Is Melatonin A Benign Supplement?

Before I get too carried away the answer to the question is most likely yes - it is a benign supplement.  That is based on all of the studies and reviews I have about melatonin used to treat insomnia and other sleep disorders.  Nobody seems to report any major side effect from even very high doses taken for periods of time.  Those same reviews have a lot of qualifiers.  As an example some will say that doses in the 4-6 mg per night range are unlikely to cause major side effects.  Others will suggest that even though melatonin use is widespread, there have not been any large clinical trials to assess long term safety.  There probably never will be.  When people ask me about the safety of melatonin that is exactly what I tell them.  Individual use of over-the-counter melatonin varies greatly.  The average self-administered dose that I encounter these days is 10 milligrams.  The range of outliers is to the high side.  Nobody uses the 1 mg or 3 mg tablets but there are people using 10-20 mg.

My concerns come from a number of perspectives.  First there is the issue of normal excretion of melatonin and pharmacokinetics.  Second there is the role of melatonin in other systems in the body. And third there is the question of the toxicology of melatonin.  In the case of supplements, the presumed toxicology is often based on the exposure of large numbers of people to the supplement and no alarming or immediate side effects.  Melatonin is ubiquitous in some tissues in the body and this gives the impression that it may be a benign compound.  On the other hand it is a metabolite of 5-HT (serotonin) and this has additional implications.  5-HT is a highly politicised molecule with unquestionable roles in human physiology and pharmacology.

When I start to think about the general approach to this problem - the first thing I look at is what the physiological levels of melatonin might be in both blood and CSF.  The published medical literature is scant. Normal levels are often determined as part of an experimental intervention like peripheral sympathectomy.  In one study (1), the normal diurnal fluctuations were noted with a peak ranges of peak plasma levels varied from 122-660 pmol/L, and the peak CSF levels from 94-355 pmol/L.   In this study the authors demonstrated that bilateral T1-T2 ganglionectomy abolished both the diurnal rhythms and resulted in lower levels of melatonin suggesting that the peripheral sympathetic nervous system has input into melatonin secretion.

Other studies have looked at the effects of melatonin supplementation on plasma and CSF levels.  This is always important because average natural melatonin secretion in humans is about 0.15 mg per day.  As I previously indicated supplementation is many times that.   An early study (2) showed that oral melatonin supplementation led to rapid increases in blood and CSF melatonin.  The authors also compared the ratio of CFS/blood melatonin and noted it was constant before and after supplementation suggesting that blood is the source of CSF melatonin.  Recent studies (4-6) suggest that melatonin is secreted directly into the third ventricle from the pineal recess or that there may be central or peripheral compartments of melatonin for different effects.

There was a recent comprehensive review of the pharmacokinetics of melatonin.  The authors reviewed 22 high quality studies looking at oral or IV  dose ranges of 0.1 mg  to 100 mg.   Cmax (maximum plasma concentration following the dose) ranged from 72.1 (10 ml/h; 0.02 mg, IV) to 101,163 pg/ml (100 mg, oral).  Tmax (time to peak plasma concentration) ranged between 15 (2 mg) and 210 min (10 mg).  T1/2 (half-life) ranged from 28 (0.005 mg, IV) to 126 min (4 mg, oral).  The response to melatonin for insomnia is unpredictable and no dose response curve has been determined. Of course there are a wide range of available melatonin preparations from pharmacies and health food stores.  Even in the research, it is often difficult to say what preparation was used, but the bioavailability is quoted as 15%.

The sleep research on melatonin shows that (as most clinician know) it has weak sleep effects but variability does exist.  Most people will notice very little effect.  Some will claim that they were "knocked out" and strongly sedated even the next day - an effect that is hard to reconcile with the short half-life.  The lack of a dose-response curve makes it difficult to determine dosing but a review in an authoritative sleep text (8) says that most studies use a dose of 4-6 mg and that the timing of the dose (1-3 hours before sleep) may be an important factor.  I have been advised myself by a sleep expert that a 1 mg dose of melatonin 3 hours before sleep may be optimal because it entrains the circadian rhythm of that individual and have seen that work in many cases.  The weak effects on sleep EEG to me suggest a strong placebo component.

 Getting back to the side effect issue - I was surprised to find a few pages on melatonin in last week's New England Journal of Medicine in their Clinical Implications of Basic Science Research section (9).   These authors discuss the implications of the MTNR1B variant as a risk factor for Type 2 diabetes mellitus.  This variant leads to an overexpression of MT2 melatonin receptors on pancreatic beta cells.  Melatonin in this case leads to a G-protein-coupled receptor (GPCR) initiated cascade that inhibits insulin secretion.  They reviewed the epidemiology of diabetes and the facts that Type 2 diabetes is typically a combination of insulin resistance in muscle and fat cells, increased hepatic glucose output and no compensatory insulin release.  They reference an experiment where the daily melatonin (4 mg dose) for 3 months reduced first phase glucose induced insulin secretion in an oral glucose tolerance test compared with baseline before melatonin secretion.  They point out that there has been some epidemiological work that associates shift work with susceptibility to diabetes mellitus.  They conclude that typical doses of melatonin of 4 mg/day or less are not likely to be associated with decreased insulin release and talk about the application of melatonin in jet lag with dosing for a few days.  They also point out in the 3-month long study that overall glucose tolerance was hardly affected and baseline glucose levels returned after 2 hours of dosing.  That may not be as assuring to psychiatrists who are seeing their patients take 5-10 mg indefinitely along with other medications that may cause metabolic syndrome.

To me this is also further evidence of just how crude many of our clinical trials are that look at the issue of metabolic syndrome and diabetes in clinical populations.  Whenever I discuss consent for atypical antipsychotics and the metabolic issues, I always tell people that weight gain and increased appetite is common.  I also tell them that I have seen people develop diabetes from these medications who were rail thin and never gained an ounce.  The 150 risk alleles for Type 2 diabetes mellitus, the thousands of associated intracellular signalling proteins, and the 300 GPCRs expressed in pancreatic beta cells probably has something to do with that.

Biological complexity rarely leads to simple answers.

I will probably encourage a lot of insomniacs from taking melatonin when there has been no clear benefit.  I will probably also discourage the practice of taking high dose (> 5 mg) of melatonin for the same reason.                


George Dawson, MD, DFAPA




References:

1:  Bruce J, Tamarkin L, Riedel C, Markey S, Oldfield E. Sequential cerebrospinal fluid and plasma sampling in humans: 24-hour melatonin measurements in normal subjects and after peripheral sympathectomy. J Clin Endocrinol Metab. 1991 Apr;72(4):819-23. PubMed PMID: 2005207.

2: Young SN, Gauthier S, Kiely ME, Lal S, Brown GM. Effect of oral melatonin administration on melatonin, 5-hydroxyindoleacetic acid, indoleacetic acid, and cyclic nucleotides in human cerebrospinal fluid. Neuroendocrinology. 1984 Jul;39(1):87-92. PubMed PMID: 6205317.

4: Leston J, Harthé C, Mottolese C, Mertens P, Sindou M, Claustrat B. Is pineal melatonin released in the third ventricle in humans? A study in movement disorders. Neurochirurgie. 2015 Apr-Jun;61(2-3):85-9. doi: 10.1016/j.neuchi.2013.04.004. Epub 2014 Jun 26. PubMed PMID: 24975205.

5: Leston J, Harthé C, Brun J, Mottolese C, Mertens P, Sindou M, Claustrat B. Melatonin is released in the third ventricle in humans. A study in movement disorders. Neurosci Lett. 2010 Jan 29;469(3):294-7. doi: 10.1016/j.neulet.2009.12.008. Epub 2009 Dec 11. PubMed PMID: 20004701. 

6: Skinner DC, Malpaux B. High melatonin concentrations in third ventricular cerebrospinal fluid are not due to Galen vein blood recirculating through the choroid plexus. Endocrinology. 1999 Oct;140(10):4399-405. PubMed PMID: 10499491.

7: Harpsøe NG, Andersen LP, Gögenur I, Rosenberg J. Clinical pharmacokinetics of
melatonin: a systematic review. Eur J Clin Pharmacol. 2015 Aug;71(8):901-9. doi: 10.1007/s00228-015-1873-4. Epub 2015 May 27. Review. PubMed PMID: 26008214.

8:  Krystal AD.  Pharmacological Treatment: Other Medications.  in Kryger MH, Roth T, Dement WH.  Principles and Practice of Sleep Medicine, 5th Edition.  Elsevier Saunders, St. Louis, 2011. p. 916-930.

9: Persaud SJ, Jones PM. A Wake-up Call for Type 2 Diabetes? N Engl J Med. 2016 Sep 15;375(11):1090-2. doi: 10.1056/NEJMcibr1607950. PubMed PMID: 27626524. (to full text link).


Attribution:

Serotonin metabolism graphic is from VisiScience.

Hospitalists.....

I was a hospitalist before the word was fashionable.  It was July 1988 and I had just completed a 3 year post residency stint at a community mental health center as part of a public health service scholarship payback.  For one of those years I commuted another 300 miles to keep a community hospital psychiatric unit open.   I headed for the hospital where I did my rotating internship in Internal Medicine, Pediatrics and Neurology.  It was the only real metropolitan inpatient treatment setting I had known at that point.  In my residency program, the interns were split up into two groups and each group worked at one of the major county hospitals in the Twin Cities.  It was a unique setting at that time because psychiatrists provided almost all of the medical coverage.  They had to be able to diagnose and treat a lot of common medical problems, write for all of the patient's medications, attend to acute medical problems and do the appropriate diagnosis and triage.  I had a wide range of medical problems admitted directly to me ranging from gunshot wounds to delirium.  Any psychiatrist working in these conditions realizes that the term "medically stable" is a relative one.  I had many patients admitted to my service with severe medical problems only because they also had a severe psychiatric disorder and were symptomatic at the time.  In many cases I had to rapidly assess them and transfer to medicine or an intensive care setting.

I had excellent back up by consultants and many of them to this day are some of the best physicians I have ever seen.  But they really did not want to hear from me unless I had a very specific probable diagnosis and most of the evaluation was done.  There are not too many places in psychiatry where jobs like that exist anymore.  If anyone asks me about similar positions - I actively discourage them from accepting a similar job.  With this arrangement the work is far too long and all of the medical care is provided for free - psychiatrists do not get any extra credit for it.

In those days there were six of us covering 3- 20 bed wards, five days a week.  The ads for psychiatrists these days often speak of "psychiatric hospitalists" - but every one of them specified no medical coverage.  They also tend to leave out the part that it is basically a rapid triage and discharge position and the job is to either maintain or cooperate with high discharge rates.  The only thing they have in common with the Internists and Family Physicians who have come to be designated as hospitalists is that they work 7 days on and 7 days off.  A schedule that very few people question.

I naturally picked up this week's copy of the New England Journal of Medicine to see what the two perspective pieces on hospitalists (1,2) had to say.  I was also interested because my brother is an Internist and over the years we have discussed the issue at length.  The initial essay by Wachter and Goldman documents the rapid rise of hospitalist care as a medical specialty.  Since 2003 the number of hospitalists has increased 5-fold to 50,000.  That makes hospitalists the largest speciality within Internal Medicine.  They cite the growth of managed care, Medicare DRG payments, and possible evidence as reasons for the growth of the field.  I am always skeptical of the term efficiency especially when it is combined with the term quality.  I guess it is difficult for some people to accept the fact that managed care and Medicare DRG payments are rationing mechanisms that are tied to quality only by the tenuous thread of government and healthcare company rhetoric and advertising.  The other critical question is efficiency for who?  It certainly is more efficient to administer a group of physicians who work 7 days on and 7 days off and happen to all be in the same chain of command.  It is a lot easier to get them to accept the role of rationing care in the interest of the hospital or health care group than the patient's personal physician who may see their part of their role as patient advocacy.

The authors have an interesting take on the deficiencies of the model.  They talk about the 7- days-on, 7-day-off model as implying that during the off period the physician is literally off and suggests that time might be better spent contributing to key institutional programs.  To me - this schedule seems more conducive to burnout and anyone who works it needs the off time to fully recover.  I have never seen a study on the cognitive efficiency during the 7-days-on, but my conversations with hospitalists suggests that by day 6 it starts to plummet.  With hospitalists supplanting specialists and subspecialists as inpatient attendings they suggest that trainees have less exposure to basic and translational science.  Although not stated in the article, the model involves eliminating whole blocks of specialty care.  I worked at a hospital where an entire Neurology service was eliminated by hospitalist care.  When I questioned that decision I was told: "We have an Internist who is interested in strokes."  Changing neurologists from attendings to consultants with hospitalists as the primary physicians for neurological problems changes the entire nature of care.  It also changes the associated nursing care when staff have no ongoing interest in the care of complex neurology patients.  The authors also note that hospitalists do not seem to have focused on investigating common inpatient illnesses.  They suggest possible remedies - but these seem like major problems that will only get worse with the increasing business rather than academic emphasis in medicine.

Gunderman points out that as opposed to the usual delineators of speciality care - patient age, physician skillset and body system hospitalists are delineated only by patient location.  He doesn't make it explicit but what is the relationship between location and his list of putative benefits? Looking at length of stay for example - that could logically follow as a concentrated effort in the location, but is that a clinical effort or an administrative one?  He points out that the increasing number of hospitalists per se,  cannot be taken as evidence of benefit and that perverse incentives exist.  I agree with the most perverse being the low reimbursement incentive for high volume practice. Seeing complex inpatients with a high frequency of initial and discharge assessments may reduce the volume necessary for productivity demands.  When I was a psychiatric hospitalist, this dimension was manipulated in a number of ways.  I was initially told, I was responsible for a set number of inpatient beds.  At some point there was a great deal of pressure for me to start running outpatient clinics because they would be more "interesting" than just seeing inpatients.  I resisted that and had significant leverage because nobody else wanted to do my job.  I eventually did run a Geriatric Psychiatry and Memory Disorder Clinic for many years while continuing inpatient work.  That clinic was eventually closed by administrators because they claimed our productivity was not high enough to work with a nurse.  The neurologist and I needed all of the collateral data that she collected to do our work.  The expectation was that we would see complex dementia patients and do everything that the nurse in our clinic did - so we closed.  In over two decades of political wrangling around inpatient productivity the current consensus is that covering 10-12 inpatient beds is a reasonable approach.  At one point I was covering 20 beds with the help of an excellent physician assistant but at the cost of doing no teaching.

The critical aspect of Gunderman's thesis is his emphasis on the physician-patient relationship exemplified by this sentence:

"The true core of good medicine is not an institution but a relationship - a relationship between two human beings."

He points out that physicians being affiliated with institutions creates significant conflicts of interest,  isolates hospital staff from the rest of the medical community and that naturally leads to less expertise in the entire community.  It also creates the illusion that an institution rather than the relationship is the core of medical care and it is not.  Government-business constructs like Accountable Care Organizations have a similar effect.  I have experienced this first hand many times as I dealt with the iterations of hospitalists consulting on my patients.  In one case I talked with a young hospitalist about a patient with Type 2 diabetes mellitus.  The patient had a trace of renal insufficiency and was on metformin - a medication that is risky in that context.  The hospitalist advised me to call the primary care Internist taking care of the patient because "He has been doing it a long time and probably knows more about it than I do."  In addition to the relationship - there is clear expertise associated with caring for people with multiple complex medical problems for years in an outpatient setting - compared to a few days as an inpatient.  The medical industrial complex does not adequately value that expertise.                             

I think that there is room for hospitalists and psychiatric hospitalists.  They have to be focused on the needs of both the patient and the patient's outpatient physician.  There have to be clear goals for the hospitalization and one of those goals is what the patient's personal physician would like to see accomplished.  Since making the transition to strictly outpatient care - it is clear that the hospitalists no matter who they might be don't have much control over who gets admitted to the hospital and what happens there.  They are having less to say about when a person is discharged.  This is probably more true for psychiatry than medicine and it results in a large number of psychiatric outpatients not being able to access needed care.

And I can't help but notice that inpatient hospital medicine is still a far better resource than inpatient hospital psychiatry.



George Dawson, MD, DFAPA




References:

1:  Wachter RM, Goldman L. Zero to 50,000 - The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID:27508924.

2:  Gunderman R. Hospitalists and the Decline of Comprehensive Care. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID: 27509007.

Minnesota's Suicide Prevention Plan

I have pointed out several times on this blog that a number of non-medical forces in the state of Minnesota have been successful in making a mediocre mental health system into one that is on the brink of becoming a travesty.  My curiosity was naturally piqued when I heard that we now had a suicide prevention plan released just in time for Suicide Prevention Week and Suicide Prevention Awareness month.  How is suicide prevention and awareness possible in a seriously deteriorating nonsystem of care?  Who are the people writing this report and what does it say?  As a person actively involved in suicide prevention every day of my career - I decided to read it and give my  impressions here.  The full text is available to anyone off the Minnesota Department of Health web site.

Scanning the document, it is very readable.  The main body is about 23 pages long with relatively large font and much if it is organized more like an outline rather than a document.  For reasons I will outline below - it could have been a lot briefer.  Task Force member are listed and it appears that none of them are psychiatrists.  Of the 19 listed Task Force members - one of them is a physician.  The stated goal of the work is:

"To reduce suicide in Minnesota by 10% in five years, 20% in ten years, ultimately working towards zero ....." (page 7)

That is certainly a laudable goal.  There are recent reviews and ongoing debates about whether suicide can be eliminated and a recent consensus statement says no (1).  Buried on page 19 is the statement "Encourage health care systems to implement the Zero Suicide Model.  There is a link provided to SAMHSA on this model and it is the product of non-experts.  Because of its promotion of managed care I do not consider SAMHSA to be a reliable source of information or expertise.  A review of what is available the Zero Suicide Model (4) illustrates that it is basically a management heavy model of what used to be considered standard psychiatric care before psychiatric care was disrupted by business interests with the usual EHR kowtowing.

 As far as reduced rates or total suicides in the state a useful question is whether or not the trends in suicide rates or total number of suicides is a real trend in Minnesota or it reflects expected variation.  The second important question is whether it is a population wide phenomenon or it reflects subpopulations that are impacting on the statewide rates.  The authors attempt to answer these questions by showing an increase in the rates of suicide from 8.9 per 100,000 (n=440) in 2000 to 12.2 per 100,000 (n=683) in 2013 - the last year of complete data for the report.  The ratio of men:women who died by suicide was 4:1.  The rate across the US was 12.6 - the Minnesota rate is slightly less than the national rate.  Among subgroups of the population the American Indian group had the highest rate at 17.2 per 100,000 (n=70) followed by White at 12 per 100,000 (n=2,941).  Black or African Americans had the lowest rate at 6.9 per 100,000 (n=104).  American Indian Youth (10-24) had the highest rate at 28.0 per 100,000 (n=30).  

A standard method to determine if death trends related to risk factors or illness are significant is joinpoint regression analysis developed by the National Cancer Institute to analyze trends in cancer deaths.  Since then it has been used by both the CDC and researchers (3) looking at trends in suicide rates.  I did not see the application of this kind of analysis to the rates over the 14 year period of time discussed in the article.  That does not mean it was not done, just not apparent.  At the minimum an analysis of longer term trends should be accomplished along with comparisons to other macro indicators like economic variables would be interesting as a basis for preventive recommendations.

The authors leap into their model called a social ecological model of suicide that was adapted from the World Health Organization.  A graphic is included in the statement.  The model appears to be generally applied - it has been widely adopted by the WHO and the CDC as a way to address suicide and violence but also colon cancer and a host of other medical problems.  It seems to be a modern equivalent of the old nature versus nurture or schizophrenigenic mother argument.   Cataloguing all of the perceived deficiencies in the environment is not the same thing as discovering the mechanism or cause of a specific problem in a specific person.  Obvious examples abound.  The vast majority of people who have had significant childhood adversity in the environment do not attempt or commit suicide.  That is a relevant question because a better approach may be studying those people and trying to figure out how they survived and either adapt to chronic levels of insomnia, anxiety, and depression or resolve it.  A consciousness based model may be the best approach.  The authors here seem to say that all of these social and economical factors need to be addressed and that is the approach that they are going to use to reduce the suicide rate.  Even using that approach they overstep the limits of the model and end up using a familiar political approach.

The political approach that I am referring to is to assume that somehow they know more about suicide than the professional trained to address it.  I speak only for psychiatrists, but this is a serious overstepping of authority.  I was board certified in Psychiatry in 1988 and it was well known at the time that if a candidate did not demonstrate that they could interview a person and assess their potential for suicide and aggression that they would fail the oral examination.  Psychiatrists have been focused on timely assessments of suicide and aggression for decades and it is incorporated into treatment guidelines at every level.  Those assessments are done very day by practically every psychiatrist working that day.  And yet the Minnesota Plan has the following guidance:


4.  Train professionals and community/cultural leaders to increase awareness of suicide and prevention efforts and mental health and wellbeing. (p.15)

3.  Train professionals and community/spiritual/cultural leaders to better understand how to talk to and encourage those at risk to access help. (p. 16)

Objective 2.2  Expect providers who interact with individuals at risk for suicide to routinely assess for access to lethal means.  (p. 17)

The authors here can make these statements because they are as non-specific as possible.  Psychiatrists are not mentioned at all in the document.  Neither are other mental health professionals.  Speaking only for psychiatrists again, we are practicing psychiatry with people who have the most severe forms of mental illness because we can assess and treat suicide and aggressive behavior.  We are certainly not looking to any state agency for training or accountability.  We are accountable to the people we treat and professional standards.  Furthermore we are acutely aware of the deficiencies in care in this state and input from psychiatrists would probably have been useful.  The tactic of pretending to tell professionals how to do their job and generally behave has been used by the managed care industry for years.  It is disappointing but not unexpected to see in in a document from a state who has been so friendly to that industry.

I can say without a doubt that most Minnesotans seeking acute care for a family member with suicidal thinking or suicidal behavior will be disappointed.  The severe rationing of psychiatric services has resulted in a lack of resources that would be comparable to any other medical emergency.  Families are frequently directed to hospital emergency departments where mental disorders are viewed creating congestion and inconvenience.  The social workers making the assessments there know that placement options are extremely limited.  The legislative response to their own rationing of psychiatric services has been to mandate that the patient be transferred to the nearest bed and that can be hundreds of miles away.  Once hospitalized most people realize the the inpatient units that were supposed to help them are grim and unsanitary places where they main goal is to convince the psychiatrist that they are no longer suicidal so that they can be discharged home. The family may find themselves in the uneasy position of monitoring their suicidal family member at home while they are trying to get them adequate treatment.  It is the logical progression of events to a government and insurance industry standard that dangerousness is the only reason a person can be admitted to a psychiatric unit these days.  Managed care reviewers call the physicians and nurses in charge looking for that day when the patient doesn't use the word suicidal.  At that point according to the insurance industry - the patient must be discharged.  They always have the excuse that it is up the the attending psychiatrist - but that has become a modern day joke.  The psychiatrist's own administration will insist that the patient be discharged or he/she might need to find another job.

How should it work?  Crisis care for suicidal or aggressive people should be based on an informed approach to the problem.  Risk factors (and protective factor) analysis is really an insufficient approach.  The approach that suicide is an epiphenomenon of other psychiatric disorders is also a limited approach.  There are certainly correlates of high suicide rates in most major psychiatric disorders - but how that person came to consider suicide is generally a unique pathway even in the case of most extreme mental illness.  First,  emergency department triage must go.  The only reason it exists is that there is inadequate funding for community mental health centers and their own crisis services.  The paradigm for this model is Dane County Mental Health Center in Madison, Wisconsin.  This has been one of the epicenters of community psychiatry in the US.  They have an active crisis service that runs all day long until 11PM.  They a have a walk in crisis center.  They are adequately staffed to avoid long waits and they do active crisis psychotherapy.  Second, inpatient psychiatry needs serious revision.  We can no longer accept the idea that a person in crisis sits on an inpatient unit until they say they are no longer suicidal.  Granted there are always social interventions along the way but a lot more needs to happen.  The units need to be clean, calm and comfortable places.  They need to provide an array of active services to treat both severe problems and address suicidal thinking.  They need to keep longitudinal data on the efficacy of their interventions.  They need to provide assessments and treatments for alcohol and substance use disorders.  There are many people who become suicidal only under the influence of alcohol or street drugs.  Most importantly, they need to admit people with severe problems even if they are not saying that they are suicidal at the time.  The reasons for that are twofold.  The majority of people with significant mental illnesses are not being treated.  If they cannot function this is a logical point to provide treatment and reduce the transition to suicide risk.  The other reason is that there are many severely ill people who clearly cannot function with their current level of distress.  They may have attempted suicide in the past.  Their psychiatrist knows they are high risk in the community, but currently there are no hospital or residential settings where these people can be admitted.

Read the document and make your own assessment.  The goals of modifying the social fabric in various communities in Minnesota seem unrealistic to me.  I think that this group and the parent document is overreaching - not just in the scope of what can be done for apparently very little funding but also the gross inconsistencies in government and business.  There are no bigger conflicts of interest these days than a government that seems to want to advertise that they are solving your problems when they are doing just the opposite and businesses that do the same.  A functional state department of health should use the usual public health tools with education being at the top.  Some more attainable and straightforward goals would be:                              

1.  Public education on suicide - especially the statistics the risk factors, and the fact that suicide is a treatable and resolvable condition.

2.  Means reduction - at a public health level these are some of the most successful interventions.  As an example, people need to know that just having a firearm in the home is the single most risk factor for suicide.  I get a letter every year telling me that I have to report the number of abortions that I performed last year and all of the abortion complications in Minnesota.  These same people have access to all of my professional information and know that I have never performed an abortion.  I have never investigated the origin of this letter but can only conclude it is a law written by an anti-abortion legislators hoping to shame physicians into not performing legal abortions.  Why isn't anyone using a more functional approach and sending conceal-carry permit holders a letter on suicide and gun possession.  Why isn't it being taught in public health classes in the schools?  Why doesn't everyone know that most deaths by firearms in this country are from suicide?

3.  Cultural permissiveness toward substance use - Minnesota has medical cannabis laws and an active group of recreational cannabis promoters.  There is a current nation wide movement to view psychedelics and hallucinogens as medications and psychotherapeutic agents.  There is very little discussion of the downside.  We are also in the midst of a highly lethal opioid epidemic.  As an addiction psychiatrist many of the people I talk with get to the point in their addiction that in their search for getting high - they don't care if they live or die.  They knew they were taking lethal or near lethal amounts and did not care.  In other cases, certain people with alcohol use problems will become suicidal only if they are intoxicated.  These correlates of substance use disorders and the suicidal lethality of substance use is practically unknown to most people.  It is not trendy or cool to push back against overwhelming pressure to get high - but that is exactly what needs to happen.  Stay sober and you reduce the chances of ever being suicidal.

4.  Don't depend on managed care companies to provide a reasonable system of care - The record is in and it is not a good one.  The idea that managers whoever they might be are going to teach or coerce professionals into providing better care for people with suicidal thinking when they have been working for three decades to do just the opposite seems absurd to me.  If the government wanted to do anything, it would be to provide functional oversight of these companies and their ongoing rationing of care.  Every state should have a physician review agency for treatments that is outside of the usual same company reviewers and insurance industry insiders placed on state regulatory boards.  That board should have the last word in what treatments are necessary.  Community mental health centers need to be refunded to provide adequate levels of care and they cannot be un like managed care companies.

These are a few of my thoughts today.  I might add another couple of bullet points as they come to mind.  This is a serious topic that deserves additional discussion and one I have been thinking about most of the time with varying levels of intensity for 30 years.                

George Dawson, MD, DFAPA



References:

1:  Shain B; COMMITTEE ON ADOLESCENCE. Suicide and Suicide Attempts in Adolescents. Pediatrics. 2016 Jul;138(1). pii: e20161420. doi: 10.1542/peds.2016-1420. PubMed PMID: 27354459.

2: 1: Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL; Centers for DiseaseControl and Prevention (CDC). Suicide trends among persons aged 10-24 years--United States, 1994-2012. MMWR Morb Mortal Wkly Rep. 2015 Mar 6;64(8):201-5. PubMed PMID: 25742379.

3: Puzo Q, Qin P, Mehlum L. Long-term trends of suicide by choice of method in Norway: a joinpoint regression analysis of data from 1969 to 2012. BMC Public Health. 2016 Mar 11;16:255. doi: 10.1186/s12889-016-2919-y. PubMed PMID:26968155.

4: Hogan MF, Grumet JG. Suicide Prevention: An Emerging Priority For Health Care.Health Aff (Millwood). 2016 Jun 1;35(6):1084-90. doi: 10.1377/hlthaff.2015.1672. PubMed PMID: 27269026.

Disclaimer:

I had no input into the Minnesota Suicide Prevention Plan and I know none of its authors.  I accessed it online and read it.

Why Is The Cirrhotogenic Dose Of Alcohol Important?

The Standard Drink http://rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/What-counts-as-a-drink/Whats-A-Standard-Drink.aspx

One of my main tasks during an interview is assessing the medical condition of the patient.  That is important in determining associated comorbidity, potential causes of psychiatric symptoms, factors that might affect how any medications I assess or prescribe are metabolized, medical tests that I need to order and follow, the insight and functional capacity of the patient - are they aware of the physical problem and doing something about it, and any referrals that I need to suggest and make to primary care physicians or specialists.  When I see people who are using significant amounts of alcohol - alcoholic liver disease and cirrhosis are high on that list.  In many cases they are seeing me and already have a diagnosis of cirrhosis, but nobody else in the current system of care seems to know that.  Continuity of care is really not an administrative priority in American health care.  We all practice in administrative silos defined by electronic health records (EHRs) that don't talk to one another and produce very low quality printouts.  Just recently I reviewed an EHR printout that was 30 pages long.  As usual the hospital and dates of service were not evident.  About 20 of those pages was a consultant's report that pulled in every lab the person across their lifetime - spread in uneven columns across the pages.

How to get to these important but obscured diagnoses?  It is always important to ask about hepatitis and cirrhosis.  I also ask about infectious and alcoholic types.  Some standard review of systems include questions about jaundice and that is a good one to ask.  Non-standard question include asking about seeing a gastroenterologist or liver specialist.  I will ask about specific imaging like hepatic ultrasounds, CTs, and MRIs.  I will ask if there has ever been upper GI endoscopy or colonoscopy, the indications, and what they were told about the findings.  I will ask about whether a doctor has ever told my patient to stop drinking and why?  In the population of moderate to heavy drinkers that I see, it is rare to find all of a person's care provided at one location.  There are typically emergency department visits and hospitalizations that the primary care MD is not aware of.  There may be attempts to treat the alcohol use problem and there is often not a very strong medical component associated with that treatment.  The patient may be actively avoiding contact with medical care out of fear of what might happen with the illness.  All of these factors make it extremely important not to miss the diagnosis and at the minimum recommend optimal care for that person.

From a strictly historical standpoint, the key question is whether there are some historical markers that allow for the stratification of risk.  Can you tell whether your patient might have cirrhosis just based on their drinking history?  Moderate to heavy drinkers vary considerably in their veracity on reporting alcohol use.  It may depend on the phase of treatment.  A reliable description of consumption may occur early in treatment after a conscious decision to "come clean" about it.  There will be a number of people who are not ready to stop drinking irrespective of the quantity they are drinking and the problems that it has caused.  They might be in the assessment because of external factors like family members who are upset by their drinking.  There are also the limits of memory.  If a person acknowledges 20-30 years of moderate to heavy drinking and multiple DWIs in their early 20s - they are unlikely to provide a detailed description of their progression of drinking and may only hit a few of the high points - like when they started experiencing blackouts on a daily basis.  In my experience, most moderate to heavy drinkers focus on the last 2 or 3 years of drinking.  That can create the impression that they have not been drinking long enough to cause significant damage.

Part of the problem in taking the clinical history of drinking is that there can be a bewildering array of drinks and measures - often to the point that the clinician is not sure about absolute quantities or alcohol concentrations.  The literature on cirrhosis and alcoholic liver disease often requires a conversion to standard drinks or grams.  Those drink sizes especially the ones that are culturally determined (there are definitely drinking subcultures in the US) or self-determined can lead to wide variation in the amount of alcohol actually consumed.  Collateral information is always very useful.  From the graphic at the top of this page 1.5 fluid ounces of 80 proof (40%) alcohol or the equivalent in any one of those drinks is considered a standard drink in the US.   That is 14 grams or 0.6 ounces of pure alcohol.  The amounts that I hear about being consumed include a mini bottles (50 ml), a pint (473.2 ml), a fifth (750 ml), a liter (1000 ml), and a handle (1500 ml).  Consuming the entire container of these beverages is the equivalent of taking 1,  10.7, 17, 22, and 33.8 - 1.5 ounce standard drinks respectively.  In the literature the standard drink size in Australia is 10 grams of alcohol or 30 ml of 40% alcohol rather than the 14 grams specified in the US.  That results in more drinks per beverage or container.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has several definitions that are based on consumption that are useful.  Binge drinking is defined as 5 or more drinks on a single occasion for men or 4 more more drinks on a single occasion for women - usually in less than 2 hours.  Heavy drinking is defined as 15 or more drinks per week for men and 8 or more drinks per week for women.  9% of the US population exceeds both the single day and weekly consumption limits of these definitions.   28% of the US population will exceed either the single day limit or the weekly limit.  37% always drink within low-risk limits and 35% never drink.  Those results are based on a sample of 44,000 Americans 18 years of age and older.                              

What are the estimates of alcohol use that cause cirrhosis?  The first time I encountered this concept was in a Medical Clinics of North America reference (1) that suggested 15 pint years of drinking a pint of whiskey per day for 15 years.  The American College of Gastroenterology makes a different estimate of 20-40 grams of alcohol daily -  will result in liver damage in most women.  They go on to specify that 80 grams of alcohol per day will lead to cirrhosis in men in 10 years and the same amount of daily alcohol consumption will lead to cirrhosis in women in 5 years.  They also specify that in their use, 4 drinks is 4 - 5 ounces of distilled spirits so the standard drink size is less than the usual definitions.  Converting all of those numbers into standard drinks -

20 grams = 1.4 standard drinks
40 grams = 2.9 standard drinks
80 grams = 5.7 standard drinks

In other words 5.7 standard drinks per day will result in cirrhosis in men in 10 years or cirrhosis in women in 5 years.  On a clinical basis, I have seen very young people with alcoholic cirrhosis and the youngest were women in their late 20s.  So the range for cirrhosis in the literature ranges from a low of about 1/2 pint of 80 proof alcohol per day for 5 or 10 years to 1 pint of 80 proof alcohol per day for 15 years.

The Australian National Health and Medical Research Council (NH&MRC) recommends that the maximum standard drinks per day for men is 4 and for women is 2.    The range between the high and low estimates of toxicity is considerable given the fact that a pint of distilled spirits contains 10.7 standard drinks.  The pint-a-day drinker exceeds both the NIAAA maximum recommended single day and weekly consumption.

There are a number of variables that affect the individual pharmacokinetics of alcohol and ultimate toxicity.  Patterns of consumption are also important.  Knowing the range of alcohol consumption that may have already impacted the patient is useful in terms of deciding if the history is accurate and how the treatment plan may need to be modified.  It is also useful to know from a public health perspective, especially in the current era of liberalizing policies and attitudes about intoxicants.  




George Dawson, MD, DFAPA


References:


1: Lefton HB, Rosa A, Cohen M. Diagnosis and epidemiology of cirrhosis. Med Clin North Am. 2009 Jul;93(4):787-99, vii. doi: 10.1016/j.mcna.2009.03.002. Review. PubMed PMID: 19577114.


Supplementary 1:

The dose of alcohol that is associated with pancreatitis is 4 or 5 drinks daily for a period of 5 or more years.

Forsmark CE, Vege SS, Wilcox CM.  Acute Pancreatitis.  N Engl J Med 2016; 375: 1972-1981.


Supplementary 2:

British National Health Service guidelines based on a standard drink of 25 ml of 40% alcohol.



Attribution:

Graphic at the top of this post is from the NIAAA we site Rethinking Drinking and is in the public domain at the references URL.

The Conscious Experience of Pain

Drawing of Pain Matrix from reference 2 with permission.

One of the main problems with the assessment and treatment of chronic pain is that there are no quantitative or even good qualitative measures of whether pain exists and how much pain is really there.  The current crisis of opioid overprescription began as an initiative to treat pain more aggressively and that started based on the use of a 10 point scale to estimate pain.  There are many problems associated with that approach but the main one is that it is completely based on the patients self report.  Self report is probably not the best measure when prescribing medications with a significant secondary gain component.  Since that scale is used as a basis for potentially high risk therapies - better metrics would be very useful.

That brings me to two papers that I caught a little earlier this year in JAMA Neurology on the Pain Matrix.   The first is a research letter on the pain matrix.  The authors define the pain matrix as the set of brain structure that are activated by nociception or pain perception.  As a general example they describe the general brain structures like the anterior cingulate cortex, thalamus, and insula.  They cite evidence that these activated structures are considered a possible biomarker for drug discovery and legal proceedings.  The paper is designed to test the veracity of this potential biomarker for pain.  Their model was the administer mechanical noxious stimuli to subjects with congenital insensitivity to pain.  These subjects had SCN9A mutations in the sodium channel of sensory neurons that results in loss of pain sensation but preservation of tactile sensation.  For a discussion of the polymorphisms of this gene see reference 3 and the link on Congenital Insensitivity to Pain (CIP) (4). There were two pain free subjects and 4 controls.  All subjects were scanned with a 3-T fMRI.  They were also asked to rate the stimuli on two dimensions - sensation and pain using a 0 (no pain or sensation) to 10 (most intense pain or sensation).

The test subjects and control reported the same responses to sensation in terms of the subjective ratings with mean ratings(standard deviations) of 4.6(0.5) and 4.4(1.2) respectively.  The painful stimulus was not rated as painful by the subjects but at a level of 3.2(1.8) by the controls.  Most importantly there were no differences on fMRI scanning between the groups with similar levels of activation seen in the thalamus, anterior cingulate gyrus, insula, and pain matrix as a whole.

The fMRI results of the pain matrix response in normal controls and patients who are congenitally unable perceive are extremely interesting.  Both groups had similar tactile sensation.  The authors suggest that caution must be used when interpreting the imaging of this pain matrix for studies looking at the treatment of chronic pain.  At another level, they seem like another addition to a long line of neuroimaging studies that do not seem to correlate very well with what they claim to represent.  An accompanying editorial by Geha and Waxman discusses the fact that the pain matrix has been validated in hundreds of studies using different nociceptive input.  They point out that some researchers equate activation of the pain matrix with the conscious perception of pain.  They review some of the evidence against the pain matrix argument.  One group has shown that activation of the pain matrix is multimodal.  They show how context (monotonous versus novel stimuli) and multisensory and multimodal processing is important.  These authors point out that they have shown fMRI activity in the pain matrix in chronic pain patients without any stimulus.  There cite a study that looks at how the pain matrix is activated in the subacute stages of chronic pain (6-12 weeks) and then as it becomes chronic at up to one year it shifts to emotional circuitry in the medial prefrontal cortex.  The authors also describe emotional and reward related decision making by the ventral striatum and medial prefrontal cortex, and how that activity decreases when chronic pain is successfully treated with carbamazepine while other areas of the pain matrix were unchanged.  Plasticity is also cited as being important both at the clinical level with some basic science support showing that hippocampal neurogenesis was necessary to develop chronic pain behavior in rodents.        

This research is extremely interesting at two levels.  The first is a possible route to quantitative assessments of chronic pain.  A lot of that will depend on a lot more data on the resting state of these brain systems and what changes can be consistently measured.  Having lived through the era of quantitative EEGs - I see too many similarities here to not be skeptical.  It is also not possible to do fMRI studies on chronic pain patients - there are just too many.  Like most psychiatric disorders we need a rapid, inexpensive marker that our patient likely has chronic pain and a measure of severity would be useful.  The second level is broadly important and that is figuring out how human consciousness occurs and how the individual conscious states of chronic pain patients differs.  

Until then - I will be paying close attention to the arguments for and against the pain matrix and research papers that use this description.


George Dawson, MD, DFAPA



References:

1:  Salomons TV, Iannetti GD, Liang M, Wood JN. The "Pain Matrix" in Pain-Free Individuals. JAMA Neurol 2016 Jun 1;73(6):755-6. doi: 10.1001/jamaneurol.2016.0653. PubMed PMID: 27111250.

2:   Geha P, Waxman SG. Pain Perception: Multiple Matrices or One? JAMA Neurol 2016 Jun 1;73(6):628-30. doi: 10.1001/jamaneurol.2016.0757. PubMed PMID: 27111104.

3: Tang Z, Chen Z, Tang B, Jiang H. Primary erythromelalgia: a review. Orphanet Journal of Rare Diseases. 2015;10:127. doi:10.1186/s13023-015-0347-1.

4:  Congenital Insensitivity To Pain (CIP).  Genetics Home Reference.  National Library of Medicine.  Link.

Attributions:

1:  From reference 2 above.  The figure is used with permission of the American Medical Association from JAMA Neurology per the above reference.  License Number 3897150095337;  License Date:
Jun 26, 2016

The State Fair.....

Grandstands At Minnesota State Fair

It has been a little over a year since I last expanded my horizons and did something I would never do on my own.  That event was going on an Alaskan cruise.  It seems like I am experiencing less and less control of my life because last night I scratched off another activity I would not typically consider and that is going to the state fair.  Not just any fair but the Minnesota State Fair.  In the runup to the event I have listed to Minnesotans apply corrections for total duration and a fairground stadium to the Texas State Fair, in order to say that Texas is not really the largest state fair - Minnesota is.  I will leave that argument up to the fair experts.  I am more focused on why people go to a fair in the first place and the fair in Minnesota is an extravaganza.

I am a fully admitted introvert and as one really do not want to be around large and loud masses of people.  So - consider the source of this review.  My entire life is structured around working and getting home and recovering for the next day.  On Friday - the focus is on recovering all weekend for Monday.  Being around people and in awkward social situations is not the pathway to recovery for introverts.  It seriously delays recovery.  In case you are not an introvert, the recovery that needs to occur is a primarily from a heightened sense of tension and anxiety.  In many cases this spills over into autonomic symptoms like accelerated heart rate, tension, feeling flushed and overheated, and a subtle change in breathing patterns.  It also probably affects the perception of situations.  That might explain why both large state fairs that I have attended (Wisconsin and Minnesota) were experienced like Fellini movies.    I expected the same when I walked through the gate and was face-to-face with a young woman wearing a T-shirt that said: "Satan wants you."  But there were more distressing problems than odd T-shirt slogans.

Minneapolis is a large city by any standard, but it is very easy to avoid the city and stay in the suburbs.  On those occasions where I have ventured downtown, I have never observed the crush of people that I have in New York City, Chicago, or Philadelphia.  The Fair is probably the exception to that rule.  Everywhere I went there was a solid stream of humanity 20-30 people wide, often travelling in opposite directions.  There did not seem to be that many destinations but during this week and a half in August the sheer number of people in foot traffic at the fair is probably the highest density of humanity that occurs anywhere in the state.

Food is a related issue.  Gluttony is probably a more appropriate term.  At some point food at the Fair began to take on absurdist qualities.  How many times could the food be deep fried or put on a stick?  At the Fair that seems to be an open question.  In the last several years bacon as a condiment has also been a popular theme with bacon being added to ice cream and donuts.  A friend I was with at the Fair, purchased a drink and a piece of bacon was added as a swizzle stick.  For my own part I had two bites of Australian Fries that are basically deep fried waffle fried potatoes dipped in batter and refried.  The serving size was 4 of these about the size of a medium pancake - covered in either Ranch dressing or liquefied cheese.  I was too conditioned against deep fried food to really enjoy it.  The average Minnesotan tends to view these forays into horrifically bad food with amusement, but at the same time - tons of the stuff are being consumed at a rapid rate and it makes the usual deep fried fast food seem like a health food by comparison.

One of the health parameters that I have not seen discussed anywhere is the air quality at the Fair.  There are so many deep frying and deep frying again establishments in operation all of that aerosolized material has to be vented somewhere.  Many of these establishments had huge roof vents with an obvious non-smoke exhaust.  Aerosolized particles from cooking is a poorly investigated field in medicine but if that was my field of interest I would be attracted to sampling the Fair.  There was more than aerosolized cooking products to deal with.  Cigarette smoke wafted in from both the designated and non-designated smoking areas.  We also now know that humans all have their own unique microbial cloud and emit up to 10⁶  bacterial particles per hour.  That raises the interesting question about whether or not introversion is more than a brain based property and whether at least part of this behavior could be mediated by the immune system.  A fair also has a large number of animals adding more particles to the environment and some of that dust can have immunogenic properties.  I recognize that all of this is speculative and skeptics will ask if there have been any environmentally based illnesses documented in fairgoers.  But my focus is on more than illness or disease.

The most clearcut health problem that I experience at the Fair was ambient sound levels.  In general the sound levels were not a problem.  I did attend a Grandstand Concert given by the Dixie Chicks as part of their DCX World Tour MMXVI.  I could not be construed as a fan of this group and my demographic was underrepresented. 80% of the crowd were women mostly in the age range of 20-45 years old.  Many of them were wearing cowboy boots, probably more cowboy boots than I have ever seen outside of the state of Texas.  Like most concert crowds there was a significant amount of drinking going on and for the first time in a long time - I caught the scent of Mad Dog 20:20.  Some claim to have smelled cannabis, but I did not detect any.  The predominant demographic and their state of intoxication was relevant to the ambient sound levels but first a digression about the actual sound system.

I have no precise knowledge of the grandstand sound systems and could not find any details online.   Apart from portable stacks of speakers and monitors being wheeled about on the stage, it appeared to be two large inverse parabolic arrangement of 20 or more speakers on each side well off the level of the stage.  The opening acts were useful comparisons.  The first act was Smooth Hound Smith a duet that reminded me of a country version of White Stripes except in this case the guitar player was also the drummer.  In terms of sound, the system seemed to be overdriven leading to some distortion and unintelligibility of the lyrics.  The second opening act Vintage Trouble was more of a traditional rhythm and blues ensemble.  Their sound and distortion levels were much less than the first act.  The psychoacoustics may also have been affected by their very dynamic lead singer.  It is risky for an opening act to ask for a lot of audience participation, but he did and was eventually very successful probably through the power of his high energy personality and vocal talent.  By the time the Dixie Chicks took the stage, the sound levels were less distorted but the intelligibility of the lyrics was still a problem.  I was in the nosebleed section far to the left of stage, so I asked people more centrally located if they noticed this problem.  Her observation was that it was a problem and she was glad to see the lyrics projected at one point.

The typical fan in the crowd had no problem at all with the lyrics because they were singing them at full volume.  Imagine sitting in in a sea of 20 year old sopranos singing at full volume and punctuating the songs and transitions with prolonged screams.  The screams were unworldly at times and befitting an audition for a horror movie.  Of course screaming at concerts is nothing new.  It has been there since the early days of rock and roll.  But was this a rock and roll venue?  Are the Dixie Chicks considered to be a rock act?  I don't think so.  There were definite rock elements including an opening recording of Prince and Let's Go Crazy as well as a tribute to Prince complete with his symbol projected on a purple background by the light show.  Judging from the crowd's memorization of complex country lyrics and synchronized movements - Dixie Chicks have produced art with significant meaning to a large segment of the population.  They have sold tens of millions of albums and had no problem at all selling out this venue of 17,000.  One valuable lesson in presentation and marketing is that country acts are presented as rock and rock events these days.  That includes, the amplification, body language, inflection, and associated light show.  The light show associated with this event was first rate including a highly stylized version of a chase scene of the stars inhabiting unlikely vehicles like old Plymouth Valiants and Mercury Montegos at an interlude for an equipment change.  There was also a stream of consciousness display of various prominent politicians flashing across the screen - a possible homage to their previous political controversy when they criticized George W. Bush  about the invasion of Iraq.  

An interesting technical observation had me thinking about what is lost with the sound system.  It brought to mind  recent story about why Freddie Mercury, the late Queen vocalist is considered one of the all time great rock and roll singers.  A study by acoustic experts point out that his vibrato range was a frequency that exceeded most opera singers.  He was also reported to have a 4 octave range.  Although I am not an audio engineer I am a serious student of high fidelity.  I doubt that a distorted and muddy sound system would allow an appreciation of of those characteristics.  You can check your own emotional response to an a capella rendition by Mercury at this link.  On the other hand - Queen fans could probably have a similarly great time at this venue in a parallel manner to the Dixie Chicks fans.    

Despite not knowing their lyrics, being deafened by their fans, and being put off by the low fidelity of the sound system I was able to relate to their music at a couple of levels.  I am a bluegrass fan.  Bluegrass of the derivations from Will The Circle Be Unbroken.  Some of their music has these origins and at one point they played a bluegrass instrumental on banjo and violin.  They also worked with side musicians who had excellent bluegrass stylings on mandolin, acoustic guitar and electric guitar.

Would I see an act like this at the Fair anytime soon?  Only extraordinary circumstances got me out there this time.  Those circumstances would have to repeat in the future.  If I did go - ear protection would be a must.  I might be tempted to bring along a sound meter and noise cancellation head phones to see if I could block the screaming and hear the act.  I would also opt for seating in the center of the Grandstand and on the same level as the speaker system since high frequencies are directional and that affects both the imaging and clarity of the sound.  



George Dawson, MD, DFAPA


References:


1:   Herbst CT, Hertegard S, Zangger-Borch D, Lindestad PÅ. Freddie Mercury-acoustic analysis of speaking fundamental frequency, vibrato, and subharmonics. Logoped Phoniatr Vocol. 2016 Apr 15:1-10. [Epub ahead of print] PubMed PMID: 27079680. (full text link).

Supplemental:

1.  Yes - I was really there:

A Letter From The Surgeon General

Like most physicians in the United States, I got a letter from US Surgeon General Vivek H. Murthy, MD last week.  The focus of the letter was recruiting the assistance of physicians in solving what he describes as "an urgent health care crisis facing America: the opioid epidemic."  As an addiction psychiatrist about one out of every three new patients that I see is addicted to opioids.  I have been lecturing on this topic for 6 years now, so I have more than a passing interest in what the SG has to say.  I have to say that Dr. Murthy wrote an excellent letter.  I was particularly impressed with his second paragraph describing how the was a combination of good intentions to treat pain and aggressive marketing by pharmaceutical companies and the single most important sentence in the letter:

"Many of us were taught-incorrectly-that opioids are not addictive when prescribed for legitimate pain."

Since I was already out practicing for about a decade at the time, I was spared that initiative.  I never assumed that opioids were not addictive, only that some people were more predisposed to addiction than others and that some had such strong adverse effects that they were very unlikely to become addicted.  But in routine psychiatric practice, even before the epidemic it was common to see patients who demanded increasing amounts of addictive drugs or who were hospitalized for adverse effects.  I had treated numerous people who appeared to have dementia, but were longstanding users of opioids, benzodiazepines, and even older sedative hypnotics.

Dr. Murthy goes on to detail the costs in terms of 2 million people with prescription opioid disorder, increasing heroin use, and increasing numbers of cases of HIV and hepatitis C.  He acknowledges that treating pain with opioids and finding the correct balance between analgesia and addiction will not be easy.  He encourages physicians to take the pledge to turn the tide on the opioid epidemic at www.TurnTheTideRx.org and reading the enclosed pocket card to the CDC Opioid Prescribing Guideline.  He also encourages physicians to approach addiction as a chronic illness rather than a moral failing.  That will probably result in some blowback from the addiction is not a disease crowd.  I hope that it is clear from my previous postings that in popular surveys, most people consider addiction to be a disease.  At the scientific level, I think it makes the most sense.  A lot of the confusion in this area comes from a lack of appreciation about how substance use disorders are stratified.  Volkow came up with a good definition in a New England Journal of Medicine paper earlier this year (1) - separating substance use disorders in general from addiction and defining addiction as severe DSM-5 substance use disorders. (the DSM-5 refrains from using the term addiction).

The enclosed card entitled "Prescribing Opioids For Chronic Pain" touches on a few of the high points.  My section by section critique follows (the entire card is below in the supplementary section for review).  Section 1 focuses on pain ratings using the old 0  to 10 scale where 10 is the "worst pain you can imagine".  The unstated problem with that approach is that it is not quantitative and cannot be taken in isolation.  There are people for example where this rating is completely unreliable.  Section 2 is a consideration of non-opioid therapies.  It lists the usual medication prescribed for chronic pain.  The problem here is that acute pain is often an entry point for addiction.  There are many people getting opioids like oxycodone and hydrocodone for what used to be considered trivial injuries, like an uncomplicated ankle sprain.  The  other acute pain entry point for addiction is post operative pain.  There have been studies that show a significant number of patients are still taking opioids a year after their surgical procedure.  It is common for me to interview very young patients who were given opioids for trivial injuries or surgery who became addicted to these drugs.  Physicians need to be very clear on appropriate pain treatments and not offer choices.  For example,  I was told by a friend that he was in a situation where patients were offered acetaminophen, ibuprofen, oxycodone, or oxymorphone.  This is exactly the wrong way to approach the treatment of pain.  In a culture where many people consider themselves to be drug savvy - the overwhelming choice will always be the most euphoria producing opioid.

 Section 3 is a discussion of the treatment plan.  Treatment contracts can be useful here, because most patients need more than a discussion.  They need a document that they can refer to.  It also gives the physician clear anchor points that can be used when discussing a taper or need to discontinue the medication.  Section 4 involves the complicated assessment of harm and misuse.  For most physicians this means the capability to expand their diagnostic capacity from the primary condition and the associated pain disorder to being able to make the diagnosis of addiction.  In some cases there are clear markers (toxicology screens), but in many cases, the patient has developed an addiction as a direct result of the physician's prescription and the line between therapeutic use and addiction is less clear.

The card also provides clear examples of milligram morphine equivalents (MMEs).  This is a term used frequently in the research literature.  When comparing patients on different opioids it is useful to convert whatever opioid they are taking to MMEs.  Mortality and morbidity with opioid prescriptions are generally associated with daily doses greater than 90-100 MME range.  The card points out that this is about 90 mg of hydrocodone or 18 tablets of hydrocodone/acetaminophen 5/300 or 60 mg of oxycodone or 4 tablets of oxycodone sustained release 15 mg.  In patients with addictions it is common to see chronic use of 120-240 mg oxycodone per day.

The card provides advice on starting low and going slow with the dose escalation as well as a suggested taper of 10% per week.  It suggests limited supplies, much more limited for acute pain.  It cautions against prescribing opioids and benzodiazepines concurrently - a practice that remains all too common.  A sentence about how that happens might be useful.  Chronic pain is typically associated with anxiety, depression, and insomnia.  Patients typically are focused on symptomatic relief in all three areas.  That can result not only in benzodiazepine prescriptions but also the prescription of cross tolerant sleep medication like zolpidem or eszopiclone.  Another worse case scenario is the patient using extra opioids for treating these associated symptoms and that is very problematic.  Educating patients about all of these contingencies easily exceeds the time that most primary care physicians have to spend with people.  That may be another reason to have ample documentation available to assist physicians.  There also needs to be a complete discussion of side effects and adverse effects from opioids.

The card transitions into treating an opioid use disorder with medication-assisted treatment like methadone, buprenorphine, or naltrexone.  At this point, I think that the expertise of most primary care physicians has been exceeded and they are looking for referrals to treat the addiction.  I think that the context of care needs to change.  It is very difficult to be in a primary care setting focused on pain as the disorder one week and then transition to addiction care the next.  Most patients will be unable to make that transition in the same clinic.  The idea of offering naloxone for those with high overdose potential on the same card is also confusing.  I could see how it might result in patients being treated for pain and getting prescribed opioids also getting naloxone.  I think that naloxone is more appropriately used with a defined addiction and plan to address the addiction.  The best approach to prevent oversedation and cognitive side effects is close monitoring and gradual dose increases.

All things considered this was a good first effort by the Surgeon General.  I would like to see him become active in changing the cultural attitudes in the US about opioids.  There is a myth that opioids are the magic bullet for pain relief and that is not true especially for chronic pain where the effects are modest and not typically better than non-opioids.  There is a large segment of the American culture that also values getting high and opioids are always discussed from that perspective.  Americans hoard opioid medications and give them away and trade them with other people for various reasons.  When a medication becomes an urban legend like opioids have - it is like the old travelling medicine shows.  Opioids are good for whatever ails you and they make you feel good as a useful side effect.

Countering all of those cultural biases about opioids is a big job - but I am reminded of Surgeon General Koop and his approach to altering American biases about tobacco smoke.                   




George Dawson, MD, DFAPA


References:  

1: Volkow ND, Koob GF, McLellan AT. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med. 2016 Jan 28;374(4):363-71. doi: 10.1056/NEJMra1511480. Review. PubMed PMID: 26816013. (full text).


Supplementary:

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