Sunday, June 23, 2013

Humorous Thoughts on the Search for Perfect Health

Chinese porcelain Laughing Buddha

"Be careful about reading health books. You may die of a misprint." —Mark Twain

"Older people shouldn't eat health food. They need all the preservatives they can get."

—Robert Orben

"Food is an important part of a balanced diet." —Fran Lebowitz

"Health nuts are going to feel stupid someday, lying in hospitals dying of nothing."

—Redd Foxx

"It's no longer a question of staying healthy. It's a question of finding a sickness you like."

—Jackie Mason 

"Quit worrying about your health. It'll go away."

—Robert Orben

"Reality is the leading cause of stress among those in touch with it."

—Lily Tomlin

"Isn't it a bit unnerving that doctors call what they do practice?"

—George Carlin

"Never go to a doctor whose office plants have died."

—Erma Bombeck

"If I knew I was going to live this long, I'd have taken better care of myself."

—Mickey Mantle

"You can live to be a hundred if you give up all the things that make you want to live to be a hundred." —Woody Allen

"My doctor recently told me that jogging could add years to my life. I think he was right. I feel ten years older already." —Milton Berle

"Never under any circumstances take a sleeping pill and a laxative on the same night."

—Dave Barry

SOURCE: http://www.psychologytoday.com/collections/201109/healing-effects-humor/twenty-quotations-about-health

Toni Bernhard www.tonibernhard.com

Saturday, June 8, 2013

Opioid Drugs

This article is for physicians but it is interesting to see the kind of scrutiny that legitimate chronic pain sufferers can be subjected to because of the behavior of a few abusers of the drugs...

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Managing Chronic Pain Patients and Opioid Drugs

Blog | June 07, 201

By Erica Sprey

Prescription drug abuse in the United States is growing at an alarming rate, especially among young adults. During the period 2008 to 2011, nearly 28 percent of adults ages 18-25 used psychotherapeutic drugs for nonmedical purposes, according to the "National Survey on Drug Use and Health for Ages 12 and Older."

Prescribing opioid medications for patients who experience legitimate, chronic pain can be risky for both physician and patient. Yet, physicians can and should prescribe opioid medication for chronic pain patients, said Daniel P. Alford, program director for the Addiction Medicine Fellowship at Boston University School of Medicine, during a recent AMA webinar on "Assessing for Risk, Benefit and Harm when Prescribing Opioids for Chronic Pain."

He went on to say that while the potential for addiction and drug diverting is significant (89 percent and 75 percent respectively), "providers can be, and want to be, trained to prescribe opioids for chronic pain — safely and competently."

So, how should physicians approach their management of chronic pain patients? Alford recommends adopting universal precautions when prescribing opioid medication: using patient agreements (that contain informed consent); assessing patients for drug abuse/ misuse; monitoring patient well-being through face-to-face visits; and setting up a program to monitor patients for adherence, addiction, and diversion — which includes pill counts and blood and urine testing.

Diana Douglas, vice president of risk management and patient safety, with California-based Cooperative of American Physicians, Inc., advises physicians to set in place policies and procedures for their staff members to assist in managing and facilitating treatment for chronic pain patients.

Twitter: 4th International Cannabis and Hemp Expo.

This site has lots of interesting comments by many and varied people in the wrld of medical cannabis..
https://twitter.com/IntcheInc

Medicinal Use of Marijuana — Polling Results Jonathan N. Adler, M.D., and James A. Colbert, M.D.

Readers recently joined in a lively debate about the use of medicinal marijuana. In Clinical Decisions,1 an interactive feature in which experts discuss a controversial topic and readers vote and post comments, we presented the case of Marilyn, a 68-year-old woman with metastatic breast cancer. We asked whether she should be prescribed marijuana to help alleviate her symptoms. To frame this issue, we invited experts to present opposing viewpoints about the medicinal use of marijuana. J. Michael Bostwick, M.D., a professor of psychiatry at Mayo Clinic, proposed the use of marijuana “only when conservative options have failed for fully informed patients treated in ongoing therapeutic relationships.” Gary M. Reisfield, M.D., from the University of Florida, certified in anesthesiology and pain medicine, and Robert L. DuPont, M.D., a clinical professor of psychiatry at Georgetown Medical School, provide a counterpoint, concluding that “there is little scientific basis” for physicians to endorse smoked marijuana as a medical therapy.

We were surprised by the outcome of polling and comments, with 76% of all votes in favor of the use of marijuana for medicinal purposes — even though marijuana use is illegal in most countries. A total of 1446 votes were cast from 72 countries and 56 states and provinces in North America, and 118 comments were posted. However, despite the global participation, the vast majority of votes (1063) came from the United States, Canada, and Mexico. Given that North America represents only a minority of the general online readership of the Journal, this skew in voting suggests that the subject of this particular Clinical Decisions stirs more passion among readers from North America than among those residing elsewhere. Analysis of voting across all regions of North America showed that 76% of voters supported medicinal marijuana. Each state and province with at least 10 participants casting votes had more than 50% support for medicinal marijuana except Utah. In Utah, only 1% of 76 voters supported medicinal marijuana. Pennsylvania represented the opposite extreme, with 96% of 107 votes in support of medicinal marijuana.

Outside North America, we received the greatest participation from countries in Latin America and Europe, and overall results were similar to those of North America, with 78% of voters supporting the use of medicinal marijuana. All countries with 10 or more voters worldwide were at or above 50% in favor. There were only 43 votes from Asia and 7 votes from Africa, suggesting that in those continents, this topic does not resonate as much as other issues.

Where does this strong support for medicinal marijuana come from? Your comments show that individual perspectives were as polarized as the experts' opinions. Physicians in favor of medicinal marijuana often focused on our responsibility as caregivers to alleviate suffering. Many pointed out the known dangers of prescription narcotics, supported patient choice, or described personal experience with patients who benefited from the use of marijuana. Those who opposed the use of medicinal marijuana targeted the lack of evidence, the lack of provenance, inconsistency of dosage, and concern about side effects, including psychosis. Common in this debate was the question of whether marijuana even belongs within the purview of physicians or whether the substance should be legalized and patients allowed to decide for themselves whether to make use of it.

In sum, the majority of clinicians would recommend the use of medicinal marijuana in certain circumstances.

Large numbers of voices from all camps called for more research to move the discussion toward a stronger basis of evidence.

N Engl J Med 2013; 368:e30May 30, 2013DOI: 10.1056/NEJMclde1305159

Source: http://www.nejm.org/doi/full/10.1056/NEJMclde1305159

Physician views on medicinal use of marijuana.

[Editor's note: The New England Journal of Medicine recently polled physicians across specialties about their views on medicinal use of marijuana.

The case vignette that was presented and the comments -- pros and con -- that it elicited can be viewed here.]

http://www.psychiatrictimes.com/substance-use-disorder/haze-surrounding-medical-cannabis

CLINICAL DECISIONS

Medicinal Use of Marijuana

N Engl J Med 2013; 368:866-868February 28, 2013DOI: 10.1056/NEJMclde1300970

Comments and Poll open through March 6, 2013

CASE VIGNETTE

Marilyn is a 68-year-old woman with breast cancer metastatic to the lungs and the thoracic and lumbar spine. She is currently undergoing chemotherapy with doxorubicin. She reports having very low energy, minimal appetite, and substantial pain in her thoracic and lumbar spine. For relief of nausea, she has taken ondansetron and prochlorperazine, with minimal success. She has been taking 1000 mg of acetaminophen every 8 hours for the pain. Sometimes at night she takes 5 mg or 10 mg of oxycodone to help provide pain relief. During a visit with her primary care physician she asks about the possibility of using marijuana to help alleviate the nausea, pain, and fatigue. She lives in a state that allows marijuana for personal medicinal use, and she says her family could grow the plants. As her physician, what advice would you offer with regard to the use of marijuana to alleviate her current symptoms? Do you believe that the overall medicinal benefits of marijuana outweigh the risks and potential harms?

TREATMENT OPTIONS

Which one of the following approaches do you find appropriate for this patient? Base your choice on the published literature, your clinical experience, recent guidelines, and other sources of information.
Option 1: Recommend the Medicinal Use of Marijuana
Option 2: Recommend against the Medicinal Use of MarijuanaOption 1 (118)Option 2 (118)
OPTION 2
Recommend against the Medicinal Use of Marijuana

Gary M. Reisfield, M.D., Robert L. DuPont, M.D.

Marilyn's query should be recognized both for the words — a straightforward question about medicinal marijuana use — and for the music — a plea for symptom relief. Both must be addressed. Although marijuana probably involves little risk in this context, it is also unlikely to provide much benefit. Simply to allow a patient with uncontrolled symptoms of metastatic breast cancer to leave the office with a recommendation to smoke marijuana is to succumb to therapeutic nihilism.6

There is burgeoning interest in the therapeutic potential of targeting the endocannabinoid system. Although most of the research into this system involves the use of specific cannabinoids, a small body of high-quality research shows evidence of clinically significant analgesia from smoked marijuana, primarily for neuropathic pain. There is little evidence to support the use of smoked marijuana for Marilyn's nociceptive pain, and less still for her other symptoms.

Smoked marijuana is a nonmedical, nonspecific, and potentially hazardous method of drug delivery. The cannabis plant contains hundreds of pharmacologically active compounds, most of which have not been well characterized. Each dispensed quantity of marijuana is of uncertain provenance and of variable and uncertain potency and may contain unknown contaminants.

There are other questions to consider in Marilyn's case. Could marijuana's cognitive side effects, particularly its effects on memory, promote or exacerbate chemotherapy-induced cognitive dysfunction? If Marilyn's pulmonary disease includes lymphangitic spread, could smoking cause hypoxemia? What effects will marijuana's potential immunologic hazards (e.g., chemical constituents, pyrolized gases, viable fungal spores, or pesticide residues) have on her health during periods of immunocompromise?7 How will marijuana, alone or in combination with other medications associated with potential cognitive and psychomotor impairment, affect her ability to safely operate a motor vehicle?8 What are the possible effects of marijuana on tumor progression? The putative cannabinoid receptor GPR55 (G-protein–coupled receptor 55) is expressed in human breast cancers, with higher levels of expression correlated with more aggressive phenotypes.9 The marijuana constituent Δ9-THC has been shown in some studies to act as a GPR55 agonist, raising the possibility that it can promote cancer-cell proliferation.10

Two prescription cannabinoids are available, dronabinol (Marinol) (a synthetic Δ9-THC) and nabilone (Cesamet) (a Δ9-THC congener), which are FDA-approved for the treatment of chemotherapy-induced nausea and vomiting. These medications have shown efficacy in the management of pain and distress. In contrast to smoked marijuana, they feature oral administration, chemical purity, precise dosages, and a slower onset but sustained duration of action. They may be less likely than smoked marijuana to induce anxiety, panic, and negative mood states,11 but they have otherwise similar side-effect profiles.

Cannabinoids, however, should be used only as lower-tier therapies for chemotherapy-induced nausea and vomiting, since other medications, such as 5-hydroxytryptamine3-receptor antagonists, dexamethasone, and aprepitant, have superior efficacy and fewer side effects.12

Assure Marilyn — and follow through on the assurance — that throughout her illness she will be accompanied, cared for, and helped to live as well and as long as possible. Reassure her that meticulous attention will be paid to symptom relief. Discuss the patient-specific potential risks and benefits of smoked marijuana and of the administration of pharmaceutical cannabinoids. There is little scientific basis for recommending that she smoke marijuana for symptom control. As Bernard Lown remarked, “Caring without science is well-intentioned kindness, but not medicine.”13

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

SOURCE INFORMATION

From the University of Florida College of Medicine, Gainesville (G.M.R.); the Institute for Behavior and Health, Rockville, MD (R.L.D.); and Georgetown University School of Medicine, Washington, DC (R.L.D.).

Source: http://www.nejm.org/doi/full/10.1056/NEJMclde1300970#t=cldeOpt2

The Haze Surrounding Medical Cannabis

This article highlights physician difficulties prescribing cannabis, barriers to research for medical uses of cannabis and potential risks of longterm use of cannabis. It is a very hazy subject medically and legally.

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By Helen Lavretsky, MD, MS

Twenty states and Washington DC have now legalized the use of medical cannabis.

With all the attention legalized medical marijuana has been receiving, it is curious that very little attention was given to this topic during the recent APA meeting in San Francisco.

It was particularly ironic because on May 18 and 19, San Francisco hosted the International Cannabis and Hemp Expo, which promoted the culture of cannabis use. All you needed to gain entry was $15 and a medical complaint. . . such as insomnia or back pain.

Given the omission of meaningful discussion during the APA meeting—and the apparent confusion on the part of many psychiatrists about prescribing the substance and the ethical issues that it poses for many, Psychiatric Times is following up with a survey on the topic.

Psychiatrists are invited to complete the survey and give their candid feedback on the subject.

Many of our patients have started asking if they are candidates for a prescription. I am a geriatric psychiatrist, and I have seen a surge in the use of marijuana (whether medicinal or not) by aging adults who may have used it in their youth. It is frequently provided to the elderly by their middle-aged children for pain, insomnia, anxiety, weight loss and—more recently—for the agitation associated with dementia. Many report improvement in these symptoms, and ask me to approve the use of medical marijuana throughout the day to help “mellow out” their parent. (The use of medical cannabis is legal in California where I practice.) This request puts me in the awkward situation of having to know about — and unwillingly consent to — marijuana use but not being able to prevent it. As a psychiatrist, I don’t feel that I can ethically approve any drug abuse in older adults.

Cannabis is commonly regarded as an innocuous drug. The prevalence of lifetime and regular use has increased continuously in most developed countries.

However, accumulating evidence highlights the risks of dependence and other adverse effects, particularly among people with pre-existing psychiatric disorders.

We all know that the use of marijuana in the context of psychiatric illness can worsen symptoms (eg, it can increase anxiety and paranoia). Others report that marijuana diminishes their symptoms of anxiety, sleep, or pain.

Long-term use of marijuana can also cause apathy and low motivation. An appreciable proportion of cannabis users report short-lived adverse effects, including psychotic states, following heavy consumption, and regular users are at risk of dependence. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis generally provokes relapse and aggravates existing symptoms.
Cannabis is a risk-factor for mental illness. It can cause or create:o Psychological responses such as panic, anxiety, depression or psychosis. These effects may be described as “toxic” in that they generally relate to excess consumption of the drug.

o Effects on pre-existing mental illness.

o Dependency or withdrawal effects.

At the same time, there is still no evidence for the use of medicinal marijuana for most disorders.

Some evidence suggests that it helps in nausea (eg, in patients receiving chemotherapy), muscle spasticity in spinal cord injuries, and in some cases neuropathic pain.

Marijuana is still classified as a Schedule I drug (in the same category as LSD, PCP, and methamphetamines), while cocaine, for example, is classified as a Schedule II drug. This limits the ability of researchers to explore potential medical uses for marijuana.

Given the paucity of evidence for the uses of medicinal cannabis, and still very unclear and conflicting local and federal laws, physicians will be careful in prescribing medicinal marijuana.

Source:
http://www.psychiatrictimes.com/substance-use-disorder/haze-surrounding-medical-cannabis

Medical Cannabis: A Survey for Psychiatrists

Here is another example of the widespread interest is medical cannabis.

2013 Psychiatric Times Medical Cannabis Survey June 8, 2013

The Haze Surrounding Medical Cannabis—A Survey for Psychiatrists

With all the attention legalized medical marijuana has been receiving, writes geriatric psychiatrist Helen Lavretsky, MD, MS, it is curious that very little attention was given to this topic during the recent APA meeting in San Francisco. It was particularly ironic because during that meeting, San Francisco hosted the International Cannabis and Hemp Expo. All you needed to gain entry was $15 and a medical complaint.

Given the omission of meaningful discussion during the APA meeting—and the apparent confusion on the part of many psychiatrists about prescribing the substance and the ethical issues that it poses for many, Psychiatric Times is following up with a survey on the topic.

Medical Marijuana Caveat

My interest in cannabis is motivated by reports that cannabis may be of benefit to people suffering from multiple sclerosis.

The articles posted on this blog are part of my process for learning about this herb. I currently do not ingest any of the products that have become legal for medical use in Canada.

The subject is being approached with an open mind but no conclusions have been reached and we do not recommend the use of marijuana. You need to talk with your medical team about any changes in your medications.

My Multiple Sclerosis