The dangers of this potent “man-made” opioid

In recent years, the media has been awash with information on the health benefits of exercise. Exercise is known to boost mood in adults. But what about younger members of society? Based on recent, high quality survey data, we can estimate that about 11% of adolescents are depressed. Sadly, this means that one in 10 adolescents between the ages of 12 and 17 experienced a major depressive episode during the year of the survey. These numbers should raise alarm bells for both parents and doctors.

Depression makes teens feel awful, but being depressed as a teen may also have life-long consequences, including being depressed as an adult. Depressive episodes in teens can contribute to poor grades, poor interpersonal relationships, and worse physical health. Depression can also increase the burden of care for parents. In a recent post, I discussed how a teen’s social network can impact his or her chances of becoming depressed. There, we explored how having friends with good spirits could exert a positive influence on a teen’s mood. We have also previously touched on some of the concerns with giving teens antidepressant medication. Today we will tackle the hot topic of exercise and depression in adolescents.
A carefully conducted analysis of exercise and depression in teens

A recent study attempted to delve into the data behind exercise as a treatment for depression in teens. The authors initially screened 543 studies and found 11 to include in their analysis. Of those 11, only eight yielded good data to use for more specific calculations. In general, although not always, these types of analyses are particularly powerful because the authors use rigorous criteria when deciding which studies to include.

The teens included in this analysis were 13 to 17 year olds, who did not have any major physical health problems, such as obesity. The data from the studies compared the use of exercise as treatment for depression against a psychosocial intervention, an educational intervention, treatment “as usual”, or no treatment at all. After combining data, the authors eventually concluded that exercise appears to lead to moderately improve depression in adolescents, particularly in those already receiving some formal treatment. But, treatment “as usual” was not well defined, and we don’t know, for example, how many of these teens were taking antidepressant medication.
Will exercise really help teens suffering with depression?

So, should we conclude from this study that all teens with depression should be treated, to some extent, with exercise? It is tempting to say yes. However, concluding that all teens with depression should be treated with exercise would over-simplify the results of this study.  A person (adult or teen) with depression will likely find that exercise helps improve symptoms to some degree. However, this study doesn’t support the statement that exercise is the best cure for depression. Instead, it would be more accurate to say that in teens who are already undergoing treatment for depression, exercise appears to be a strategy with modest benefits and little downside. This particular study is a wonderful addition to our knowledge base, in that it puts another tool into a doctor’s toolkit to help treat patients with depression in clinical settings. Every day, about 10 people die from drowning — and two of them are children. Not only that, for every child that dies from drowning, five more are treated in emergency room for injuries from drowning, which can include permanent and severe brain injuries.

Here are the five things all parents and caregivers need to know about drowning:

    Drowning can be silent. When we think about drowning, we think about flailing arms and calls for help, but that’s not how it usually works. What usually happens is that people take the biggest breath they can and go down — and don’t come back up again. They can’t flail and they can’t yell. You could miss it. To learn more about this, check out the great post, “Drowning Doesn’t Look Like Drowning.”
    Drowning can happen where there are lifeguards. In 2011, a woman slid to the bottom of a guarded public pool in the Boston area and drowned — and her body wasn’t discovered for two days because the water was murky. While that may be an extreme case, people drown where there are lifeguards all the time. Lifeguards can’t always see everything, especially when drowning can be silent — and they can get distracted just like anyone else. Just because there is a lifeguard doesn’t mean you don’t have to watch your child.
    Drowning can happen in very little water. All it takes is enough water to get your face in. Children can drown in a kiddie pool, a bathtub, a bucket of water, or a toilet bowl.
    Good swimmers can drown. They can get tired, they can get a cramp, they get can caught in a rip current or in something underwater — or they can bump their head. Just because your child is a good swimmer doesn’t mean something bad can’t happen.
    Drowning is preventable. Here’s what you can do:

    Teach your child to swim. Sign them up for a swimming class — look for one that teaches water safety skills, too.
    Learn CPR. It’s easy to learn, and saves lives.
    If you have a pool, make sure it is completely fenced all around — and has a self-latching or self-locking gate.
    Use lifejackets whenever you go out on the water, on anything.
    Teach your children what to do if they get caught in a rip current: instead of fighting it and trying to swim back to shore against it, swim parallel to shore and ease your way out of it.
    Keep your eyes on your child at all times when they are in any kind of water. This includes bathtubs and kiddie pools; if you need to take your eyes off them, take them out of the water. At the beach or pool, keep your eyes on your children even if there is a lifeguard. You can read or look at your phone later. Nothing is more important than your child’s life.
In July, the Centers for Disease Control and Prevention announced that a woman in Miami-Dade County in Florida had tested positive for the Zika virus. Follow-up to this case led health officials in Florida to report a total of 15 cases in the area. These weren’t the first people in the United States, or even in Florida, to contract Zika. But these cases were unique in one important way –– they were likely caused by mosquitoes in the United States.

The CDC promptly issued a travel warning for pregnant woman and their partners, warning them not to visit the small community of Wynwood, just north of Miami, where these Zika cases first occurred. This is the first time the CDC has ever issued a warning to pregnant women about traveling to a place within the United States because of the threat of infectious disease.
It’s no surprise that local mosquitoes carry Zika

For many health officials it wasn’t a question of whether Zika was going to get to the United States, but rather when it would arrive. Currently, there are more than 1,400 travel-related Zika cases in the United States, and U.S. territories like Puerto Rico are grappling with more than 3,800 cases. Also, parts of the United States are home to the Aedes aegypti mosquitoes that carry the virus, with southern states like Texas and Florida bearing the greatest risks for outbreaks due to their warmer climates.

The news that mosquitoes in the United States have been found to carry Zika is certainly concerning, but experts say that Zika likely won’t spread here as it has in countries in Central and South America. “Our housing is generally better here, and since we’re more likely to have AC, we can keep our houses sealed off better,” says Dr. John Ross, an infectious disease expert and professor of medicine at Harvard Medical School. “We also tend to have more robust healthcare in the U.S. than in other places, so we can track and treat these cases more effectively.”
How do you know if you have Zika…and how can you avoid it?

The CDC reports that only about 20% of people who get the virus go on to show symptoms, which are usually mild and typically include a low-grade fever, sore or aching joints, conjunctivitis (“pink eye”), and a rash. However, the virus does pose a greater danger to pregnant women and their unborn children, as studies have shown that Zika may cause microcephaly. Microcephaly is a birth defect in which a baby’s head is unusually small. Often, the brain has not developed properly, which can result in neurological and developmental problems. Current research estimates that 1% of all pregnant women with Zika will give birth to a child with these neurological issues.

In addition to their travel advisories, doctors at the CDC have also provided information about how to prevent mosquito bites and decrease the risk of developing Zika:

    Avoid areas with Zika. Women who are pregnant or who are trying to become pregnant should avoid areas with known Zika cases.
    Use insect repellant. It’s a simple and maybe obvious step — using insect repellant helps deter mosquitoes and prevent bites.
    Wear clothing that provides coverage. Long sleeves and long pants protect your arms and legs from mosquitoes and help prevent bites.
    Practice safe sex. Zika can be spread through sex, so it’s important to use a condom to prevent sexual transmission. If you have been anywhere with an outbreak of Zika, doctors recommend that you use a condom for 8 weeks after your return if you don’t show symptoms of Zika, and for 6 months if you do show symptoms in order to prevent transmission to you sexual partner.
    Travel safely. If you are traveling to an area with known cases of Zika, take the proper safety precautions and watch for travel advisories. Doctors may recommend vaccines or other medications.

Although it’s concerning to see cases of Zika in the United States, they don’t necessarily signal the beginning of a widespread epidemic. “We always need to be vigilant,” says Ross. “The good thing is that people are aware of the dangers of Zika, and we have the tools we need to limit and monitor its spread.” As we watch the devastation of the opioid crisis escalate in a rising tide of deaths, a lesser known substance is frequently mentioned: fentanyl. Fentanyl’s relative obscurity was shattered with the well-publicized overdose death of pop star Prince. Previously used only as a pharmaceutical painkiller for crippling pain at the end of life or for surgical procedures, fentanyl is now making headlines as the drug responsible for a growing proportion of overdose deaths.
So what is fentanyl and why is it so dangerous?

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Its potency also means that it is profitable for dealers as well as dangerous for those who use it, intentionally or unintentionally. Increasingly heroin is being mixed with fentanyl so someone who uses what they think is heroin may in fact be getting a mixture with — or even pure — fentanyl. More recently, pills made to look like the painkiller oxycodone or the anxiety medication Xanax are actually fentanyl. This deception is proving fatal. It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol. While many people don’t know they are getting fentanyl, others might unfortunately seek it out as part of the way the brain disease of addiction manifests itself into compulsively seeking the next powerful high.
Helping people who use fentanyl

The way to help patients who are using fentanyl is the same as for other forms of opioid use disorder: to provide effective addiction treatment. However, the first and most important step is helping patients stay safe and stay alive until we can get them that treatment.

It’s worth remembering that dead people don’t recover.

To stop the deaths, we must provide immediate access to lifesaving treatment on demand. While any opioid use is risky, fentanyl has raised the stakes. Every single episode of fentanyl use carries the risk of immediate death. This highlights the need to change how we think about treatment. Many of the traditional models of addiction treatment were designed for alcohol use disorder. Misuse of alcohol can be fatal, but it usually takes many years or even decades to kill someone. In contrast, opioid addiction is imminently fatal, so waiting for treatment is and should be considered unacceptable. We must try to initiate treatment at every opportunity — in the emergency department, at the hospital bed, or even on the street. The best evidence we have shows that a combination of medication and psychosocial treatments is most effective for opioid use disorder. A study of MassHealth patients found that patients on medication treatments like methadone or buprenorphine are 50% less likely to relapse. Other studies have shown that patients treated with these medications are 50% (or more) less likely to die. And yet significant stigma and misunderstanding still exists around these medications. We have treatment programs (and doctors) that don’t offer these medications and patients who are doing wonderfully in recovery thanks to them, but who are also scared to speak out and say they are on medication because the stigma is so pervasive.

Even with our best efforts, it can take time for some people to be open to treatment. In those cases, our priority is to keep them alive and to keep working with them on their readiness to consider treatment. This requires access to naloxone, the antidote to overdoses. But it also includes other education and harm reduction services. People who have loved ones who are actively using and those who are using themselves need to know how to stay safe. There is very concrete education that can reduce the risk of overdose and we need to ensure it is getting to those at the greatest risk.
Moving forward

In Massachusetts alone, deaths due to fentanyl overdose have risen to 57% between 2015 and the first half of 2016. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

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How to Answer Exam Questions Correctly

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Related Post: How to Answer Exam Questions Correctly

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See: How to Study for Exams in Less Time 2019

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Let’s recognize caregivers and make it easier for all of us to do the right thing

Recently I saw a young woman in my clinic for her annual exam. As usual, I asked her if she would like to be tested for sexually transmitted infections, and then we reviewed the “menu” of options: we could collect a swab of her cervix for chlamydia, gonorrhea, and trichomonas, and a PAP smear for human papillomavirus. We could collect blood for HIV, hepatitis C, syphilis, and herpes. We discussed the pros and cons and details of testing — not everyone wants every test. But she cheerfully consented to all of it, and when the results came back positive for chlamydia, she was shocked.

“But I had no symptoms!” she exclaimed.

Like most primary care providers, I am a huge fan of screening for STIs and believe every patient should be asked at every annual exam if they would like to be tested, even if they feel fine. Why? Because most people don’t even know that they are infected.
How many people actually have a sexually transmitted infection?

The Centers for Disease Control and Prevention (CDC) recently published its summary of reportable sexually transmitted infections in the United States over the past year, and it is not good. Rates of every reportable STI, which includes chlamydia, gonorrhea, and syphilis, have all increased significantly; all told, we are seeing a 20-year record high in the number of these cases.* What’s extra concerning is that it is the third year in a row that these rates have increased.

Chlamydia is king, with over 1.5 million cases in 2015, a 6% increase from 2014. Gonorrhea follows with 400,000 cases, a 13% increase. These infections can result in pelvic inflammatory disease, which is a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. A pregnant woman with chlamydia can pass it to her baby; the baby can then develop serious eye and lung infections. The people at highest risk were young people between the ages of 15 and 24; they accounted for over two-thirds of the cases of chlamydia. This is why the CDC has been recommending that every sexually active woman under age 25 be screened.

There were 24,000 cases of syphilis, which may the most harmful of the three, and this was a whopping 19% increase. Gay and bisexual men remain at highest risk for syphilis and gonorrhea, though there were also significant increases in syphilis among women, as well as in congenital syphilis, which is spread from infected mothers to their newborns. Untreated syphilis can lead to blindness, paralysis, and dementia in adults, and seizures or stillbirth in babies. The CDC recommends that every pregnant woman be tested for syphilis, and sexually active gay and bisexual men should be tested for syphilis annually.
Barriers to preventing the spread of STIs

If someone doesn’t know that they are infected, they can’t get treated. If they don’t get treated, they may have sex with many partners, or without a condom, and spread the infection. So, screening tests like the ones we offer at the annual exam are important for the prevention of new infections.

Many people can’t access clinics like mine. They may be young people worried about what their parents may think. They may be uninsured, under-insured, or undocumented. That’s where the “safety net” comes in. These are the free or lower-cost clinics that focus on STI diagnosis, treatment, and prevention. But since 2003, there has been a slow and steady decrease in funding for these safety-net clinics, and we are paying a serious price for that now.

CDC officials blame the surge in STIs on these budget cuts: they point out that over 40% of health departments have reduced their clinic hours and tracking of patients, and at least 20 STI clinics flat-out closed in the past few years due to lack of funds.

Dr. Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, points out that, “STI prevention resources across the nation are stretched thin, and we’re beginning to see people slip through the public health safety net.”

Combine this decrease in public health clinics with the rise in popularity of dating apps like Tinder and Grindr, and ongoing inconsistent condom use, and we have a huge problem.
Keys to preventing STIs

Chlamydia, gonorrhea, and syphilis can be prevented with condoms, and cured with antibiotics. And all can present with minimal symptoms, or none at all.

Sexual education programs that include instruction about condom use have been shown to help youth to delay first sex and use condoms when they do have sex. But, only 35% of U.S. high school students are taught how to correctly use a condom in their health classes. So it’s not surprising that among teens, only about a third of males and nearly half of females reported that they or their partner did not use a condom the last time they had sex.

What can we do about this? Obviously, we need to better fund our public health clinics. Anyone who is or has been sexually active needs to go get tested. We need to push for comprehensive sexual education in schools. Parents should talk openly with their kids about sex and STIs, and ensure that they have access to confidential medical care. We need to promote safe, protected sex through consistent condom use for everyone. These interventions are all cheaper and better than ongoing rampant infection.

*What about other STIs, like herpes and trichomonas? These were not included in the report, as they are not reportable in the same way. However, the CDC estimates that there are 20 million new STI cases yearly, costing the U.S. health care system approximately $16 billion. News last week about celecoxib shows how challenging it can be to understand the risks and benefits of newly developed drugs. This is particularly true when the findings of one study contradict those of past studies. And that’s exactly what has happened with celecoxib.
Anti-inflammatory medications: pros and cons

The FDA approved celecoxib (Celebrex) in 1999. This anti-inflammatory medication can be a highly effective treatment for arthritis and other painful conditions. It was developed with the hope that it would be at least as effective as other anti-inflammatory medications (such as ibuprofen or naproxen) but cause less stomach irritation. Developing a safer anti-inflammatory medication is a worthy goal, since stomach irritation can not only cause annoying pain or nausea, but it can also lead to ulcers, bleeding, or perforation. These medications can also increase blood pressure and cause kidney problems.

Celecoxib is known as a COX-2 inhibitor — that’s because it targets an enzyme (COX-2) involved in inflammation. Ibuprofen and naproxen (and many other anti-inflammatories) target COX-1 and COX-2. They’re called “non-selective” anti-inflammatory drugs. Because of where these enzymes are found in the body, the COX-2 selective medications seemed capable of dampening down inflammation while going easier on the stomach.

And that was true. Celecoxib — and other COX-2 inhibitors, such as rofecoxib (Vioxx) — did cause less stomach trouble. But soon after its approval, studies suggested other concerns: an increased risk of heart attack and stroke. Rofecoxib was removed from the market in 2004. And while the FDA allowed celecoxib to remain on the market, it required the manufacturer to issue additional warnings to patients. It also required additional study. And that’s why celecoxib is back in the news this week. The results of the PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety versus Ibuprofen or Naproxen) trial were released. And the news is good for celecoxib.
Results suggests lower cardiovascular disease risk — and fewer side effects — than expected

The PRECISION trial is a carefully designed and powerful study that analyzed the impact of celecoxib on cardiovascular disease. The study spanned 926 medical centers in 13 countries and enrolled more than 24,000 patients with two of the most common types of arthritis (osteoarthritis and rheumatoid arthritis). Each study subject had a higher than average risk for cardiovascular disease due to a history of high blood pressure or high cholesterol.

Study subjects were divided into three groups who took anti-inflammatory medications every day: one group took celecoxib, one group took ibuprofen, and the last group took naproxen.

Study subjects taking celecoxib in moderate doses were

    no more likely than those taking ibuprofen or naproxen to have a fatal or non-fatal heart attack or stroke
    less likely than those taking ibuprofen or naproxen to have significant gastrointestinal problems, such as serious bleeding
    less likely than those taking ibuprofen to have kidney problems or hospital admission for high blood pressure.

What does this mean for you?

It’s rare that a single study provides a definitive answer or changes practice overnight. But this was a large, well-designed, and expensive study that is unlikely to be repeated any time soon. And, another study of lower-risk people came to a similar conclusion just last year.

Still, questions may yet come up regarding:

    The lack of a placebo group. As suggested by some prior research, it is possible that all three of the drugs used in this study increase the risk of cardiovascular problems; without a control group, it’s impossible to say.
    Dosing. Study subjects were allowed to take up to 400 mg/day of celecoxib if they had rheumatoid arthritis but only 200 mg/day if they had osteoarthritis. In real life doctors may prescribe a wider range of doses.
    Reason for treatment. This study only included people with rheumatoid arthritis or osteoarthritis. The results might be different if people with other conditions had been included.
    Other medical problems. The risks and benefits of celecoxib in people with other medical problems (such as significant kidney disease) are uncertain because this study excluded them.
    Other medical treatments. All patients in this study took a medication to protect the stomach; outside of studies, that’s not always the case.

While these issues are valid, I think this study does provide a significant measure of reassurance regarding the cardiovascular risks of celecoxib. And it may encourage doctors who thought the drug was too risky to prescribe it more often.

This new research shows in a dramatic way why “more research is needed” is not just a tagline at the end of so many medical news stories. And in the case of celecoxib, the result of the additional research is good news indeed. Since 2003, the Movember movement has been raising public awareness of testicular and prostate cancer. The common theme that links cancers of all types is that early detection tends to lead to better outcomes. Because cancer often has no symptoms in its early stages, screening for cancer has been an integral part of primary care routine visits.
I go for an annual physical every year. Do I really need to do self-examinations?

Although routine screening by a health care provider is critical, it does not alleviate the need for self-examinations. In terms of gender-specific cancers, breast cancer is one that receives a great deal of attention due to its prevalence, as one in eight women will develop breast cancer during their lifetime. It is the most commonly diagnosed form of cancer in women, and the second leading cause of cancer death in women. As with any form of cancer, early detection is critical, and the importance of routine breast self-examinations cannot be stressed highly enough. For these reasons, multiple foundations and even the National Football League promote awareness.
What is the deal with men’s health?

Far fewer people know the facts about prostate and testicular cancer. Regarding prostate cancer, about one in seven men will be diagnosed during their lifetime. It most often affects men over the age of 65, and it is the second leading cause of cancer death in men. Although there is no proven way to do self-exams, a digital rectal examination (DRE) performed by a health care provider is a useful screening tool in the detection of prostate cancer. During a DRE, a healthcare provider uses a gloved, lubricated finger inserted into the rectum to feel the prostate gland.

Testicular cancer is fortunately much less common than prostate cancer, as about one in 263 men will be diagnosed during their lifetime. Unlike prostate cancer, testicular cancer is a disease of young and middle-aged men, with about 7% of cases occurring in teens and young boys. Although the number of deaths from testicular cancer is far lower than breast or prostate cancer, it is estimated that about 380 men will die of testicular cancer in the U.S. in 2016. Early detection is critical, and we must stress the importance of routine testicular self-examinations.

Prostate and testicular cancers, especially when not detected early, can lead to difficult treatment, sterility, and potentially a lifetime of hormone replacement therapy. Men tend to be less likely in general to access the health care system, particularly for routine care, which further punctuates the need for awareness. Many men find the thought of a DRE or a testicular examination embarrassing, but such embarrassment can be lifesaving.
 Why is a neurologist so interested in prostate and testicular cancer?

A few years ago, I met a colleague who was similar to me in many ways, a relatively young physician and father of two with no health problems. That is, until he discovered a small nodule on one of his testicles during a self-exam. Follow-up tests confirmed testicular cancer. Fortunately, with early intervention, he was cured after the surgical removal of one of his testicles.

So when I heard about the Movember movement, I felt compelled to do my part to raise awareness.
So here are some of my Movember experiences…

For the past few years, I have grown out a full beard in October, and then shaved it down to a mustache on November 1. For a man who never wears a mustache to suddenly have one is very much an attention grabber. I fondly recall my daughter who is now 4 saying, “Papa, you look like Super Mario with that mustache.” Fortunately, some of the comments I received have been a little more flattering. After sharing the story of Movember with some coworkers, one of the nurses said, “That mustache reminds me of Tom Selleck’s mustache. The only difference is, he is Magnum P.I., which I guess makes you Magnum P.M. (my initials).” During Movember, I begin every patient encounter explaining why I have a mustache, the importance of prostate and testicular cancer awareness, and how early detection can be lifesaving. It has always amazed me how many patients reply with a personal story of their own about a brother, uncle, coworker, etc. who was diagnosed with prostate or testicular cancer.

I fondly recall one such patient, a woman in her 70s, later changing the subject by saying, “Dr. Mathew, do you know that it tickles very much to kiss a man with a mustache?” I replied with a big smile while shrugging my shoulders, “I wouldn’t know (implying that as a heterosexual married man, I have never tried to kiss a man with a mustache),” One of my most rewarding Movember experiences occurred when I had a female patient in the medical field ask me how to perform a testicular exam. I was initially shocked by the question, but then later elated that my mustache served its purpose and then some. Not only did I raise awareness of testicular cancer, but this woman may actually help detect a case, and save someone’s life.

Then came the difficult part … showing this woman how to perform a testicular exam. My mind quickly scrambled, and after scanning the room, I noticed an Angry Bird toy from a Happy Meal that my daughter did not want. As I picked up the rotund bird, and used it as a teaching prop, she seemed to grasp the concept perfectly. I then put the Angry Bird down, and I could not help but feel that one just flew over the cuckoo’s nes. I walked out of the doctor’s office, overwhelmed and paralyzed. My daughter had just been diagnosed with multiple food allergies from nearly all fruits, numerous vegetables, seafood, nuts, soy, wheat, and more. We headed straight to the grocery store to figure out what she could eat without wasting away from malnutrition, or so I thought.

Two hours later, we were still in the grocery store, reading every label.

You would think I would know what to do. After all, I am a doctor. But that day, I was simply a mom and a caregiver.

My problem was simple in the big scheme of things. Many years later, we figured out what my daughter can and can’t eat, how to go out to dinner, have friends over, and basically return to normal everyday life.

But for many of the more than 40 million caregivers in the USA today, it’s not so easy.
The costs of caregiving: health, time, and money

Fully 32% of family caregivers provide at least 21 hours of care per week with the average of 62.2 hours, according to a June 2015 AARP and National Alliance on Caregiving research report, Caregiving in the U.S. Those who provide caregiving 14 hours per week or for two or more years doubled the risk of developing cardiovascular disease and significantly increased the risk of developing high blood pressure and depression.

And it’s not just the time burden and health risks, but there’s also the expense.

A just-released AARP study, Caregiving and Out-of-Pocket Costs: 2016 Report, concludes that “family caregivers are spending roughly $7,000 in 2016 on caregiving expenses which amounts to, on average, 20% of their total income.” Some groups, including Hispanic/Latino, African American, and those caring for someone with dementia experience higher than average out-of-pocket expenses.

Many caregivers are forced to cut back on their own personal spending, reducing leisure spending or retirement savings, to accommodate caregiving costs.

When I think back to the day our family life changed, I am struck by how little doctors seem to know about the impact of our recommendations to our patients. My problem was minor — just changing grocery shopping habits and recipes.

But think about a new diagnosis of diabetes. It’s not just the recipes and grocery habits, but more trips to the pharmacy, tracking blood sugars, and follow-ups to doctors. According to a Harvard Medical School study, it takes two hours on average for one doctor visit for travel, waiting time, and visit. Even more time is spent if one needs public transportation or to arrange a ride.
Maybe it’s time to contemplate new measures for health care delivery

What if doctors and health systems were measured by how much they reduced the time, money, and the overall burden of care that patients, family, and caregivers need to follow recommended care? What if we told our patients, their families, and their caregivers not only what they “should do,” but “how to” with the least disruption to their everyday lives?

We need to make it easy to do the right thing.

Doctors care about having meaningful time with their patients. So, every time a new guidance or documentation rule is mandated, physicians understandably complain about the new time burden to incorporate the new tasks into the workflow of their practice.

Similarly, every time we give our patients and caregivers new recommendations to follow, we are disrupting the “workflow of their lives.” Is it any wonder that compliance is challenging for our patients? Do we address the daily changes that will be needed in everyday living? The Lasix prescription that means figuring out where all the nearest bathrooms will be when the fluid reduction pill takes effect. Or the cost of dressings, bandages, tape, and time to manage wound care at home? And the anxiety of not knowing if one just broke sterile technique at home? What a steep learning curve we expect from our patients following each visit!
A thank you from health care providers to caregivers

November is National Family Caregivers Month. Kudos to all family and friend caregivers, not only for “care taking” — ensuring your loved one is safe, taking the correct medications at the right time, preventing falls, making the right meals, and helping with bathing — but also for “care giving” – the giving of love, compassion, and care. You are spending your precious hours and your own money to do what you do best: sharing your love to your parent, your spouse, your children, or your friends. You are making a difference to our patients (your loved ones). It’s time we clinicians pay tribute, recognize, and thank you for being a caregiver, and not just a caretaker.

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Tips for making the most of your child’s checkup

It’s that time of year again, when people gather with friends and family to celebrate the holiday season. The festivities often feature wine, champagne, and other alcoholic beverages. But before you raise your glass, make sure you’re aware of just how much alcohol you’re actually consuming — and how it may affect your heart.

For the most part, moderate drinking — defined as one drink per day for women and two drinks per day for men — is considered safe. But there are some caveats.
Defining “one” drink

“We ask people about numbers of drinks, but you have to be careful about what they really mean by that,” says cardiologist Dr. Stephen Wiviott, associate professor of medicine at Harvard Medical School. For some people, “one drink” may be 6 ounces of whiskey, which is actually four drinks, he notes. One standard drink contains roughly 14 grams of pure alcohol, which is found in:

    12 ounces of regular beer (about 5% alcohol)
    5 ounces of wine (about 12% alcohol)
    1.5 ounces of distilled spirits, such as whiskey, rum, and vodka (about 40% alcohol)

Despite popular belief, the evidence that alcohol is good for your heart is fairly weak and based solely on what researchers call observational data. “We observe that people who drink moderately have lower rates of heart disease and death from heart disease, but that doesn’t prove cause and effect,” says Dr. Wiviott. For example, light-to-moderate drinkers tend to be educated and relatively wealthy, and they’re likely to have heart-healthy habits that may explain their lower risk.
Holiday heart

There’s a well-established connection between binge drinking and atrial fibrillation or afib, an irregular heart rhythm that can increase the risk of a stroke. It’s known as holiday heart syndrome because it typically happens around the holidays and on weekends, when some people drink to excess. It’s not exactly clear why binge drinking (defined as consuming about four to five drinks over a two-hour period) triggers afib. But it can happen in people with and without a history of the heart rhythm problem.

A recent study found that even as little as one drink a day may enlarge the heart’s upper left chamber (atrium) and increase the risk of developing afib. Researchers found that every 10 grams of alcohol consumed was linked to a 5% higher risk of developing afib. About 24% (and in some cases, up to 75%) of the higher risk could be traced back to an enlargement of the left atrium. Stretching of the atria — which can also result from longstanding high blood pressure or a genetic problem — seems to make the heart more electrically unstable, Dr. Wiviott explains.
So what should you do?

These new findings don’t change the observation linking moderate drinking to a lower risk of heart attack noted in some studies. But no one should ever start drinking in hopes of avoiding a heart attack, he says. For his patients who do drink alcohol, he suggests no more than one drink a day, even for men. If you have afib and drink alcohol, you should probably have a discussion with your doctor, Dr. Wiviott advises.

The National Institute on Alcohol Abuse and Alcoholism already advises people ages 65 and older to limit themselves to one daily drink. Age-related changes, including a diminished ability to metabolize alcohol, make higher amounts risky regardless of gender. As a headache specialist, the topic of sinus headache is a frequent point of discussion. Many patients deny that they have migraines, believing sinus problems are the cause of their headaches. Some of the more tech-savvy patients believe that they have both migraines and sinus headaches after consulting with “Dr. Google.” The reality of the situation is that 86% or more of patients who suspect that they have sinus headaches in fact have migraines.
Why the confusion between sinus headaches and migraines?

It begins with the many symptoms that both migraines and sinus headaches share, which include pressure in the face, an association with barometric/seasonal weather changes, and autonomic nervous system dysfunction. The autonomic nervous system controls many of the involuntary functions in your body including heart rate, blood pressure, and sweating. In the case of migraines, autonomic dysfunction can cause eye redness, eyelid swelling/drooping, tearing, sinus congestion, and even a runny nose.

Response to treatment can also further drive patients to believe that they have sinus headaches rather than migraines. For example, a patient may have a headache involving a pressure sensation in the face, and calls their primary care physician thinking a sinus infection is causing the symptoms. The primary care physician then prescribes antibiotics and steroids to treat this assumed sinus infection. The patient feels better after taking these medications, and believes that the infection is cured. The reality of the situation is that steroids can be effective for the treatment of sinus issues and migraines. Even without steroids, antibiotics can be perceived as an effective treatment for two reasons. First, the patient truly believes he or she has an infection, so the antibiotic has a powerful placebo effect. The other reason is that with time, the migraine would have gone away anyway.

Unfortunately, this cycle of antibiotics with or without steroids for the treatment of a migraine masquerading as a sinus infection can go on periodically over years and even decades. Taking steroids can cause many problems including weight gain, hair loss, and bone weakness. Inappropriate use of antibiotics can contribute to the rise of antibiotic-resistant bacteria. Conversely, if a sinus headache responds to a migraine-specific treatment like sumatriptan, migraine is more likely the diagnosis than sinus headache.
Here’s why you want to know whether you have migraines and not sinus headaches

An incorrect diagnosis of sinus headaches can also serve to skew a patient’s family history. Migraine is a genetic disorder that is passed down through family members. Patients often deny that any of their family members have migraines, but when asked about sinus headaches, they will often respond, “Actually, my mother had sinus headaches.” When questioned about the mother’s sinus headache behavior, the same patients frequently respond, “She would lay down, and insist that the room be dark and quiet. She would also ask for a bucket to be placed by the head of the bed even though she rarely ever threw up.” Such responses tend to lead the physician and patient to the conclusion that migraines actually do run in the family, as sinus headaches are not typically accompanied by light sensitivity, sound sensitivity, and nausea. The same patients will also return for a follow-up appointment noting, “It turns out that my sister, cousin, and aunt all have migraines, which they thought were due to sinus problems.” In a jocular way, I at times reply, “Discovering family members that suffer from migraines can be both unfortunate and comforting, but such discovery is not as devastating as routinely encountering a family member who regularly causes headaches, which I refer to as ‘mother-in-law syndrome.’”
Three telltale signs it’s a sinus headache and not a migraine

While I was lecturing on distinguishing sinus headache from migraine with some Harvard medical students, they came up with the phrase Mathew’s Sinus Triad to encompass three features that are more suggestive of sinus headache than migraine. These are:

    Thick, infectious looking mucous. A little clear drainage can be seen with a number of conditions, and is not necessarily indicative of a sinus infection.
    Fever. It would be very unusual for migraine to present with fever, but fever is a primary symptom of a sinus infection.
    Imaging. If an imaging study or evaluation with an endoscope looking up the nose shows a sinus problem, then the headaches are likely related to that — unless the headaches continue after the sinus problem is successfully treated.

In conclusion, if you suffer from frequent sinus headaches, there is a good chance that you are actually experiencing migraines. Making the correct diagnosis and formulating an appropriate treatment plan can reduce the frequency and intensity of headaches, as well as avoid unnecessary testing, visits to specialists, and taking medicines that are not actually treating the problem. The yearly check-up: it’s the time when your child gets a total look-over. As a pediatrician, I’m often struck by just how much I need to cover in that appointment. I need to find out about eating, sleeping, exercise, school, behavior, even about peeing and pooping. I need to ask about the dentist, about screen time, about changes in the family’s health or situation. I need to do a full physical examination and check on growth and development. I need to talk about and give immunizations — and make sure parents have the health information they need and want. And of course, I need to address any chronic health problems the child might have, and any concerns the parents have.

In our practice, the longest I have to do this is 30 minutes. Usually I have 15 minutes.

After 25 years of being a pediatrician and doing thousands of check-ups, I’ve learned about what can help parents get the most out of whatever time they have. Here are some tips:

    Think about what you want to talk about before the visit. This sounds really obvious, but too often parents don’t do it. They get caught up in scheduling and getting to the visit, or in the forms they need, and don’t take the time to think about what they want to ask the doctor. Keep a list somewhere (like on your phone, so you don’t leave it at home); jot things down. As you go along, prioritize the concerns: what is most important to cover at the visit? Which leads me to…
    Don’t leave it all for the visit. This happens all the time. Parents store up all their worries— and have a list that is so long and complicated I can’t possibly tackle it all and still do what I need to do medically. While sometimes we schedule a follow-up visit to finish up (more on that below), another alternative is to find ways to get some of your questions answered ahead of the visit.

    Most practices have nurses that can answer common health questions and otherwise help families. You may be able to leave a message for your doctor and have them call you back; this can be particularly helpful when there are concerns, such as behavioral problems or bullying, that might be best discussed without the child present.
    Use portals or other forms of communication. More and more, practices are devising ways for families and doctors to communicate. You can use these to get a question answered or get advice. I’ve also had parents send me written information about their child ahead of a checkup exactly to save time at the visit — and allow us to be more efficient and focused when we are together.
    Consider making an appointment before the checkup. This sounds odd, but it can be really helpful, especially when there is something complicated going on — like asthma acting up, school problems, worries about behavior, or a family crisis. That way, I can fully focus on the problem, instead of having to ask about sleep or poop or daily servings of vegetables. Plus, it gives us a chance to try something — and then at the checkup, see if it helped or not.
    Ask your doctor which health and parenting websites they recommend. There’s a lot of great information out there.

    Have any forms or papers ready — and have your child undressed before the doctor comes in. Little stuff, but it really helps things move smoothly. If you have to fill out something for the visit, get it done. Have the argument with your modest child about the gown before the visit starts. If you have forms you need for school or sports, let the nurse or clinical assistant know; sometimes they can help.
    Work with your doctor to set an agenda for the visit. Too often, we docs come in with our own agenda. Or, parents start in with their first concern — and then time runs out before they get to the second or third. As soon as the doctor comes in, say something along the lines of, “I have three things I want to be sure we talk about today, and I know you have things you need to ask. How can we best make this work?” Planning it out together can make all the difference.
    Be brief whenever you can. I’m not saying you shouldn’t say everything you need or want to say. But if all is going fine in a particular area, say it’s fine rather than giving lots of details. Or if all isn’t going fine, just say it’s not, rather than defending or giving excuses. Save the time for questions and conversations that can help you and your child.
    Let your doctor know if your needs aren’t met. Sometimes we just can’t pull it off in that one visit, but that doesn’t mean that you can’t get all of your needs met. As I said before, sometimes a follow-up visit makes sense. Maybe there is a nurse who can spend some time helping you before you leave or a social worker who can give you a call. Maybe you can get a handout about a topic you are interested in or a recommendation for good online information. Never just leave saying, “Oh well, maybe next year.” That’s not how primary care works; it’s an ongoing relationship. We are here to support you, every step of the way.

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Don’t take fatigue lying down

Sure, everyone gets tired sometimes, and often bounces back after a quick rest or a good night’s sleep. However, if bouts of fatigue occur more often and last longer, you shouldn’t ignore them.

“Older adults may chalk up fatigue to aging, but there is no reason you should battle ongoing tiredness,” says Dr. Suzanne Salamon, a geriatric physician with Harvard-affiliated Beth Israel Deaconess Medical Center.

Here are signs that you should take your tiredness seriously:

    inability to do activities you enjoy
    waking up exhausted, even after a good night’s sleep
    not feeling motivated to begin the day
    sudden bouts of exhaustion that go away and then return
    shortness of breath.

This type of fatigue can affect your health in many ways. You may have less energy to exercise. You may have trouble concentrating, staying alert, and remembering things. You may anger easily and become more socially isolated.
It’s worth checking in with your doctor

Fatigue also could signal a medical condition, according to Dr. Salamon, and you should consult your doctor to see if you have any of the following issues.

    Anemia. This occurs when your blood has too few red blood cells or those cells have too little hemoglobin, a protein that transports oxygen through the bloodstream. The result is a drop in energy levels.
    Heart disease. Heart disease can cause the heart to pump blood less efficiently and lead to fluid in the lungs. This can cause shortness of breath and reduce the oxygen supply to the heart and lungs, making you tired.
    Sleep problems. Sleep apnea is characterized by pauses in your breathing, often lasting several seconds, or shallow breathing while you sleep. It is common among older adults and those who are overweight. Another sleep-related issue is an overactive bladder, which forces repeated nighttime bathroom trips. Either of these can disturb your sleep enough to leave you feeling tired during the day.
    Medication. Certain medications can make you feel tired, such as blood pressure drugs, statins, antidepressants, antihistamines, nonsteroidal anti-inflammatory drugs, and cold medications. “People react to medications differently and they often end up taking more as they get older,” says Dr. Salamon. Check with your doctor, especially if you have added a new medication or recently increased your dosage. “Sometimes it helps to take certain medicines, which may cause fatigue, at night rather than in the daytime,” she says.
    Low-grade depression or anxiety. Mental health issues often drain energy levels. “You may suffer from depression or anxiety and not even know it,” says Dr. Salamon.
    Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This is a complex disorder that causes unexplained extreme fatigue, which can worsen after physical or mental activity and does not improve with rest. Its cause is unknown, but may be linked to one or more underlying issue.

Some simple ways to boost energy levels

For regular, everyday fatigue, try these tips:

    Drink a cup of coffee or tea. A little caffeine can jump-start your day, she says. “You don’t need more than that, but it can offer a mental and physical lift, especially if you have trouble with morning fatigue.”
    Go for a 30-minute walk. “If you can’t get outside, walk around your house in bouts of 10 to 15 minutes, two to three times a day,” says Dr. Salamon.
    Take a nap. A midday nap can help overcome tiredness later in the day. Keep naps to about 20 to 30 minutes, as studies have suggested that napping for 40 minutes or longer can have the opposite effect and leave you feeling groggy rather than refreshed. “Also, don’t nap too late in the day or in the early evening, when it could interfere with your normal sleep schedule,” says Dr. Salamon.
If you Google “coconut oil,” you’ll see a slew of stories touting the alleged health benefits of this solid white fat, which is easy to find in supermarkets these days. But how can something that’s chock-full of saturated fat — a known culprit in raising heart disease risk — be good for you?

Coconut does have some unique qualities that enthusiasts cite to explain its alleged health benefits. But the evidence to support those claims is very thin, says Dr. Qi Sun, assistant professor in the Department of Nutrition at the Harvard T.H. Chan School of Public Health.

“If you want to lower your risk of heart disease, coconut oil is not a good choice,” he says. It’s true that coconut oil tends to raise beneficial HDL cholesterol more than other fats do, possibly because coconut oil is rich in lauric acid, a fatty acid that the body processes slightly differently than it does other saturated fats.
Coconut oil’s effect on cholesterol

But there’s no evidence that consuming coconut oil can lower the risk of heart disease, according to an article in the April 2016 Nutrition Reviews. The study, titled “Coconut Oil Consumption and Cardiovascular Risk Factors in Humans,” reviewed findings from 21 studies, most of which examined the effects of coconut oil or coconut products on cholesterol levels. Eight were clinical trials, in which volunteers consumed different types of fats, including coconut oil, butter, and unsaturated vegetable oils (such as olive, sunflower, safflower, and corn oil) for short periods of time. Compared with the unsaturated oils, coconut oil raised total, HDL, and LDL cholesterol levels, although not as much as butter did.

These findings jibe with results from a study by Dr. Sun and colleagues in the Nov. 23, 2016, issue of The BMJ, which examined the links between different types of saturated fatty acids and heart disease. Compared with other saturated fats (like palmitic acid, which is abundant in butter), lauric acid didn’t appear to raise heart risk quite as much. But that’s likely because American diets typically don’t include very much lauric acid, so it’s harder to detect any effect, Dr. Sun notes.
Tropical diets are different

Coconut oil proponents point to studies of indigenous populations in parts of India, Sri Lanka, the Philippines, and Polynesia, whose diets include copious amounts of coconut. But their traditional diets also include more fish, fruits, and vegetables than typical American diets, so this comparison isn’t valid, says Harvard Medical School professor Dr. Bruce Bistrian, who is chief of clinical nutrition at Beth Israel Deaconess Medical Center.

Some of the coconut oil available in stores is labeled “virgin,” meaning that it’s made by pressing the liquid from coconut meat and then separating out the oil. It tastes and smells of coconut, unlike the refined, bleached, and deodorized coconut oil made from the dried coconut meat used in some processed foods and cosmetics. Virgin coconut oil contains small amounts of antioxidant compounds that may help curb inflammation, a harmful process thought to worsen heart disease. But to date, proof of any possible benefit is limited to small studies in rats and mice, says Dr. Bistrian.
Unsaturated fats

In contrast, there’s a wealth of data showing that diets rich in unsaturated fat, especially olive oil, may lower the risk of cardiovascular disease, Dr. Sun points out. The evidence comes not only from many observational studies (like those in the aforementioned BMJ report) but also a landmark clinical trial from Spain, which found that people who ate a Mediterranean-style diet enhanced with extra-virgin olive oil or nuts had a lower risk of heart attack, stroke, and death from heart disease than people who followed a low-fat diet.

Of course, there’s no need to completely avoid coconut oil if you like the flavor. Some bakers use coconut oil instead of butter in baked goods, and coconut milk is a key ingredient in Thai cooking and some Indian curry dishes. Just be sure to consider these foods occasional treats, not everyday fare. High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, researchers reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said. As a primary care physician at Massachusetts General Hospital (MGH), I am profoundly grateful for my 10 years in recovery from opiate addiction. As detailed in my memoir Free Refills, I fell into an all too common trap for physicians, succumbing to stress and ready access to medications, and became utterly and completely addicted to the painkillers Percocet and Vicodin. After an unspeakably stressful visit in my office by the State Police and the DEA, three felony charges, being fingerprinted, two years of probation, 90 days in rehab, and losing my medical license for three years, I finally clawed my way back into the land of the living. I was also able to return, humbled, to a life of caring for patients.

There is one question that I invariably get asked, by my doctors, colleagues, friends, family members, and at lectures and book talks: now that you are in recovery from opiates, what are you going to do when you are in a situation such as an accident or surgery, when you might need to take opiates again? I have blithely answered this question with platitudes about how strong my recovery is these days, and how I will thoughtfully cross that bridge when I come to it. In other words, I punted consideration of this difficult issue into some unknown future time.

Unfortunately, that future is now, and that bridge is awaiting my passage.

Last week I slipped on my top outside step, which was covered in ice, went into free fall, and managed to completely tear my left quadriceps tendon. This required a surgical repair in which doctors drilled three holes into my kneecap and then tethered what was left of my quadriceps muscle to the kneecap. Taking Tylenol or Motrin for this kind of pain is kind of like going after Godzilla with a Nerf gun. I was sent home with a prescription for one of my previous drugs of choice: oxycodone.

My leg was hurting beyond belief. I literally felt as if it were burning off. But, I had spent the last 13 years of my life conditioning myself, almost in a Clockwork Orange kind of way, to be aversive to taking any and all opiates.

What is a person who used to suffer from a substance use disorder (SUD) to do? There are millions of us in this country who may eventually face this choice.

Fortunately, I am not the first person who has confronted this issue. There exist safeguards one can put in place. It is important that all of your doctors know about your history of SUD. It is also helpful if you have a significant other or partner at home who can manage the pills for you, and dole out two of them every four to six hours as directed, to avoid the temptation to take more than prescribed in order to get high. (Old habits die hard.) Finally, the key to all addiction treatment is being open and honest. It is critical to check in with one’s support network about medications, cravings, and fears, and to use all of the recovery tools that are available to you, such as asking for help if you need to, and not trying to control things that can’t be controlled.

In the end, my level of pain was so great that there really wasn’t any choice but to take the oxy. My nerve receptors made the decision for me. I’m sure there are Shaolin monks somewhere who can block out high levels of pain, but that just isn’t me.

I am reassured, and even pleasantly surprised, by several aspects of having taken the oxycodone. First, it worked well for the pain. Second, I did not get high from the pills. I guess that taking two pills is different from taking (or snorting) 10 or 20, as we tend to do when we are addicted. Finally, it was very easy to stop taking them, and I have had absolutely no cravings or dreams about using since stopping.

This is a critical issue. It would be cruel and inhumane to not sufficiently treat any patient’s pain, especially after surgery, and it is important not to discriminate against people with SUDs. There are millions of people in recovery from opiates in the United States alone, and they are as deserving of pain control as anyone else.

Finally, I am grateful beyond belief to have survived my opiate addiction, and to not have become one of those all too common overdose stories we all read about in the newspapers. I am also grateful to my excellent doctors at MGH for fixing my wounded knee, and for providing me adequate pain control. Fortunately, my recovery and my pain control do not seem to have been mutually exclusive.

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Tips for using this versatile piece of exercise equipment

Sodium is an essential part of our diet. It helps nerves and muscles function as well as hold onto water. Sodium in the blood is what keeps it viscous, but too much sodium means your body could retain too much liquid. This surge in volume increases blood pressure, which is the root of many serious ailments including heart and kidney disease. Experts estimate that we could save 280,000 lives in the United States if we lowered the average daily sodium intake by 40% for the next 10 years. And that’s just because lowering blood pressure protects the heart.

The average American consumes 3,409 milligrams of sodium each day, according to a new report from the Centers for Disease Control and Prevention. That’s way above the amount we should be getting per day: 1,500 mg. It means we’re ingesting 1.5 teaspoons of salt each day, when we really need only a third of that. And most of that sodium comes from prepared and processed foods — 75%, actually. Salt helps to preserve and add flavor to food, which is great when you want that strawberry Pop-Tart to taste the same whether you eat it the day after you buy it or a month after. But the CDC recently published a list of the 10 most sodium-dense foods in our diets. You know what’s at the top? Yeast bread, pizza, and sandwiches. The good stuff, the convenient stuff, the stuff like Pop-Tarts.
Dialing back the sodium

Cutting back on sodium in our prepared foods has been made easier by the increase in packaged food companies’ creating reduced-sodium versions of them, like low-sodium chicken broth. While that sounds simple, sodium lurks in some unexpected places. Kathy McManus, director of the Department of Nutrition at Brigham Health/Brigham and Women’s Hospital, says there are some ways to cut back on sneaky salt.

McManus says a good way to reduce the amount of sodium you eat is to focus on natural and whole foods. Preparing your own food, while sometimes inconvenient, can cut down on a lot of the sodium you consume. For instance, a frozen dinner of Marie Callender’s Vermont White Cheddar Mac and Cheese contains more sodium in one meal than you’re supposed to have in an entire day. But it’s not that hard to prepare a decadent mac and cheese yourself with Barilla pasta, your own white cheddar cheese, and a little cream. The sodium count comes out to around 715 mg. That is much more manageable when watching your sodium intake. It’s less convenient, but it works.

Buying low-sodium products and then adding salt to them is still better than buying the regular version. Cooking techniques can also help compensate for flavor lost when cutting back on salt. McManus suggests playing around with grilling or stir-frying with healthy oils to change the flavor. You can also add fresh or dried herbs to enhance taste. Over time, your taste buds will adjust. Your palate will change. You’ll be less accustomed to salt and less desensitized to it, so a little bit will travel farther in terms of flavor.

Restaurants remain at the top of the list for sodium-dense meals. Looking at the menu online ahead of time can help you prepare and research your options, but so can keying in on words that indicate healthier options. Look for baked, grilled, or steamed as a description for lean meats like fish or poultry. Keep an eye out for sides that are prepared simply, like vegetables. Avoid soups or pastas with sauces. Put salad dressing on the side, and definitely avoid the bread basket.
Top 10 high sodium foods

Nutrition is not a one-size-fits-all kind of science, but it does get us thinking about what we eat and how it affects us. You could never cut sodium completely out of your diet, nor would you want to, but you can be more aware of the sodium in the foods you eat. To see the complete list of high-sodium foods, check out the table below. Seasonal allergies can be frustrating. When spring crawls in, many people begin to experience all-too-familiar itchy and watery eyes, runny nose, and congestion. Symptoms of seasonal allergies are the result of an immune system in overdrive in response to pollen and other allergens. Those bothersome symptoms are intended to protect you from unwanted foreign particles, but in this situation they end up causing misery. There are quite a few options when it comes to controlling allergy symptoms, but we want to watch out for a few that can be quite dangerous when used incorrectly.
Nasal steroids

The first-line treatment for seasonal allergies is an intranasal corticosteroid such as fluticasone propionate (Flonase). These sprays are available without a prescription and you can use them as-needed. Nasal steroid sprays have been shown to help with both nasal symptoms of runny nose and congestion, as well as eye symptoms. When using these sprays, it is important to direct the spray away from the nasal septum, as there have been some cases of nosebleeds from using these sprays. If this happens, stop using the medication and let your doctor know.

To date, most studies looking at the effect of intermittent use of nasal steroids on growth in children have been inconclusive. However, a large study reported a slight reduction in the rate of growth when nasal steroids were used daily over 52 weeks by children before puberty. Therefore, it’s a good idea to discuss steroid nasal sprays with your doctor if you find your child needs it on a more regular basis.
Oral antihistamines

Antihistamines such as diphenhydramine (Benadryl), loratidine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) can also be quite helpful. The key is to take the medicine before symptoms develop, such as early in the morning. Another important thing to remember is that some of these medications can cause drowsiness and should be used cautiously during the day, especially if you are driving.
Decongestants

Nasal decongestant sprays such as phenylephrine and oxymetazoline (Afrin) should be used cautiously. Although they may work well in the short term when used occasionally, if used regularly for more than a few days (approximately five days), you may find your nose more congested than usual. This is called rebound congestion or rhinitis medicamentosa. I usually recommend patients not use these products for more than three days. Using these sprays too often causes a biochemical change in certain receptors on your cells, resulting in a vicious cycle of dependence — the more you use it, the worse your symptoms, and the more you need to use it. If this happens, stop using the medication, and talk to your doctor about switching to another type of nasal spray (intranasal glucocorticoid spray) which has been shown to help with this condition.

Oral decongestants such as pseudoephedrine or phenylephrine may help reduce symptoms as well. You should also use these medications cautiously. They mainly work by constricting blood vessels, and may cause side effects such as increased blood pressure, palpitations, headaches, nervousness, and irritability. These medications should not be used by patients with a history of uncontrolled high blood pressure, heart rhythm problems, strokes, glaucoma, or other conditions.
Alternative therapies

Other therapies that have been shown to be beneficial include nasal saline irrigation. Irrigating the nasal passages with prepared solutions, such as with neti pots, has been shown to improve symptoms of runny nose, congestion, and itchy throat, and to improve quality of sleep in children with acute sinusitis and allergic rhinitis. When using these products, however, make sure you are using distilled, sterilized, purified, or previously boiled water, as there have been rare cases of fatal infections by amoeba when using tap water that was contaminated. Although the evidence for menthol rubs such as Vicks is limited, some patients find that rubbing a little menthol ointment under the nose can sometimes also offer congestion relief.\

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A point in the right direction, or a stab in the dark?

In 2015, motor vehicle accidents claimed the lives of more than 35,000 Americans. Sadly, the toll exacted by motor vehicle accidents has now been eclipsed. Data from the American Society of Addiction Medicine show that more than 52,000 of we Americans lost our lives to opioid overdose in 2015. Here in the Commonwealth, the story is even more grim; even accounting for differences in average age from community to community — younger people are still more likely to be affected than older people — the opioid overdose death rate has climbed to 23 per 100,000 residents as compared to 9 per 100,000 for the nation as a whole. The causes are numerous and a subject for another day. Similarly, approaches to solve the crisis are numerous and no one solution works for everyone who decides he or she has developed an opioid problem.
Medication Assisted Treatment (MAT)

One approach to treat people who are addicted to opioids is Medication Assisted Treatment (MAT) that combines medications to treat addiction with more traditional counseling approaches. One medication often used in MAT programs is buprenorphine-naloxone (trade name Suboxone, among others). This preparation — hereafter BN — combines buprenorphine, an opioid medication with partial activity that blunts cravings, and naloxone, an opioid overdose reversal medication that discourages abuse of the medication. When we compare groups of people addicted to opioids who are treated with and without BN, we see that those who receive the medication have a significantly higher rate of remaining free of other opioids. But how long should one continue the medication? A month? A year? A lifetime? And is it safe to continue the medication? We do not have the full answers yet, but early signals from the research indicate that not only is it safe but that longer treatment is better than shorter treatment.
Long-term treatment for a chronic condition

Many in the medical community have come to view addiction as a chronic disease. And, like many chronic diseases, it is one that can be managed but not yet cured. The thinking goes that just as those of us with high blood pressure take high blood pressure fighting medication each day for years, those of us with addiction would take addiction-fighting medication every day over years. The evidence shows that long-term proper treatment for high blood pressure lowers the risk for heart attack; evidence is now beginning to grow that long-term MAT can similarly decrease risk for relapse in those with addiction. As reported in a 2008 study in the American Journal on Addictions, patients who were successfully stabilized with a short course of BN could then be switched to long-term treatment with the medication. Forty percent of patients remained in treatment at two years and 20% at five years. When we remember that nearly half of people prescribed medication for blood pressure do not take their pills, we see that people on BN are not more likely to skip their medication than are people with better-studied chronic diseases. More importantly, though, greater than 90% of urine samples from those in the study remained free of opioids other than BN.

Long-term treatment with BN works.
How do people do without longer-term buprenorphine-naloxone treatment?

It is one thing to say that someone on a medication has a good outcome, but it is something else to prove that without the medication the person would not do well. Many advocate short-term treatment with BN. Help a person become stable and then taper off the medication. We now have evidence that this approach, however well intentioned, may be misguided. A 2014 study reported in the Journal of the American Medical Association demonstrates that over half of people who continued on BN maintenance remained free of opioids compared to just a third of those who were stabilized on BN and then tapered off. Further, far more of those treated with maintenance BN remained in the study compared to those who were tapered, suggesting that people remain committed to treatment while receiving BN.
Is long-term MAT safe?

Even if many people can be helped by extended BN treatment, it is important to consider possible side effects. Though we do not know the effects of being on BN for many decades, the 2008 American Journal on Addictions study looked for but did not find any serious adverse effects on the people treated. Earlier concerns that BN could cause liver damage also appeared to be unfounded as blood tests did not show signs of liver problems in any of the patients in the study.

More research is needed, of course, but the early evidence suggests that BN can safely help people remain off unwanted opioids over the long term just as blood pressure medication can protect people from the effects of high blood pressure. That is good news because each day off unwanted opioids is a day a person can focus on improving his or her life. Of course, buprenorphine-naloxone maintenance is not for everyone, but when it works it can work well and can give people room to breathe and rebuild their lives. Many people do focused brain exercises to help develop their thinking. Some of these exercises work, while others do not. Regardless, the focus network in the brain is not the only network that needs training. The “unfocus” network needs training too.
The “unfocus network” (or default mode network)

Called the default mode network (DMN), we used to think of the unfocus network as the Do Mostly Nothing network. And this network uses more energy than any other network in the brain, consuming 20% of the body’s energy while at rest. In fact, effort requires just 5% more energy. As you can imagine, this network is doing anything but “resting” even though it operates largely under the conscious radar. Instead, when you turn your “focus” brain off, it will retrieve memories, link ideas so that you become more creative, and also help you feel more self-connected too. Somewhat surprisingly, although the DMN is involved in representing and understanding your self, it also helps you read the minds of others. No wonder then, with all these functions on board, this network metaphorically converts your brain into a crystal ball, allowing you to predict things more accurately too. This is the kind of sharpness that you will develop if you train the DMN.

There are many ways to activate the DMN. Below are some that will give you a good start.
Surprising ways to train the default mode network

Some simple interventions could help you engage this network, depending on your goal.

Napping: If, for example, you are dog tired in the midafternoon, and just need your mind to be clear, a 10-minute nap might be all you need for sharper thinking. But if you have a major creative project ahead of you, whether it is an innovative idea at work, or redecorating your house, you will need at least 90-minutes of napping time. This gives your brain enough time to shuttle around ideas to make the associations that it needs to make.

Positive constructive daydreaming (PCD): It’s hard to imagine daydreaming as a type of training, but it is. It has to be the right type of daydreaming. According to Jerome Singer, who has studied this for decades, slipping into a daydream is not of much use; neither is guiltily rehashing everything that makes you feel bad — like the expense you incurred when you bought the shoes you liked, or the one-too-many drinks that you had at a party. But there is a type of daydreaming that will make you more creative and likely re-energize your brain. Called positive constructive daydreaming (PCD), it is best done while you are engaged in a low-key activity, not when you are fading. And as opposed to slipping into a daydream, which is more like falling off a cliff, you must parachute into the recesses of your mind with a playful and wishful image — perhaps one of you lying on a yacht or floating on your back in a pool on vacation. Then comes the swivel of attention — from looking outside, to wandering inside. With this move, you engage your unfocus brain and all the riches that it can bring.

Physical exercise and free-walking: In the brain, thinking supports movement, and movement supports thinking. In fact, exercise improves your DMN function. It normalizes it in obese people (who have too much of it) and increases connectivity in young healthy people. Even a single session can make a difference. Aerobic exercise can help prevent atrophy of key regions within the DMN, and also help the connectivity between different regions too.

Walking does boost creative thinking, but how you walk matters. One year of walking boosts the connections between the different parts of the DMN too. In 2012, psychology professor Angela K. Leung and her colleagues tested three groups of people. One group walked around in rectangles while completing a mental test; one group walked around freely; and the last group sat down while taking the test. The free-walking group outperformed the other two groups. Other studies have shown that free-walking results in improvements in fluency, flexibility, and originality of thinking. So if you want to boost your creativity, go on a meandering hike on a safe path less traveled. Furthermore, walking outdoors may be even more beneficial than puttering around the house (unless you’re using PCD, of course!) Acupuncture is a treatment that dates back to around 100 BC in China. It is based on traditional Chinese concepts such as qi (pronounced “chee” and considered life force energy) and meridians (paths through which qi flows). Multiple studies have failed to demonstrate any scientific evidence supporting such principles. Acupuncture involves the insertion of thin needles into the skin at multiple, varying locations based on the patient’s symptoms. Once inserted, some acupuncturists hand turn the needles for added therapeutic benefit. Although there are many uses for acupuncture in traditional Chinese medicine, in Western medicine it is primarily used for the treatment of pain.
Acupuncture (im)pales in comparison to Western medicine

At a time when people are increasingly concerned about drug side effects, some consider acupuncture an attractive non-medication option. Unfortunately, many studies show that the potential benefits of acupuncture are short-lived. In my experience, I put acupuncture, massage, and chiropractic interventions in the same bucket. You may feel better for a day or two, but there is limited lasting improvement.

In one study, 249 people with migraines occurring two to eight times per month received either acupuncture, sham (fake/placebo) acupuncture, or were put on an acupuncture waiting list. The two treatment groups received treatment five days per week for four weeks. Twelve weeks after treatment, the acupuncture group had on average 3.2 fewer attacks per month, the sham acupuncture group had 2.1 fewer attacks per month, and the wait-list group had 1.4 fewer attacks per month. These results are modest at best, and carry an approximate treatment cost of $2,000 per month (estimating $100/session x 20 sessions). This figure does not include lost income from time away from work to attend appointments, travel costs, pain from the procedure, and recovery time.

In general, the effectiveness of standard treatment (medication and injectable therapies) is supported by much stronger scientific evidence than acupuncture, including large clinical trials with thousands of subjects. For those averse to medications, physical therapy is a great alternative — one based on actual human anatomy and scientific principles. My patients often complain that they do not feel significantly better after the five to 10 sessions of physical therapy that insurance companies typically approve. I advise them that the true benefit of physical therapy comes when the stretching and strengthening routines taught by the therapist are continued at home on a long-term basis. Expecting an instant and permanent cure from physical therapy is like going to the gym for a week, and expecting to lose 20 pounds — without any chance of regaining the weight. (If any readers find a gym like that, please let me know….)
Stuck with needles, then stuck with a bill

At a cost of around $100 per treatment, and with sessions that can last over an hour, acupuncture treatments can be limited by both time and cost. Some patients may confidently argue that they do not mind the cost, because their insurance plan covers acupuncture. I would caution those same patients that money does not grow on trees, especially in the health insurance forest. If money is spent on one expense, it cannot be spent on something else. A plan that covers acupuncture may include fine print about excessive co-pays or limited coverage for basic medications. In some cases, covering acupuncture or massage may affect other patients in the same pool. Imagine if everybody received free massages, but in turn a cancer patient’s lifesaving chemotherapy becomes unaffordable. Although this is an exaggerated example, it does demonstrate the economics of health insurance.
Skewer side effects?

Side effects are not just limited to medications; procedures can also have negative effects. Acupuncture is relatively safe when the practitioner uses single-use, sterile needles with a clean technique. Side effects can include skin infections, bleeding, and pneumothorax (collapsed lung) if the needles are inserted too deep in the chest. Physicians sometimes perform acupuncture, but medical training is not required, and the qualifications to secure a license to practice acupuncture vary by state. It is probably worth the added expense to have a more experienced and/or highly credentialed acupuncturist.
Needle-less to say, the procedure went well

I fondly recall meeting an elderly lady who had a good experience with acupuncture for the treatment of her migraines, but the benefit only lasted one to two days after each session. After failing multiple treatments, she tried Botox injections with physicians not named Dr. Mathew, which she found effective. Due to scheduling issues, she ended up seeing me for injections. After I explained the risks and benefits of the procedure, she asked, “Dr. Mathew, are you experienced?” I replied, “Well, I trained the other two doctors who performed your previous injections.” She replied, “Well, I guess that makes you experienced. Are you gentle?” I paused and then replied in a stern tone, “Well, I am known as the Butcher of New England.” The woman was mortified, and she actually turned a little pale. I then advised her that I was just kidding, and that I am one of the gentler injectors in the practice. We then proceeded with her treatment. After we were done, she said, “That was the gentlest set of injections I ever received, and my pain is actually better.” I then said, “Please don’t say that… you will ruin my horrible reputation as the Butcher of New England.”

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