Why Am I Reading This?

THE VIEW FROM THE OFFICE

WHY AM I READING THIS?

            Before we answer that question, I want to you to read and remember these 4 words.

APPLE            MR. JOHNSON        CHARITY                  TUNNEL

            Moving on. Now your second task, before I let you go is to:  DRAW A CLOCK THAT SAYS 11:15 am.

            The question I would like to discuss in this essay is:  When is poor and declining memory significant?  As we each experience it, do we also need to worry about Alzheimer’s disease? Fortunately, the answer is mostly NOT. But let me explain.

            We’ll start with consideration of a case that was recently described in the New England Journal of Medicine (1):  A 77-year-old woman has been noticing increasing forgetfulness over the past 6 to 12 months. Although she has always had some difficulty recalling the names of acquaintances, she is now finding it difficult to keep tract of appointments and recent telephone calls. The process has been insidious. She lives independently in the community and drives a car. She pays her own bills and maintains good hygiene and an attractive appearance.

            This case is an example of what is called “mild cognitive impairment.” To put this into perspective it is worth noting that only 1% of all elderly patients will be fortunate enough to experience NO cognitive decline. For the rest of us, we have to expect some. In fact, 10-20% of us who are over the age of 65 will experience this same condition—mild cognitive impairment.  The good news is that, of this 10-20%, only 10% will go on to develop Alzheimer’s disease.  As we get even older, among persons aged 70-89, 11%  will experience mild cognitive impairment; 4.9% will develop Alzheimer’s disease.

            A more recent New England Journal of Medicine published another case, one that I feel can lift some our anxieties if we are among the unfortunate few who develop Alzheimer’s disease.(2) Here is Michael Donohue’s story.

            "At the age of 69, a year after retiring from his practice as a Minneapolis trial lawyer, Mike Donohue noticed his driving skills deteriorating. His wife persuaded him to undergo a simulated driving examination. 'I flunked it miserably,' he recalls. Donohue consulted his physician, underwent tests, and learned that he had early Alzheimer's disease. His doctor told him, 'Take this medication, call me in a year, and call the Alzheimer's Association.'"

    Try to imagine for a moment your reaction to both this information and this manner of care.

    Fortunately, this patient did not resign himself to such implied pessimism. He called the Alzheimer's Association's local office. He volunteered there, where he met other people with early-stage disease, helped to launch some programs for them, and now, 5 years later, serves on an advisory committee about services for people with newly diagnosed Alzheimer's disease and their family. Recently, he and several friends with the condition entered a new program where they’ll serve as mentors for others with a new Alzheimer's diagnosis.

    'There's a great loneliness out there, Donohue says. 'It comes from the stereotype that we’re all drooling in a corner,' even though most people living with the diseases are in community settings rather than nursing homes. 'My cognition remains good, and until recently my memory remained reasonably good. These friendships are so important to me.' 

One of  the pieces of major good news amid the spreading epidemic of Alzheimer’s disease is that we are having larger numbers of people survive and function well with a meaningful social life. The modern Alzheimer’s disease is not the end of the road. This is a more important fact than that research so far has failed to identify any medications that truly make a big difference for persons with Alzheimer’s.

Let’s return to our original point. There is mild cognitive impairment and there is Alzheimer’s disease. Where in this spectrum , for the 99% of us not destined to have no cognitive impairment at all, do we fit in with our ordinary failings of memory. What do you forget?  Here are some typical examples.

•         Difficulty with word finding (we all do this)

•         Difficulty with recalling names (most of us do this at least some of the time)

•         Forgetting why you went into a room (we all do this)

•         Forgetting where you put something (we all do this)

•         Forgetting appointments (this is a little bit more severe forgetfulness)

•         Forgetting telephone calls (this is a little bit more severe forgetfulness)

•         Forgetting recent events that you participated in (this is quite severe forgetfulness)

So assume you or I are doing at least the first four items a lot. What does it mean? Are they going to take us away in the morning? Fortunately not. The lesson here is that this is the new normal. When 99% of the population repeatedly encounter this kind of experience, on a statistical basis, it is clearly normal behavior.

So, when should I worry?

There are some simple cues.

First of all, if you’re aware enough to be concerned about how memory may be interfering with your overall function, you probably don’t have Alzheimer’s. It is characteristic of the global cognitive defects in Alzheimer’s that the patient is not explicitly aware of the number and nature of the defects and the degree of impairment. Patient’s with Alzheimer’s don’t go on their own to the doctor to ask about their memory. Friends or family members bring them and the friends or family members ask the questions about memory and provide the behavioral details. On the other hand, patients with mild cognitive impairment frequently go to the doctor to express their concern about their slow decline from their peak mental performance. The question they ask the doctor is, “Is this anything to worry about, Doc?”  If the patient is asking this question, then the doctor can generally be very comfortable in say, “Nope. This is just part of the new you (and me, I might add).”

Remember the little tasks I asked you to do right at the beginning of this essay. This would be a good time to take a look at the clock you drew. If you drew a clock with a full closed circle, 2 hands, one longer than the other, centered in the middle of the clock, 12 digits, each at least in the appropriate quadrant, and had the hands at the right time, you’re good. You don’t have Alzheimer’s disease.                                                         

 

Figures 1 and 2: This clock passes the test. All the other clocks below do not.

Why can we say this? It is because Alzheimer’s disease affects more than simple memory. One of its prominent effects is impairment or destruction of our sense of space, which is what, is tested with the clock test. The inability to pass this test is one of the earliest signs of Alzheimer’s disease. It’s one you can use yourself for someone about whom you may be concerned. (Just ask them to draw a clock that shows 11:15 a.m.) Generally, as long as all the little cognitive defects are only in the area of memory, and not in the realm of visuospatial sense, motor skills, or coordination, that the worst we are talking about is mild cognitive impairment, which all your friends have too. So don’t feel so bad.

Another way to recognize whether it is more than just mild cognitive impairment is to think about how you function in your life. Can you adequately do all your routine daily tasks? People with mild cognitive impairment can, no matter how irritated they may be at forgetting some of the details. People with Alzheimer’s can’t. They just can’t.
Here are some of the tasks that patients with Alzheimer’s often cannot do:

1.      Write checks, pay bills, keep financial records

2.      Put together tax records, business records, or personal papers

3.      Shop alone for clothes, household necessities, or groceries

4.      Play a game of skill or work on a hobby

5.      Heat water, make a cup of coffee, or remember to turn off the stove

6.      Keep track of current events

7.      Pay attention to a TV program, book, or magazine and report the story

8.      Remember appointments, special family events, holidays, or medications

9.      Drive out of the neighborhood safely in a car, or plan how to use a bus system.

So, if you’re currently doing all these functions OK, you have nothing to worry about at this time. You still, however, will forget things.

OK. So now you’re at the point of accepting that you have some memory lapses and probably have mild cognitive impairment. What do you do about it? First, don’t worry so much about it. Second, become proactive. There’s a lot you can do.

The first proactive step is to get active. Exercise prevents cognitive impairment and a host of other problems too. "Recent epidemiologic, cohort, and clinical-trial data support a role for physical activity in maintaining cognitive health. This was studied in more than 2800 female health professionals over the age of 65 with at least 3 vascular risk factors (e.g., diabetes mellitus, hypertension, hyperlipidemia, body-mass index > 30, family history of premature myocardial infarction). Participants reported mean one-year physical activity levels a mean of 3.5 years before an initial global cognitive evaluation. Women in the two highest quintiles of physical activity level--equivalent to brisk walking > 30 minutes daily--had significantly slower rates of cognitive decline than those in the lowest quintile. When the data were compared to an analysis of age-associated cognitive decline, participants in the 2 highest quintiles of physical activity were cognitively 5 to 7 years 'younger' than those in the lowest quintile.  A secondary analysis specific to walking showed a possible threshold effect, with at least 30 minutes of brisk daily walking required for significant cognitive benefit." (3)

      My recommendation, following the US national exercise recommendation, is to engage in at least 150 minutes of exercise, at least brisk walking, each week—broken up in any way you want to do it.

Second, do mental exercises regularly. In a recent comprehensive review of all studies of various kinds of mental exercises “The data showed statistically significant improvements at the end of training on 44% of objective measures of memory and statistically significant improvements after treatment were obtained on 49% of subjective measures of memory, quality of life, or mood.” (4)

And, of course, I am going to recommend eating healthy—5 servings of fruits and vegetables a day, lots of grains, small (4 oz) portions of red meat, and a regular multiple vitamin with calcium and vitamin D.  All this is with a view to keep your BMI (body mass index) below 30.
            Of course, you’re not going to smoke because smoking leads to narrowed blood vessels, and, if you care about your memory, you want your precious little brain cells to get every ounce of circulation they can.
            Finally, carry out a plan for some time spent relaxing every day. Relaxing can be going for a quiet walk, time with a pet, reading, dancing, reading the Bible, watching a good movie  (no sex, no violence, no commercials), of doing something creative—gardening, painting, writing, interior design, refurbishing an old car, whatever gets you in your groove. Memory cells like it when you relax and turn off all the other chatter and clutter of your daily life.
Actually, this advice is rather simple. You’ve heard it before. It’s no more than the Formula for Health. Give it a try!

By the way, if you can still remember     APPLE           MR. JOHNSON        CHARITY

TUNNEL, you’re doing pretty good.

Colin Kopes-Kerr, MD
December 1, 2011

References:
1. Petersen RC. Mild Cognitive Impairment. New England Journal of Medicine 2011; 364: 2227-34.
2. Okie S. Confronting Alzheimer’s Disease. New England Journal of Medicine 2011; 365: 12: 1069-72.

3. Middleton LE et al. Activity energy expenditure and incident cognitive impairment in older adults. Archives of Internal Medicine 2011; 171(14): 1251-7.

4. Jean L et al. Cognitive intervention programs for individuals with mild cognitive impairment: Systematic review of the literature. American Journal of Geriatric Psychiatry 2010; 1

SOME DRUG INFORMATION

The View From the Office

SOME NEW DRUG INFORMATION

Cholesterol Medications: The cholesterol medication with the greatest name recognition, Lipitor, goes generic at the end of this month; it will then be the preferred generic statin medication. Many people should consider changing their cholesterol medication in order to take advance of this more potent, and now finally, less expensive drug for cholesterol.

Drugs for Osteoporosis:  (Fosamax, etc.): The new consensus is that patients should not just remain on these medications forever, once they start. Most experts are calling for stopping the medication after 5 years, unless there is a recent osteoporotic fracture. Some experts recommend stopping after 3 to 5 years and then rechecking a bone density test in 2 to 3 years to see if there is relapse. The problem with taking these medications too long are that you can get a condition called "osteonecrosis of the jaw" (no fun) and/or atypical femoral fractures. All of these drugs are different forms of a chemical called BISPHOSPHONATES, and these stay in the bone for years even after stopping the medication. 

     Prescriber's Letter recommends that everyone take 1200 mg of elemental calcium daily and 800 to 2000 IU of vitamin D3.

SAW PALMETTO is Losing Its Fans: Prescriber's Letter predicts that saw palmetto will fall out of favor for treating symptoms of enlarged prostate (BPH). Two new NIH-sponsored trials now suggest that saw palmetto is NOT better than placebo for BPH symptoms...even at high doses. "In fact, our Natural Medicines Comprehensive Database is downgrading its rating of saw palmetto to "Possibly Ineffective."

     This expert group recommends telling men not to rely on saw palmetto for BPH. Explain that benefits are modest at best. There is no need to be overly concerned, however, if men want to try it, there's no evidence of serious adverse effects.

PROBLEMS with MAGNESIUM and PPI medications (e.g., Prilosec, Nexium, Protonix, Prevacid, Aciphex, etc.): Medications like Prilosec (omeprazole) may lower magnesium levels. These experts recommend checking a blood test for magnesium in patients who have been on PPIs for a long time. Other drugs that can lower magnesium are diuretics for hypertension or heart failure, and some of the cancer drugs like cisplatin. Also, if you are having a problem with either calcium or potassium, consider doing blood tests for all 3 -- calcium, potassium, and magnesium. It will be difficult to correct low calcium or potassium if the magnesium remains low.

     If your magnesium is low and you need a supplement, consider the one that is best absorbed--magnesium lactate (Mag-Tab SR), magnesium chloride (Slow-Mag), or magnesium aspartate (Maginex).  Magnesium oxide is easier to get (Mag-Ox) and has more elemental magnesium than the others, but it is not well absorbed. Better absorption means less diarrhea. You can use IV magnesium sulfate for severe deficiencies. Ultimately, if the magnesium does improve in a patient on a PPI, stop the PPI, and substitute an anti-histamine acid drug like Pepcid.

     Prescriber's Letter  recommends avoiding magnesium supplements in patients with renal insufficiency, which is pretty common in our neck of the woods.

A Guideline to Reduce Your Risk of Ulcer from ANTI-INFLAMMATORY DRUGS:

                 LOW GI RISK      MODERATE GI RISK                HIGH GI RISK

LOW         ibuprofen or     1.Celebrex alone                      1.avoid NSAIDs

CARDIAC   Alleve              2.ibuprofen, etc, + PPI             2.Celebrex + PPI

RISK                                    or Cytotec

                                       3. NSAID + double-dose 

                                           Pepcid or Zantac (etc.)

HIGH          Naproxen        1. Naproxen + PPI or Cytotec     Avoid all NSAIDS

CARDIAC                          2. Naproxen + double-dose 

RISK                                     Pepcid or Zantac, etc.

Note: NSAIDs include all anti-inflammatory drugs except aspirin--e.g., ibuprofen, Advil, Nuprin, Alleve, naproxen, Mobic, Relafen, Clinoril/sulindac, etc.

THYROID MEDICATION: You May Not Need As Much: The fact is that younger people, if their thyroid gland is not producing enough hormone,  need more hormone replacement (levothyroxine) than older people. Younger adults need about 1.7 mcg/kg/day of levolthyroxine but some seniors need only 0.5 mcg/kg/day. I have been seeing several older patients recently who have been on the same dose of levothyroxine for over 10 years, but all of a sudden on a routine thyroid test (TSH), their TSH is too low, indicating they are getting too much thyroid hormone. The explanation of this is just normal aging. After a certain time, we need to reduce the dose a bit. That is why it is so important to check your thyroid blood test (TSH) at least once a year, if you're taking thyroid medicine. Then check it again 6-8 weeks after any dose change, suggest the editors of Prescriber's Letter.

FISH OIL TO LOWER YOUR TRIGLYCERIDES: The rule of thumb is that 1 gram a day of omega-3 fatty acids from fish oil will lower triglycerides by 5 to 10%.  You can go up to 4 grams a day, if you're not having side effects. 

THE NEW DRUG FOR ATRIAL FIBRILLATION: Pradaxa (dabigatran) Can Replace Warfarin: Pradaxa is generally very good news. It is more effective at preventing strokes than warfarin (Coumadin) and it does not require any blood testing. It costs about $240 a month (for twice daily dosing) compared to about $80 (with blood testing) for warfarin. There are, however, a few caveats:

1. If you are already on warfarin and want to switch to this, you should stop your warfarin, wait until your INR is less than 2.0, then start the Pradaxa.
2. If you are doing well on warfarin, don't change. Changing will create an increased risk of bleeding, particularly gastrointestinal bleeding.
3. Missed doses of Pradaxa: Pradaxa lasts in the system for about 15 hours. Thus if you miss a dose, you should take the missed dose as soon as you remember it, but NOT  if your next dose is due in less than 6 hours. That would increase the risk of bleeding.
4. If you do experience bleeding on Pradaxa, the old remedy of vitamin K which we use for excess bleeding due to warfarin, will not work. You will need a blood transfusion.
5. Pradaxa is only good for 30 days after the bottle is opened. 
6. The most common side effects of Pradaxa is upset stomach. Taking it with food, or with an OTC medication like Prilosec or Pepcid or Zantac may help.

Reference: Prescriber's Letter, Vol 18 No 1 January, No 6 June, No 7 July, and No 11, November 2011 

PROSTATE CANCER SCREENING IS OUT!

THE VIEW FROM THE OFFICE

The United States Preventive Services Task Force (USPSTF)
Will Advise Against Routine Prostate Cancer Screening

     The U.S. Preventive Services Task Force has concluded that healthy men should not undergo routine prostate-specific antigen (PSA) testing, the
     The recommendation, which will be made available for public comment next week, was based on an analysis of five trials and applies to men of all ages. The Times quotes the task force's chairwoman: "Unfortunately, the evidence now shows that this test does not save men's lives ... This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime."


In 2008, the USPSTF recommended against PSA testing in men aged 75 or older, and said evidence was insufficient to recommend for or against testing in younger men.

     Read the full story in the New York Times here. 

http://www.nytimes.com/2011/10/07/health/07prostate.html?_r=1&scp=3&sq=prostate%20cancer&st=cse

      As Jerome Groupman says in his new book ("Your Medical Mind"), to make a reasonable decision on screening, you have to look at the numbers. "Prostate cancer is slow-moving; more people die with it than from it. According to one 2004 study, for every 48 prostate surgeries performed, only 1 patient benefits--the other 47 patients would have lived just as long without surgery...Moreover, the 47 who didn't need the surgery are often left with an array of unpleasant and irreversible side effects, including incontinence, impotence and loss of sexual desire. The likelihood of one of these side effects is over 50%--24 of our 47 will have at least one. This means a patient is 24 times more likely to experience the side effect than the cure...Returning to prostate surgery, consider that 6 weeks is the advised recovery period. Coincidentally, the operation will, on average, add 6 weeks to your life. (This averages across the 47 people who had no benefit from the operation and the one person who did.) To my way of thinking, the decision then becomes this: When do you want to 'spend' those 6 weeks? When you're relatively young and feeling well, or at the end of your life, when you're old and only dimly aware of your surroundings?"*

* Quotation taken from the Daniel Levitin, "Heal Thyself," New York Times Book Review, Sunday, October 9, 2011, pp28-29.

COMMENT: As I have previously reported, I do not recommend this test and do not get it for myself. The test cannot tell which men will have a problem with their prostate cancer and which will not. This is the only information we really want to know. There are new tests under development, maybe one of them will provide a better option. I have already had patients asking me about the new urine test for prostate cancer, which is still in the research phase and is not yet commercially available. Another link to information on this test can be found here.

WHEN TO GET A PNEUMONIA VACCINE

THE VIEW FROM THE OFFICE

(FIRST SNOW: OCTOBER 6TH, 2011)

WHO SHOULD GET A PNEUMONIA SHOT (PNEUMOCOCCAL VACCINE) AND WHEN? This is just a brief note to clarify this question. There are separate recommendations for children and adults.

     For children, the recommendations are to do primary immunizations at 2 months, 4 months, 6 months, and a booster immunization any time between 12 and 18 months. This immunization in children is clearly and highly effective. It has dramatically reduced the rates of meningitis, pneumonia, infected arthritis, and high fever in children without an obvious source. This vaccine and the H Flu vaccine are the primary reasons why we almost never see meningitis any more. This is the standard recommendation for healthy children.

     For older children the guideline calls for performing a primary vaccine series in any individual who has any kind of immune deficiency or chronic cardiorespiratory condition (like cystic fibrosis or congenital heart disease); for adults under the age of 65 a single dose of the vaccine is recommended for persons with a chronic cardiorespiratory or immune condition with a single booster shot 5 years after the first. 

     One example of a chronic immune condition is someone who has been in a bad accident and ruptured his/her spleen with the result that it has to be surgically removed. The spleen is a major organ of the immune system which protects against severe bacterial infections. So that anyone who has had their spleen removed for any reason should get a primary series of pneumococcal immunizations; they should also receive immunizations against the H Flu germ and the meningococcal germ. Also any individual who has a chronic cardiac or respiratory condition should receive the pneumococcal vaccine because the occurrence of pneumonia with a weakened lungs or heart could be fatal.

     For young and older adults under the age of 65 pneumococcal vaccine, in a single dose, is recommended for patients with cardiorespiratory conditions. These include: asthma, smoking, emphysema, and any form of heart disease.

     For ADULTS, the recommendation is simpler. All healthy adults should receive a pneumococcal vaccine at age 65. If you receive it at age 65 and are otherwise healthy, you only need to receive this single vaccine. You do not need a booster. For some reason that I cannot readily explain, a majority of older people in the Portola-Graeagle area believe they need routine pneumonia boosters every 5 years. This is NOT the case.

     There are two groups of adults who need pneumococcal boosters after age 65:

     (1) Any healthy adult who received their initial pneumonia shot before the age of 65 is recommended to get just one booster 5 years after the first.

     (2) Any adult who has a chronic immune system problem (examples include patients on long term systemic cortisone medications, on dialysis from chronic kidney failure, or who have received any organ transplantation, or who have cancer receiving chemotherapy, or who have HIV infection, or who have had their spleen removed) need to get a single booster 5 years after the first. The experts do not recommend repeated pneumococcal boosters for anyone.

SUMMARY:  Pneumococcal vaccine is recommended for:

     1. Healthy children at 2, 4, 6, and 12-18 months.

     2. Any older children with chronic immune or cardiorespiratory problems.

     3. For all adults under 65 who have a chronic  immune or cardiorespiratory problem.

     4. For all healthy adults at age 65.

     5. A single booster shot is recommended 5 years after the first immunization for:

         a. Healthy adults who received their pneumonia shot before the age of 65.

         b. For all adults who have a chronic cardiorespiratory or immune condition.

   

Chronic Medication is Not the Answer for Chronic Pain

A VIEW FROM THE OFFICE

Doctors Call For Pullback 

On Narcotics For Chronic Pain

Courtesy of NPR: http://www.npr.org/blogs/health/2011/09/16/140540259/doctors-call-for-pullback-on-narcotics-for-chronic-pain?ft=1&f=1001

by Scott Hensley

05:26 pm

September 16, 2011

Sue Ogrocki/AP
     Painkillers like these being counted at the Oklahoma Hospital Discount Pharmacy in Edmond, Okla., need to be used far less often, some prominent doctors say.

Sue Ogrocki/AP

         In a bracing call to action, three doctors from California are telling their peers to think twice before prescribing potent narcotics for patients with chronic pain.

Drugs such as Vicodin, Percocet and Oxycontin have become among the most prescribed in the country. Between 15 and 20 percent of patient visits with physicians the U.S. include a prescription for an opioid, the modern painkilling medicines whose roots can be traced back to the opium poppy.
But their editorial, published this week in the Archives of Internal Medicine, says there's a troubling shortfall in the evidence to support the use of such drugs for long-term treatment of pain. And, there's ample evidence of harm.
"Unfortuantely, the use of prescription opioids currently results in more deaths in the United States due to intoxication than heroin and cocaine combined," says Dr. Mitchell H. Katz, a co-author of editorial, in a podcast. "That's shocking."
  Doctors' prescriptions for the medicines that are supposed to decrease pain and improve patients' ability to function, he says, are "killing more people than two drugs that we think of as lethal, so much so that they're illegal." The death toll from the legal pain pills is about 12,000 a year, he says. "It's a public health problem."
So what's their prescription? Until there's more scientific evidence, doctors "should not continue to prescribe high-dose opioids" for chronic non-cancer pain. Narcotic drugs for short-term relief of pain are fine, but Katz says there's insufficient evidence to support their use over the long haul.
Instead, doctors should talk with patients about the limits of pain relief and give alternatives to opioid drugs, such as physical therapy or yoga, their due. To some patients, doctors may need to give a sobering message, Katz says in the podcast: "This is not something I'm going to be able to completely take away."
The bottom line of the editorial, part of a series in the journal called "Less Is More," is that a rethink on these narcotics is overdue.
What do the pain specialists think? I asked for a comment on the editorial, and got a statement from Dr. Robert Chou, who heads the group at the American Pain Society working on guidelines for clinical practice.

While it's important for clinicians to be more thoughtful about who they prescribe long-term opioids to and to stop opioids when they aren't helping or there is evidence that it is causing problems, the American Pain Society believes opioids have a role in the management of chronic non-cancer pain in carefully selected and monitored patients.
There is evidence from long-term observational studies and evidence coming from some long-term clinical trials that opioids are effective for improving pain in some patients.
For example, we do not believe that a trial of low doses of opioids should be denied to a low-risk woman in her 70's who has severe hip arthritis, who may be able to garden and walk with decreased pain on it.

While the data on overdose deaths and abuse of opioids should concern all members of society, it does not justify an extreme blanket position of no opioids for chronic non-cancer pain.

My observations:

No one has any objection to treating the acute pain of a sprained ankle, broken bone, or sprained back. These are generally 1 to 2 week situations. Of course, we all know plenty of people who have injured their back and are still taking pain medications 3, 6, 9 months later, perhaps even years later. 
     If you are an astute observer, what you will notice about these people after 6 months, 9 months, or a year, is that they are NOT getting any better. If one looks at it from a strictly objective point  on view, the common theme to patients who take chronic pain medicines is that they do not get better. To this some will say, "That's no surprise. They have a condition which is just not going to get better." But what the experts have come to learn is that the mere fact of taking chronic, usually high-dose narcotics, actually and directly keeps you from getting better.
      A lot of this, of course, depends upon how you define "better." The patient in chronic pain may simply prefer to be narcotized and out of it so as not to have to deal with life and his or her chronic pain. But pain, whether acute or chronic, is just a small part of life, and life can indeed go on.
     The real test of the value of a pain medication in chronic use is whether it is helping the patient to achieve any of their well-planned goals and objectives for their life. For example, taking pain medication right before a painful physical therapy session so that you can get through the session and accomplish to work needed to heal is an excellent use of pain medication, no matter how long it goes on. On the other hand, pain medication that keeps you so foggy and energyless that you won't go out to social events, meet with friends, try something new means you're letting the pain medication kill you.
      Thus the usual rule in the context of chronic pain is that most pain medications tend to hold you back from getting on with your life. They all do some terrible things to your system. 
      Everyone who takes chronic pain killers is going to experience severe constipation, and I mean constipation so severe that stool will be backed up all the way past your rectum, sigmoid colon, transverse colon, right colon, all the way to your appendix. This is a very uncomfortable, frankly miserable way to live. You'll be getting cramps every time you want to eat in the advanced condition and then start losing weight.
      Chronic opiates all have an adverse effect on the cardiac electrical conducting system. Methadone is clearly the worst, but they all do it to some extent. They can lead to a condition called long QT syndrome, which can be fatal without warning. Many experts recommend a routine annual ECG for all patients on chronic pain medications just to try to detect this condition early.
      The other bad news, particularly for men, is that chronic use of opioid pain medications leads to lower levels of sex hormones. Testicles can start to atrophy; libido goes down; actual serum testosterone levels can go quite low--to low to support adequate sexual function. (This also happens to some extent in women, but the exact effects are not as clear.)
     So there are lots of reasons not to be very keen to keep using pain medications long after the time of initial injury.
     On the other hand there are a whole host of things that have significant pay-offs. Consider some of these:
meditation
yoga
vegetarian diet
water aerobics
Sudoku
prayer
crossword puzzles
volunteer activity
reading to the blind
being a big brother/big sister
adopting a child online
rescuing a pet
try alternative medicine
try acupuncture
try physical therapy or chiropractic
consider non-habit forming pain adjuvants like antidepressants (amitryptyline, nortriptyline), gabapentin, etc.
pursue a new hobby (like photography, drawing, woodworking, jewelry, etc.)
become an expert on some subject of interest to you.


All of these tend to work towards the development of a better mind. All chronic pain medications work in the opposite direction of numbing your mind and stifling thought and creativity. To go and fulfill your special gift to the world you are going to need an alert open mind, a flexible outlook, and a willingness to try things, anything. If you consciously work on expanding your own possibilities you can build yourself a great palace in the sky and relegate the pain to the hall closet. You just have to think bigger.

The Cough That Won't Quit

The View from the Office

The Cough That Won't Quit:

Pertussis in Portola

     In the middle of this past Winter I wrote an article about the cold that wouldn't quit--that keeps hanging on with a deep cough for 6 to 8 weeks. There I reported that most of that was due to bronchospasm triggered by the infection, which was best treated with an albuterol inhaler or comparable medication.

     There was one other cause of cough that won't quit which I didn't mention then because it is much more rare. But now that we have seen several cases of pertussis (whooping cough) in Portola, it is worth discussing this and explaining how it differs from common post-viral bronchospasm.

                                        The Pertussis Quandary

     In Plumas County we're now seeing several confirmed pertussis cases. Pertussis (whooping cough) has always been a confusing, poorly understood, commonly misdiagnosed, and always seriously underestimated clinical infection. It is not entirely clear that we know a whole lot more now (in 2011) about this organism than I did when I started my career. Nonetheless, here is a recent update.(1)

    

     The first pertussis vaccine was developed in the 1930s and became routine in the 1940s. A majority of us have probably had the vaccine. A few of us can remember having the classic whooping cough when we were young. One problem is that childhood vaccination  confers only limited immunity that wanes after 5 to 10 years and rarely lasts more than 12 years. Another problem is that having the pertussis infection does not leave you with good antibodies against pertussis. Thus one never knows how protected the population is, but whatever it is, it's waning fast.  Another problem is that the immunization prior to the 1990s had a lot of significant side effects; in particular, there was concern (overblown as it turns out) that pertussis vaccine could cause brain damage. This led many parents to elect to forego vaccination for their children. We are now seeing the results of this reduced immune protection in the general population.

    Classic pertussis presents in 3 stages: a 2 week catarrhal (mucousy) stage with nonspecific symptoms like an ordinary cold in which it is nearly impossible to make the diagnosis; the astute clinician might notice unexplained excessive lacrimation (tearing) and/or conjunctival redness. 

     The paroxysmal stage begins in the 2nd weeks and lasts for 2 to 3 months. The onset of paroxysmal cough is the hallmark. A paroxysmal cough is defined as a series of coughs occurring during a single expiration; these tend to occur in groups throughout the day and night with few or no symptoms in between. "A cough paroxysm causes low lung volumes, leading to a vigorous inspiration that may result in a whoop, particularly in infants and children, in whom the caliber of the trachea is smaller." Listen to these classic whoops. [Click on link.] 

     The final phase is the convalescent phase in which the cough slowly disappears over 2-3 months. 

     So the total illness can run for 6-7 months.

     Unfortunately for modern clinicians whose patients have been previously immunized (or  infected), the characteristics of the cough illness are atypical and may manifest just as chronic cough. Several recent epidemiological studies have shown that pertussis is present as the cause in 12-32% of prolonged cough illness in adolescents and adults.

    Once you suspect pertussis, which test do you use? Alas, there is no good choice. The CDC endorses only the culture and PCR (a specialized DNA assay) methods for diagnosis in community practice. Culture, however, lacks sensitivity (will miss a lot of cases), and PCR lacks specificity (it will be positive in a significant number of people who do not have pertussis infection). Swabs for testing need to be obtained on Dacron swabs since cotton is toxic to B Pertussis and calcium alginate swabs interfere with PCR assay. "Importantly, the  sensitivities of PCR, serologic testing, and, particularly, culture decrease with the duration of illness." Direct fluorescent antibody testing (DFA) is inexpensive and rapid but is no longer recommended because of its poor sensitivity and specificity. Serologic testing (with serial titers showing 4-fold change) is useful for epidemiological research, "but is neither widely available nor standardized and no FDA-approved test exists." Thus, in practice, there are many more people who have pertussis as a cause of their chronic cough than we are able to identify on testing.

The CDC Case Definition: The CDC clinical case definition for endemic or sporadic cases of pertussis is a cough illness lasting 2 weeks or longer without other apparent cause with 1 or more of the following:

• paroxysms of coughing (sometimes leading to a faint, called tussive syncope)
• inspiratory whoop (more likely in children) [Click on link to hear what it sounds like.]
• post-cough vomiting

Alas, again--"Importantly, our data do not apply to an outbreak setting [like now in California] in which the pretest probability of pertussis for a patient with a cough illness may be substantially higher and the thresholds to test and empirically treat for pertussis may be lower...[A]n important finding in this study is that the absence of classic symptoms of pertussis may not have sufficiently low probability to exclude the diagnosis of pertussis, and the presence of classic symptoms is common in patients who do not have evidence of pertussis infection."

COMMENT: So what is a reasonable clinician to do?

    In the epidemic context, just treat everyone with cough > 3 weeks to prevent secondary spread.

    In the sporadic case context, test with PCR (if available) or culture after 3 weeks, and treat empirically after 8 weeks.

    I was interested to note that, just before our current epidemic in California had started, I had seen an abrupt increase in patients seeking evaluation for cough > 8 weeks duration (i.e., 4 patients in a 2 month period). None of them were ultimately diagnosed with pertussis, most likely due to the quality of the available tests; but in retrospect I sure do believe that they had pertussis. Of course, it doesn't help them or anyone very much to diagnose it in retrospect.

                            The Bottom Line for Patients

1. If you have persistent cough for more than 3 weeks, consider being treated for pertussis. If you have cough for 8 weeks, definitely get treated for pertussis. This won't cure you, but it will protect everyone you come into contact with.

2. The treatment is with azithromycin (250 mg tablets); 2 tablets for the first dose, then 1 a day for 4 days. Persons who live with a patient with this infection should also be treated.

3. Understand that treatment prevents the spread of pertussis from one person to another, and is therefore highly advisable from a community health perspective. Treatment does NOT alter the course or symptoms of pertussis infection. Thus patients may have symptoms for up to 2 to 3 months even after treatment. Try not to blame your doctor.

4. The current recommendation is that all adults receive at least one pertussis vaccine booster (called a TDaP). You should receive the vaccine even if you have actually had pertussis infection because the infection does not lead to good antibody levels. 

     Best yet, ask your doctor for this immunization way before you ever get sick.

Reference: 

Cornia PB et al. Does this coughing adolescent or adult patient have pertussis? JAMA 2010; 304(8): 890-6.