Friday, September 26, 2008

Hypertension: Get Meds or Get Moving?

In August, a “HealthDay News” headline reported that “exercise reduces blood pressure…but too few doctors recommend it to their patients.”

I recently got hold of the article:
Halm J, Amoako E. Physical activity recommendation for hypertension management: does healthcare provider advice make a difference? Ethnicity and Disease, 2008 Summer;18(3):278-82. PMID: 18785439.

The researchers drew upon a big, longitudinal health survey to examine specific aspects of hypertension: for patients with hypertension, what portion reported that their physician had urged them to exercise to treat hypertension.

Only a third of these hypertensive patients reported that their physician had urged them to exercise.

A sad finding. Despite evidence that physical exercise lowers blood pressure, and has a range of other “side effects” that are basically good, such as warding off depression, reducing risk of cancer, lowering bad cholesterol, etc., physicians in the U.S. are not advising hypertension patients to exercise.

Why not? Could it be because the recommendations don’t work? Well, according to further questions, that is not the case. Actually, it seems that, for hypertension patients who reported that their physician did recommend exercise, about 70% reported that they were following the recommendation! A much higher rate of regular exercise compared to those who reported receipt of no such advice.

Well, did the advice-giving work? As well as this data set can indicate, the exercisers had great results: average 3-4 blood pressure points lower (in mmHg): average systolic of 126 versus 129.

Now, this type of study has a host of limits. It is possible that hypertensive patients did receive advice, but did not remember it – totally conceivable: it makes more sense that if you as a patient are receptive and ready to act on advice, you will later remember getting that advice. It is also possible that a healthy user effect is operating: those who are willing to figure out anything to do to improve health may ask for advice, and thus actually get advice. Similarly, if a physician judges that a patient is more likely to act on advice, the physician may be more likely to give the advice.

We don’t know. The nature of this data set does not eliminate these alternatives. But, a host of similar research does support the same story: patients do act upon physician advice, and accordingly do achieve decreases in blood pressure, but physicians often do not ask about exercise or give good advice about exercise.

Why? My suspicion is that Big Pharma, and other forces, are creating the belief that hypertension is a medical disorder that needs to be treated with a real treatment – meaning meds. And if the meds don’t work, try more, or try a different med.

Rarely do you hear of a physician doing the full-court press for their patient to begin and maintain a regular aerobic exercise habit. Sad. Despite benefits from hypertensive meds, including proven efficacy in reducing blood pressure, and also reducing the more important outcomes such as stroke and kidney disease, blood pressure meds have host of annoying side effects. Structured instruments for these side effects range from inquiring about 10 or a dozen recognized side effects (nothing to sneeze at) up to 70 or a few more side effects.

And what kind of "CME" are physicians receiving? Well, it is recognized that Big Pharma is a major provider of CME. And yes, you can give enough blood pressure meds to get blood pressure into the normal range. But at what cost? Who is out there in the physician offices advocating for Asics along with or instead of ACE inhibitors?

All the while, the side effects of exercise are, what, blisters? Decrease in quality of life because you have to do more laundry?

Anyway: the article is a nice read: it reviews the problem of hypertension and presents decent detail on the study data (NHANES). Finally, it is yet another piece of data indicating that too many physicians may not be encouraging an effective treatment for a very treacherous disease.

An update: Reuters has just put this out as a headline story:

Monday, September 22, 2008

Meds Vs. Therapy: Drinking Water Safety

AP news story from September 11, 2008:
"46 million in U.S. have drugs in drinking water.”
“Testing shows traces of meds in water greater than previously reported."

Here is a link:

If the link has expired, just enter the headline above to find the story.

Basically, we are filling prescriptions for medications to such an extent that these meds are showing up in drinking water supplies.

A quote:
"Many cities found the anti-convulsant carbamazepine. Officials in one of those communities, Colorado Springs, say they detected five pharmaceuticals in all, including a tranquilizer and a hormone."

Meds will end up in the water supply. There are legitimate situations for many meds. But also, we have gone greatly overboard with meds – taking meds for a great range of problems and situations where there are, simply put, better alternatives, and also, simply put, situations where the meds just don’t have the “benefits” to justify the “costs.” The degree that any unnecessary meds are contaminating our water is unknown, but – per this story and others – may be a serious problem. This contamination is yet another negative on the side of medications in the cases where therapy is a viable treatment. As I have said in at least one other posting, meds for psychiatric reasons are overprescribed. Meds are also overprescribed for other conditions, but I am just more expert in psychiatric treatment efficacy.

To the degree that carbamazapine, AKA CBZ, is being prescribed for seizures, then that is a clear situation of: meds wins. But CBZ is prescribed for psychiatric disorders as well. If prescribed appropriately, then meds wins again, and the challenge is just to figure out whether the CBZ in the water supply poses any threat to the rest of us, and how to deal with it. But to the extent the CBZ is inappropriately prescribed, that is a downside potentially affecting anyone drinking the water, thus a negative influence far beyond the usual circle of patient, physician, and payer.

Tranquilizers: generally, in my opinion, therapy almost always wins. Technically, the term “tranquilizer” almost always refers just to the “benzodiazepines,” such as Valium and Klonopin. In my opinion, therapy wins this one hands-down: the tranquilizers in any water supply are generally posing an unknown risk with benefits that can be conveyed by therapy. Tranquilizers may also include other “sedative / hypnotics” such as Benadryl and other antihistamines, as well as a range of other soporifics / somnalytics / whatever term-you-like-for-sleeping-pill. There are many.

Therapy wins for sleep, and therapy wins for antianxiety. So, all of those “tranquilizer” meds contaminating the water, at unknown risk, pose a largely avoidable risk.

“Hormone:” my guess is that this is related to birth control pills. The use of estrogen/progesterone type meds (“HRT”) for menopausal symptoms decreased greatly once everyone figured out that, in contrast to the belief that they had the side effect of protecting users from heart disease, they actually are associated with increased risk of heart disease. So, although HRT had been about the most widely prescribed and taken med for the span of several years, the past 6 years has seen that level of use decrease. [BTW: recent headline about menopausal symptoms where therapy beats meds:
"Yoga soothes worst symptoms of menopause"]

So, my guess is that the “hormone” related to birth control pills (widely prescribed, but potentially may be greatly affected if I am correct in my suspicion that they generally cause blood clots despite various specific drugs and doses and dosing schedules).

This AP story also notes that traces of antidepressants can be detected in some water supplies. Again, in my opinion, a great deal of this is not beneficial, so the unknown risk posed is generally unnecessary.

What to do?
Well, obviously, the threats to health needs to be determined. This includes determining the level at which some med in the water can cause problems. This is obvious, but vey challenging to figure out scientifically.

Also, water authorities need to figure out what might be in the water, and test for these. Unlike other water contaminants, this may not be a “local” challenge:

Finally, maybe we just need to start ending our dependence upon meds, like we are talking about ending our dependence on foreign oil. Like the foreign-oil issue, there are just too many workable alternatives.

Wednesday, September 10, 2008

Back pain tx: Great work if ya can get it.

Expenditures increase while improvement is, well, have you looked at the stock market lately?

Expenditures and health status among adults with back and neck problems. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, SullivanSD. JAMA. 2008 Feb 13;299(6):656-64.

Well, I was looking into another topic, and came across this January JAMA article.

Martin and colleagues use some wide-ranging hospital data to calculate expenses for back pain. Along with this, the cool thing is they are able to look at the benefits of this treatment.
The data set was: the Medical Expenditures Panel Survey. Or, MEPS.

MEPS is carried out year after year. A big federal attempt to describe where you and I spend our health care dollar, and for what problem or symptom. Questions are asked about problems and symptoms, and the researchers also try to figure out what you paid to treat the problem. This is a big study, folks, with many people looking over the shoulder of the design and implementation, as well as sample sizes well beyond 10,000. So, this is no "Dewey Beats Truman" poll. (Although it could be in the future, depending upon how they transition to cell phone recruitment).

Now, either you are a current back pain patient, or you are a "pre-consumer." Either way: ask yourself: for my current or future back pain, as I spend money on my care, what do I want for my dollar? what are the outcomes I am concerned about?

This is what the researchers evaluated. This JAMA-published MEPS study compares results from 1997 to 2005 -- almost a decade.

Here are the outcomes. "Physical functioning:" Can you rake the yard? Load the dishwasher? Reach the top shelf? "Work:" are you able to get back to the same job you had before back pain treatment? "School:" Are you able to get back to scholastic pursuits, if any, that were interrupted by the back pain?

The answer:
Costs (as proper, dollars adjusted for inflation) increased per patient from $4700 in 1997 to $6100 in 2005.
Outcomes: the same. These people spent more to arrive at the same outcome.

Because this is an amazing finding, and because ink is cheap on the internet, let me repeat:
These people spent more to arrive at the same outcome.

So, if practicing back pain treatment, and a patient asks about empirical evidence for outcomes, what do you tell them? "I will carry out the recognized interventions, but chances are that you will not get better"?

To be honest, that seems to be the answer.

This is consistent with an extensive body of knowledge that has indicated that: results for back pain treatment, notably medication and surgery, are not great; and a decent, satisfactory body of evidence indicating that physical therapy and almost-mandatory emphases on activity do achieve results, but the pills and surgery lead to both worse outcomes, and to the sad result of a patient who sees the answer solely in terms of the right pill or the right surgery.

Some day soon I will put together a handful of info for this blog on the lousy outcomes for traditional, recognized, reimbursed back pain interventions, and also share some of the evidence showing the unorthodox but encouraging evidence for appropriate physical therapy, including where this concept parallels Pilates and yoga, and also for the benefits of more psychological-type interventions like social involvement and psychotherapy.

Speaking of pain and orthodoxy, there has even been a small but decent emphasis on evaluating yoga intervention for carpal tunnel syndrome.

Meds Vs Therapy for back pain. Therapy continues to lead on this one.
Frankly, having resolved my own lower back pain, at no expense, and hearing similar successes of others, plus having done training rotations in "pain/aneasthisiology," (and binging on the free lunches as the new meds and devices emerged), and having read a bunch on the topic, including Block specifically but Cochrane as well, this topic just seems ready to declare: stick-a-fork-in-me.

Social Phobia: Pill or Hypoxia?

Social Phobia: Pill or Hypoxia?

Meds Vs. therapy, and it looks like therapy is gonna win this one!

Hypoxia means low oxygen. The mental health world has known, for a long time, that the detection of low oxygen, or even the fear of low oxygen, can start a panic attack. People with panic attacks “know” part of this problem all-too-well, but have to be convinced, by various means, of the other part of this problem: when, for whatever reason, the oxygen that you are breathing gets a bit low, it “triggers” a panic attack. If you start to get scared in some situation, and your body has a typical fear reaction including your chest tightening up AND your heart beating faster, the amount of “air” or oxygen getting in your body will be reduced. It is the same as if you were holding your breathe for a few moments. The feeling is light-headedness, as if you were spinning around a couple times, or dipping your head between your legs then raising back up a couple times, or breathing through a narrow soda straw, like a coffee stirrer.

The mental health world has also known, for a long time, that learning to handle this problem can drastically reduce panic attacks.

SIDEBAR: If you have panic attacks, get a self-help book on the topic, or find a decent therapist who acknowledges this established treatment, or check the youtube videos on panic attack, and get help! You have a strong possibility of greatly reducing panic attacks with modest, little or no professional cost or help, as long as you can grasp hold of the basics and train yourself accordingly, or get this done with the guidance of someone who knows the established science of this, and is skilled in helping you gain some control over panic attacks. And this includes the use of pills ONLY as a reassuring security-blanket backup plan, such as when traveling/flying. Now back to my blog.

A recent study published in the Journal of Psychiatric Research indicates that, along with people suffering from panic attacks, people suffering from social anxiety, but who do NOT have panic attacks, may also be sensitive to reduced oxygen.

The unhelpful thoughts and the body response that is part of social phobia may be triggered by low oxygen in the body.

So, you are about to do a job interview, or attend a work party, or give a public talk. The fearful thoughts - what if this, what if that - make your body tense up - this includes your muscles generally, including chest muscles. You all-of-a-sudden are breathing shallow, and your heart is going a little faster. After a few moments, your brain detects low oxygen. From this, your social phobia symptoms are on a roll. Off on their own, out of your control.

What is new is that the researchers in this new study have discovered that low oxygen in the body is part of this. Social phobia, and the problematic behaviors that follow from it, are not just from the off-base, unproductive thoughts, but also, somehow, low oxygen is part of this.

That’s good news! That is like discovering that Wellbutrin, supposedly effective for depression, might also help people quit smoking!

This suggests that a new avenue of treatment is available for social phobia!!!! And it totally already exists!! It just needs to be borrowed from panic attack treatment!!!!

Or, you could go to your physician, and they can start prescribing pills. Which pills? Antidepressants and or “anxiolytics,” also known as ant-anxiety drugs. Anxiolytics include “valium,” Klonopin, and other similar pills - that have side effects including dependence, withdrawal, and being unable to “operate heavy machinery” such as a job interview, public speaking, work holiday party, or an automobile.

Also, some pills that are primarily used for blood pressure -such as propanolol - will work, and do not have the addictive-type side effects except, possibly, eventually leading you to believe you cannot perform in certain situations without a pill, and the slight increase in risk of fainting from lowered blood pressure.

So, how do you treat this sensitivity to low oxygen? Low “air?” Well, it translates directly from what I said above, about the dizziness and feeling short-of-breath.

One: therapists, or self-help books, will train people to breathe deeply. This is why they always tell ya to breathe deeply.

Two: therapists, or self-help books, will train people to practice coping with slightly low oxygen so you can feel it, but not have it lead to a bunch of calamitous, disastrous thoughts in your head - those thoughts that crowd out what you really want to have in your head - like answering questions, keeping your balance, not dropping food on yourself in a social setting, etc.

The self-help books and the therapists can help anyone learn this, with fancy techniques such as: put your head between your knees, then raise it, then repeat, but keep breathing deeply, and keep telling yourself reassuring thoughts. Or breathe through a coffee stirrer (after managing to breathe through a soda straw). Etc.

There are lots of ways to conquer social phobia. All of this knowledge is widely known and widely available. The reason I am glad to see this study is because it holds the promise of even more strategies for treating social phobia -- these recognized therapies for panic attacks may also benefit people with social phobia but no panic attacks. That is cool.

At the same time, it is worth mentioning because, as this knowledge marches forward, the pharmaceutical companies are marching forward with the idea that pills will solve social phobia.

On the web, the power of cognitive/behavioral therapy, as I have alluded to, is widely recognized. However, some sources delve into the pharmaceutical aspect, such as this site:
It is bothersome that, rather than some in-depth discussion of the types of maladaptive thoughts addressed by cognitive therapy, or the many possibilities for behavioral, cognitive, and social-skill exercises to deal with social phobia, the discussion is centered on the various antidepressants and how one might be different from another.

The erroneous belief that various psychotherapeutic interventions are not “therapy” but are some other kind of help (I don’t know what kind, but my recent Phelps/ADHD post indicates that one term is “tips”) pops up on some websites:
The NIMH website shows this view:

“Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy.”

Uh, what? --Stress management and meditation is therapy, not something that might “help” or “enhance” therapy.

So, to wrap this little discussion up, it is cool to see some decent, organized study investigating social phobia, since it affects so many people. It is cool to see that, if sensitivity to being out-of-breath is part of social phobia as it is for panic attacks, then the treatments for panic attacks might also work for social phobia. Non-pill treatments. In the future, we may see meds vs. therapy for social phobia, and therapy will win this one.

Friday, September 5, 2008

That '65 Mustang in the garage. Parenting. Things I will get around to one day.

Computer working again. Plenty of topics to blog abt right now, but I jacked up my computer and it took me a while to get it running again - I need to have a backup computer.

For a great, recent story: Gurgle this headline to find the AP news story:
"Help-wanted ad for nanny: `My kids are a pain'"

As soon as I see the headline, I know what is coming. The kid is gonna have one of these diagnoses that get given to kids who are not adequately parented.

If you haven't read the story yet, basically, the mom in a busy family posts an ad for a nanny, NY style. Let's cut the crap, yes I am hard to work for deal with it, etc.

And, in the ad, there it is: if you don't believe in Ritalin for kids, don't apply.

I do not know these people. I just have this image in my head. I can see it now. Mom is busy with her social group, and Dad is keeping the rent paid with his business. No one has time to parent. So, hire a nanny.

Sure enough, the kid is gonna fail to please. Neglect your children and they will get your attention one way or another. So, the kid is restless at school, or whatever. So, you take the kid to the head-shrinker, and within 30 minutes, you have your ADHD diagnosis. Now, you can blame any unsatisfactory behavior, performance, mood etc. on the ADHD, not your lack of involvement in your kid's life.

It just bugs me. I see it a lot.

A kid is not like that project car you have in the garage, under the tarp, that you are gonna restore one day. The kid is not and old Mustang. I understand the desire to have good intentions but never get around to some project. I have an old, classic Austrian road bike (Austro-Daimler) waiting to be restored. I will get to it one day.

But kids are different. They require parenting. They are not a hobby, or some project. when you don't parent them the right way, you will end up with trouble. The worst is that there are docs are ready to help you pin the blame on the kid.

Diagnostically, you need to rule out social confounders before diagnosing ADHD. In the research on ADHD (not to mention any names, Dr. Biederman), I never see this assessment as part of the diagnostic process for defining a study group of kids with ADHD. They report that they merely conducted the eval per DSM, then randomized the kids or whatever step was next. In the real world, we all hear of docs providing the ADHD (or bipolar or whatever) dx after only assessing for 30 minutes.

That is not right. Kids are suffering from this disservice in research and in clinical practice.