgery or radiation. Some of the men in the monitoring group had what’s known as “intermediate-risk” prostate cancer that has a higher grade and progresses more often than low-risk prostate cancer. Laurence Klotz, a professor at the Sunnybrook Health Sciences Centre, in Toronto, Canada, who was not involved in the study, says it’s likely that most of the men who progressed on active monitoring were in the intermediate-risk category, although the authors did not report this. As time went on, more and more of the monitored men wound up being treated.

In an accompanying study with the same group of men, those treated with surgery reported more long-term problems with sexual performance and urinary continence. Conversely, the radiation-treated men reported more bowel problems, while the urinary and sexual side effects from radiation treatment typically resolved within six months. Both the monitored and treated men reported the same amount of anxiety and depression.

Taken together, the studies bolster a growing consensus that men with organ-confined prostate cancer can safely avoid treatment for some period of time. The results show that one case of metastatic cancer was prevented for every 27 men treated with surgery and every 33 men treated with radiation. “These studies again confirm the lack of evidence that treatment interventions for so-called early prostate cancer lead to any meaningful benefits in survival,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Additional analyses will be required to see if we can identify those men in each group who did develop metastases and then design treatment programs to see if we can modify that risk.” I come from a long line of skilled soup makers. In the late 1800s, my great-grandmother Enrichetta Cavagnolo, newly arrived from northern Italy, was a soup chef at Delmonico’s in New York City. Enrichetta’s daughter and granddaughters (my grandmother, mother, and aunts) were talented soup makers as well, to the delight of our well-fed family.

But the soup-making gene seemed to skip me. I was never interested in boiling bones for broth, chopping mounds of vegetables, and stirring soup — with love — for hours. It was too much fuss, I thought — until I learned the shortcut.
Fast and healthy

Turns out, making a delicious batch of soup doesn’t require homemade bone broth or all-day simmering. Just boil your favorite vegetables and spices in some water and low-sodium (store-bought) soup stock. There’s no right or wrong combo of ingredients; it’s whatever appeals to you. Want a small batch? Use two cups of liquid. Want a big batch? Use four. Add more liquid to make it soupier, or less liquid to make a stew. Boil, add the ingredients, and you’re in business in about 20-30 minutes.

It’s also easy to go a step further, and make soup a complete meal. “Add protein such as lentils or beans, fish, extra-lean beef, turkey, or chicken,” says registered dietitian Kathy McManus, director of the Department of Nutrition at Harvard-affiliated Brigham and Women’s Hospital. She recommends increasing the nutrient power and fiber by adding as many vegetables as possible, such as peppers, asparagus, broccoli, spinach, onions, and carrots.
Too busy? Beware

Knowing the shortcut is important in an age when soup tops the list of culturally cool comfort food. It’s featured in trendy soup “bars,” tiny take-out windows, and all varieties of grocery stores. While it’s tempting to skip the stove and buy prepared soups, you should note that they often contain preservatives and other unhealthy ingredients. In particular, be on the lookout for these:

    Saturated fat. Any soup with a cream base, such as cream of tomato, is made with cream and butter, which contain unhealthy saturated fat. Too much saturated fat in your diet may drive up your cholesterol and lead to blockages in arteries.
    Sodium. Canned soups often contain high amounts of sodium. Too much sodium in your diet can lead to high blood pressure, heart attack, stroke, and heart failure. Federal guidelines limit sodium intake to 2,300 mg per day for most people.
    Sugar. Added sugar is found in chilled fruit soups and even some vegetable soups. The American Heart Association recommends limiting added sugars to no more than 24 grams per day for women and 36 grams for men.
    Calories. Soups are generally lower in calories than other entrée choices, but that changes when you top soup with cheese, sour cream, or croutons, or pair it with a piece of bread.

Keep it healthy

McManus recommends avoiding prepared soups for the most part. “They’re okay in a pinch and on occasion, as long as you set limits. Aim for less than 500 calories, 600 mg of sodium, 5 grams of saturated fat, and 5 grams of added sugar in a bowl of soup,” she says, “and cut that in half for a cup of soup.”

It’ll take some detective work to stick to those limits and find healthier prepared soups. Look at the nutrition information on a restaurant’s menu or website, or on a product’s Nutrition Facts label. If it’s too much work to hunt down healthy soups, then consider making the soup from scratch, like I do now. You’ll find some healthy soup recipes to get you started here. You can control the ingredients, and you can give it your own special flair. And trust me, it doesn’t take a soup-making pedigree to be good at it.
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Monday, 28 January 2019

Comparing medications to treat opioid use disorder

My first day returning to work after being treated for a severe opiate addiction was one of the most daunting moments of my life. Everyone in the office, from my manager to the administrative assistants, knew that forged prescriptions and criminal charges were the reason I had been let go from my previous job. My mind was spinning. What would my coworkers think of me? Who would want to work alongside an “addict”? Would they ever come to trust me? Did I even deserve to be here?

When my life was crashing and burning due to my addiction (detailed in my memoir Free Refills: A Doctor Confronts His Addiction), a return to work seemed like a distant prospect, barely visible on a horizon clouded by relapses, withdrawal, and blackouts. My finances, my professional reputation, and my family life were in terrible shape due to my drug-seeking behavior. Working was not a tenable option until I received treatment and established a solid track record of recovery, which a potential employer could rely on.

The fact that I was now in recovery was a great development, and it was further ratification of my progress that I had landed a job and was returning to work. So, why wasn’t I feeling overjoyed?
How stigma affects the return to work

As it turns out, the transition back to work after someone is treated for an addiction can be profoundly stressful. People recovering from addiction already tend to suffer disproportionately from guilt, shame, and embarrassment, and these feelings are often brought to the forefront during the unique challenges of returning to work.

Stigma is what differentiates addiction from other diseases, and is primarily what can make the return to work so difficult. If I had been out of work to receive chemotherapy or because of complications from diabetes, I certainly wouldn’t have felt self-conscious or self-doubting upon resuming my employment. With addiction, due to the prejudices that many people in our society hold, the return is psychologically complex and anxiety-producing. As I entered my new office, I was walking right into the fears, preconceptions, and potential disdain that my new officemates might share toward people suffering from a substance use disorder. For all I knew, I was the “dirty addict” that they now, against their wishes, had to work with.
“Bring your body and your mind will follow”

What I was taught in recovery, to deal with situations like this, is to “just keep your head up” and to “put one foot in front of the other.” Or, “bring your body, and your mind will follow.” When I first heard these phrases, I thought that they were mere platitudes, phrases without content, provided to motivate us through dark times. Now, I think they hold a great deal of wisdom.

As I walked through the door on my first day back, I did feel everyone’s eyes on me, and I did wonder if they were judging and criticizing me, but I made it to my desk without incident, and managed to power through my self-consciousness and get into the flow of my work. Every day, it became easier as I did a good job, deepened my connections with my colleagues, and accumulated good will, which would eventually replace any negative images that may have accompanied my arrival. Within weeks this was a non-issue, though at office get-togethers, my co-workers still somewhat awkwardly don’t know whether to put a wine glass at my place setting.

With all I had learned in recovery about communication, about humility, about connecting with others, I feel that I was in a better position to thrive in my workplace than I was before my addiction started in the first place. As more of my brothers and sisters in recovery return to employment, and as we succeed, the more difficult will it be for people to hold on to their negative attitudes and prejudices about substance use disorders. We can defeat the stigma by confronting it, putting one foot in front of the other, one step at a time.
This one got by me. I’d never heard of “man flu” but according to a new study of the topic, the term is “so ubiquitous that it has been included in the Oxford and Cambridge dictionaries. Oxford defines it as ‘a cold or similar minor ailment as experienced by a man who is regarded as exaggerating the severity of the symptoms.’”

Another reference called it “wimpy man” syndrome. Wow. I’d heard it said (mostly in jest) that if men had to carry and deliver babies, humankind would have long ago gone extinct. But wimpy man syndrome? I just had to learn more.
What is man flu?

As commonly used, the term man flu could be describing a constitutional character flaw of men who, when felled by a cold or flu, embellish the severity of their symptoms, quickly adopt a helpless “patient role,” and rely heavily on others to help them until they recover. Another possibility is that men actually experience respiratory viral illnesses differently than women; there is precedent for this in other conditions. Pain due to coronary artery disease (as with a heart attack or angina) is a good example. Men tend to have “classic” crushing chest pain, while women are more likely to have “atypical” symptoms such as nausea or shortness of breath. Perhaps the behavior of men with the flu is actually appropriate (and not exaggerated), and based on how the disease affects them.

Here are the highlights from the study:

    Influenza vaccination tends to cause more local (skin) and systemic (bodywide) reactions and better antibody response in women. Testosterone may play a role, as men with the highest levels tended to have a lower antibody response. A better antibody response may lessen the severity of flu, so it’s possible that vaccinated men get more severe symptoms than women because they don’t respond to vaccination as well.
    In test tube studies of nasal cells infected with influenza, exposure to the female hormone estradiol reduced the immune response when the cells came from women, but not in cells from men. Treatment with antiestrogen drugs reduces this effect. Since flu symptoms are in large part due to the body’s immune reaction, a lessened immune response in women may translate to milder symptoms.
    In at least one study reviewing six years of data, men were hospitalized with the flu more often than women. Another reported more deaths among men than women due to flu.
    A survey by a popular magazine found that men reported taking longer to recover from flu-like illnesses than women (three days vs. 1.5 days).

Taken together, these findings suggest that there may be more to “man flu” than just men exaggerating their symptoms or unnecessarily behaving helplessly. While the evidence is not definitive, they suggest that the flu may, in fact, be more severe in men.
If it’s true that men get sicker with the flu, why?

Some have suggested that early man evolved to require more prolonged rest while sick to conserve energy and avoid predators. In more modern times, the advantage of a longer recovery time is less clear beyond the obvious. When you don’t feel well, it’s nice to be taken care of. Of course, that’s true for women as well.
The bottom line

Diseases can look different in men and women. That’s true of coronary artery disease. It’s true of osteoporosis, lupus, and depression. And it may be true of the flu. So, I agree with the author of this new report, who states “…the concept of man flu, as commonly defined, is potentially unjust.” We need a better understanding of how the flu affects men and women and why it may affect them differently.

Until then, we should all do what we can to prevent the flu and limit its spread. Getting the flu vaccination, good handwashing, and avoiding others while sick are good first steps. And they’re the same regardless of your gender. Using medications to treat opioid use disorder is a lifesaving cornerstone of treatment — much like insulin for type 1 diabetes. The flawed but widely held view that medications like methadone or buprenorphine are “replacing one addiction for another” prevents many people from getting the treatment they need. In actuality, people successfully treated with these medications carefully follow a prescribed medication regimen, which results in positive health and social consequences — as in patients with many types of chronic medical conditions.

However, even among those who embrace treating opioid use disorder (OUD) with medication, there is a difference of opinion as to which medications are most effective. A new study offers important insight into the advantages and disadvantages of the two medications for OUD that can be prescribed in a doctor’s office (that is, on an outpatient basis). These medications are buprenorphine and extended-release (ER) naltrexone. This study was widely covered in the press, and many of the sound bites and headlines reporting the two treatments to be equally effective were a bit misleading.
The advantages and disadvantages of buprenorphine (Suboxone, Subutex, Zubsolv, Probuphine, Sublocade)

Buprenorphine is a partial opioid agonist medication. This medication activates the same receptors in the brain as any opioid, but only partly. Because its effects are long-lasting, it can be taken once a day to relieve cravings, prevent withdrawal, and restore normal functioning in someone with opioid use disorder. Because it is a partial agonist, it has a ceiling effect. This means once all the receptors are occupied by the medication, even if a person takes 20 more tablets she wouldn’t feel any additional effect or be at risk of overdose.

Any doctor who has completed special training (a primary care provider, addiction specialist, OB/GYN, etc.) can prescribe buprenorphine. The advantage is, theoretically, that a person with OUD could receive treatment from any provider he or she might see for a routine health issue. I say theoretically because, despite its availability, only about 4% of physicians have done the necessary training to be able to prescribe it. The research on buprenorphine is robust, with multiple studies showing it reduces the risk of death by more than 50%, helps people stay in treatment, reduces the risk that they will turn to other opioids (like heroin), and improves quality of life in many ways.
The advantages and disadvantages of naltrexone (Vivitrol, Revia)

Naltrexone is a pure opioid antagonist. It sticks to an opioid receptor, but instead of activating it to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect. The research on naltrexone has been mixed. Naltrexone in pill form is basically no better than placebo because people simply stop taking it. Studies on extended-release naltrexone are more promising and have shown it to be better than no medication at all. However, there has never been a US trial comparing extended-release naltrexone to either methadone or buprenorphine, until this study.
The X-BOT study: Comparing buprenorphine and extended-release naltrexone

This study enrolled individuals with opioid use disorder who had voluntarily gone to a detoxification program. Researchers then randomly assigned them to either daily buprenorphine or monthly extended-release naltrexone. Both groups were followed for 24 weeks, to see how many people relapsed.

One of the most important things investigators learned is just how hard it was to get participants onto extended-release naltrexone, revealing a potential barrier to its usefulness. Before a person can start taking ER naltrexone, they must be completely off opioids for seven to 10 days. Only 72% of the group assigned to ER naltrexone even got the first dose, and among those who were randomized during the detoxification process, only 53% started the medication. In contrast, 94% of the group assigned to buprenorphine started the medication.

The other important finding was what happened with relapses. The researchers analyzed their data using an “intention to treat analysis.” This means that once a person is randomly assigned to a treatment (or placebo), their data counts even if they don’t stick with the treatment. Here’s why this is important: if you don’t include that data, then you miss other important outcomes that influence how effective a treatment really is. Thanks to this type of analysis, researchers learned that relapse was significantly more likely in the extended-release naltrexone group (65% compared to 57% in the buprenorphine group).

Immediate relapses were even more likely in the naltrexone group due to failures to start the medication — 25% of the naltrexone group had a relapse on day 21, compared to 3% in the buprenorphine group. Overall there were more overdoses in the naltrexone group, but no difference in fatal overdoses between the groups. Most of the overdoses occurred after the study medication was stopped, highlighting the lifesaving importance of getting on, and staying on, treatment. The naltrexone group also had a longer length of stay in inpatient detoxification programs, which may be an important consideration when we think about overall healthcare costs.

So, why did many headlines claim extended-release naltrexone was as effective as buprenorphine? Well, that was the finding of a separate analysis that looked only at people who successfully started each medication. When the data was viewed that way, there was no difference between the two medications, but that’s just part of the picture. If it’s harder to get a person to successfully start and stick with a medication, that should factor in evaluating its “effectiveness.”
Take-home messages from X-BOT

This is an incredibly important study. The findings are generally consistent with what I see in my clinical practice. Overall buprenorphine is a more effective treatment for opioid use disorder, in part because it’s easier to get patients started on it and they are more likely to stick with it. Extended-release naltrexone may be as good for people who can successfully complete the detoxification required before starting on it. Both medications have a place, but as with so many conditions and treatments, one size does not fit all.
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