CDC Announces New Opioid Prescribing Guidelines; Naloxone Pen Distribution is Best Life Saver
There has been a big controversy over the release of the new guidelines by the Centers for Disease Control (CDC) but it seems to be an over-reaction. The guidelines advise that Vicodin or Norco are not first-line treatment for acute pain, nor for mild chronic pain. The guidelines do allow for some patients to use some quantities of opioids, but with caution. There is no prohibition on using opioids when a patient has severe, chronic, noncancer pain. The condition must be evaluated and properly diagnosed; efforts to correct orthopedic problems that cause wear and tear with chronic inflammation are very important.
If a patient has pain, it must be controlled well enough to continue with the activities necessary to daily living. Going to work is necessary for many people, and if it causes pain that can’t be controlled with non-steroidal anti-inflammatory drugs, then sometimes hydrocodone is necessary. The problem is that there are many people who say they have pain, who really don’t have significant pain. There are other people who have started taking opioids and are dependent on them, even though they don’t have significant pain.
The primary care provider, the receptionist, and the nurse take the brunt of patient demands for opioids. The patient is sure to be dissatisfied if their demands are not met. In some cases, the patient may become violent and there are stories about patients brandishing firearms in their efforts to get drugs. I know of more than one fatal shooting that occurred because the patient demanded, and was denied, a common narcotic pain killer.
What is just as bad, is the overdoses. The number of fatal opioid overdoses has increased by 200% since 2000 and is now at a record level, parallel with the increase in prescriptions and sales of narcotics. The exact mechanism for the increase in overdoses is not completely clear, but it appears that patients sometimes take an unexpectedly potent form of a known drug such as heroin, or take a larger than normal dose because of prior shortage. Perhaps the overdoses are in part intentional and reflective of a suicidal predisposition; that possibility has not been completely ruled out.
According to the CDC’s Morbidity and Mortality Weekly Report for January 1, 2016, there has been a dramatic rise in overdose deaths due to fentanyl because of the production of illicit fentanyl by underground chemists. In 2014, there were 47,055 deaths from all drug overdoses, exceeding deaths from motor vehicle crashes by one and a half times. There were significant increases in death rates in both sexes, all age groups, ethnic groups, and regions of the country. West Virginia had the highest rate of deaths from drug overdoses. 61% of drug overdose deaths were from all opioids, including heroin. Heroin overdose death rates increased 26% in one year and have more than tripled since 2010.
It seems that heroin use has also increased dramatically in the last few years and that the biggest factor in the increase has been the transition from prior use of prescription opiates. The relative cost of heroin and its high purity has contributed to the patients’ switches from prescription to illicit opioids. Illicit fentanyl has also been available and is sometimes mixed with heroin. Pure heroin and fentanyl are probably contributing to accidental overdoses due to product potency.
The fact that the quantity of opioids prescribed has increased four times since 2000 has a great deal to do with the epidemic of opioid overdose deaths. Patients receive significant amounts of drugs from doctors but are eventually cut off or find the drugs inadequate, so they switch to heroin. The high quality, nearly pure heroin cheaply available on the street is satisfying the desire to “get high” but puts the user at risk of accidental overdose.
Illicit fentanyl is being mixed with high purity heroin and sold as “China White”; since fentanyl is 50 times as potent as morphine, the chance of overdose increases further.
Based on this reasoning, the single action most likely to reduce overdose deaths is the widespread distribution of naloxone injectable pens to addicts, emergency workers, and anyone else who is likely to run into a patient who has overdosed. Naloxone can temporarily reverse the respiratory suppression caused by overdose and could save the life of a patient who has lapsed into a coma and stopped breathing after using too much heroin or fentanyl.
Zika Vaccine Not Soon
An article in the New York Times states that the World Health Organization (WHO) has announced that a vaccine against Zika virus will probably take years to develop and will not be in time to help with the current epidemic. Although many organizations are researching potential vaccines, the furthest along is six months from human trials and probably three years from widespread release.
Research has also shown that spraying insecticides against mosquitoes is ineffective at reducing the incidence of dengue fever, a closely related virus. Nonetheless, spraying will continue as there is no other effective approach. The use of genetically engineered mosquitoes to reduce the population is promising, but the numbers are still small and again there is likely to be several years delay before a large enough number of mosquitoes can be produced.
The most effective approach at present is to stay in air-conditioned residences and to wear mosquito repellent on exposed areas whenever outdoors.
At the current rate, Zika is expected to spread to the southern US within two years.
Anonymity and Anonymous
“Hacker, Hoaxer, Whistleblower, Spy: the many faces of Anonymous” written by Gabriella Coleman, is an account of her mostly online encounters with many personalities, most of them unidentified, collected over the period from 2010 to the present. It discusses what the writer describers as the “culture” of hackers. This “culture” includes a number of people who were arrested for Internet crimes such as the “theft” of information up to and including credit card numbers and passwords. The period of time referred to in the book runs from about 2010 to early 2015. A number of the people are identified by name only because they were arrested and imprisoned. During that time, the writer, acting as an anthropologist, communicated with many other, unidentified people who described themselves as hackers. She eventually did obtain a graduate degree in anthropology and now teaches.
The entire culture could be described as the Anonymous group or web, a large and very loosely associated group or groups of individuals who communicated over the Internet. Many of these groups claimed to be able to obtain information on a group that could be vulnerable, sometimes security firms. In more than one case, secret information was obtained from sensitive sites. A number of people were indicted and imprisoned for obtaining unauthorized information in the US. One young man, indicted for a wholesale downloading of an open-access journal, committed suicide after the prosecution demanded decades of imprisonment.
Many of these people were sincere in the belief that the vast majority of this information should be public and the government is in the wrong to punish people harshly for this kind of disobedience. Others felt that exposing oneself to danger in this fashion would be unwise in the long run. Fortunately for Anonymous as a movement, the most important members of the movement have managed to keep their identity, in fact their very existence, hidden from the government. Anonymous could only survive by being fully hidden from view.
The conclusion that the book makes is that any survivors have melted away and are saving their strength for a later occasion.
“The pipeline itself is just too small,” Marc Nivet, EdD, MBA, chief diversity officer of the Association of American Medical Colleges (AAMC), told MedPage Today. “The barriers exist up and down the continuum to our segregated education system … Too many of our minority students are in poor-performing or underperforming K-12 school systems.”
via Deep Roots for Lack of Minorities in American Medical Schools | Medpage Today.
This article was linked to by Ivan Oransky’s Twitter feed. I don’t normally read Twitter feeds, but it caught my attention because it is reposted along with his regular web site / blog posts.
This calls attention to a serious problem which has gotten worse, not better, since I was in medical school. Only five percent of the first year class in my school was African-American. What’s worse, half of them dropped out after the first year. They just couldn’t cut it academically. I talked to some of them, and they studied hard, they seemed intelligent, they didn’t goof off, but they couldn’t cut the material. Either they hadn’t taken enough courses in college that prepared them, like biochemistry, or they just hadn’t been exposed to large amounts of rote memorization, like anatomy and the rest of the first year courses.
The problem is that most black kids start first grade at schools that are just no good. They are relatively or absolutely underfunded, they have lousy teachers, low standards, and an environment not conducive to learning. So even black kids who want to become doctors, in the worst way, either wind up following the Ben Carson path, or just don’t make it.
It’s not their fault. It’s the fault of the system of funding for primary education, which is based primarily or entirely on local funds. Since black kids live in low-rent districts, their tax base is grossly inadequate to fund their primary schools. This is a political crime, and it has been perpetrated against low-income, primarily black or Mexican kids ever since universal primary schooling was instituted (after the Civil War?)
The only solution is federal funding for primary school to make sure everyone gets an equal amount of money (if not extra money to make up for other deficits) to attend school.
It’s not fair to send black kids to crummy grade schools. It just perpetuates the disadvantages they were born with and aggravates the other problems, the chronic lead poisoning, the broken families (one or both parents in prison for no good reason), etc. I could go on, but I only have so much space, and what I’m saying is well known to everyone with a brain who has been exposed to the facts. The system is unfair from the beginning.
A dozen cases of Zika virus in China have been reported in the last month, all imported, according to the National Health and Family Planning Commission in Beijing. An article in the New York Times (NYT) indicates that the islands of Taiwan and Hainan are at risk for locally transmitted Zika because the Aedes aegypti mosquito, which carries the virus, is resident in those areas. Zika virus has not yet been reported north of Thailand and Polynesia, but it has been spreading rapidly in South America.
Taiwan had a severe outbreak of dengue fever last year, which is caused by a similar virus that is carried by the same mosquito. Because of the dengue outbreak, Taiwanese authorities are taking special precautions to prevent entry of Zika, dengue, and chikungunya, all of which are carried by the same mosquito.
A laboratory study also reported in the NYT showed that fetal cells which form the precursors to the cortex in the brain are especially susceptible to infection and death from the Zika virus. This study forms a basis for the finding of microcephaly that has so alarmed scientists in Brazil recently. Babies born with microcephaly are missing a large part of the cortex of their brains, dooming them to mental retardation. This study doesn’t prove that Zika is the cause of microcephaly, but it makes scientists very suspicious.
Ryan Hoffman was a college football player, a star offensive linesman, at the University of North Carolina. After college, he began a downward spiral that included alcoholism, drug abuse, and homelessness. He said repeatedly, “Something is wrong with my brain.”
It was not until he died in November 2015, and his brain was pathologically examined, that he was diagnosed as having chronic traumatic encephalopathy (CTE), now known to be caused by multiple concussions while playing football. He was said to have Stage 2 (out of 4) of CTE by the pathologist at Boston University (Dr. Ann McKee) who examined his brain. This is the same stage as the football player Junior Seau, who shot himself in the chest in 2012 after suffering the agonies of depression, loss of memory, loss of impulse control, and fits of rage.
The New York Times (NYT) reporter who knew him stated:
“Dr. McKee said that Stage 2 C.T.E. can be especially symptomatic, causing problems like depression, short-term memory loss, lack of impulse control, irritability and mood swings, and that some of those symptoms could be confused with mental illness. Last year, Hoffman told me that he had received diagnoses of various mental illnesses, including manic depression, but that medications never seemed to help.”
Mr. Hoffman was jobless and homeless, penniless, and dependent on drugs and alcohol when he died. His sister said, ““I wanted to know exactly what happened to my brother, and I just knew football did it…” He rode his bicycle head on into traffic on a dimly lit road in Haines, Florida, and died in an ambulance on the way to the hospital.
Peach Orchard 2016
Peaches and Plums
Peach Blossom 2016
Those of you who have been following the statements of Donald Trump (Drumpf is his real family name, like “Schickelgruber”) may have noticed the wild inconsistency and extreme superficiality of his positions. This post will discuss his statements that appeared to encourage violation of the Geneva Conventions that define war crimes. First, Drumpf has advocated killing the families of terrorists because this will “hit them where it hurts”, whereas killing the terrorists themselves will not discourage them. The “families of terrorists” include their fathers and mothers, some of whom will be elderly noncombatants, and their wives and children, many of whom will be minors, who are also civilians and not arms-carrying soldiers. These persons are a protected class under the Geneva Conventions: civilians and noncombatants. Targeting these individuals for murder is a war crime.
Second, Drumpf has advocated torture, “worse than waterboarding” to extract information from prisoners. Torture is, of course, a war crime, and waterboarding crosses the line between “enhanced interrogation” and “torture.” Most reasonable people believe that waterboarding is torture, especially if they have been personally subjected to the practice. More importantly, the use of torture has not been shown to yield significant actionable information.
The tortured prisoner will make up any story to stop the torture; the prisoner’s story will be questionably truthful at best and more likely completely unreliable. Prisoners who have given up useful information under torture have been shown to have already revealed that information before the torture began, and the more torture applied, the less useful the information gained. Apologists for torture have frequently claimed that they have obtained information that could not have been gotten any other way, but under close examination these claims have been shown to be false.
Drumpf has made multiple statements of this nature, and in response to those who have said that his subordinates would refuse to carry out his orders (lawfully, because his orders would be unlawful) he has claimed that “they will do it.” Nothing could be further from the truth. No true soldier will follow an unlawful order: this has been emphasized to them repeatedly in training, and they have been told that the statement that “I was just following orders” is not a defense.
Interestingly, Drumpf has changed his story in the last few days. He now states that he will not give orders that would run counter to the rules of the Geneva Conventions. It seems that he has been told by persons unknown that he would be in serious trouble with our military and our European allies if he were to start ordering airstrikes that target civilians associated with the Islamic State, or if he were to admit that we are torturing our prisoners. That is, assuming that his subordinates would even be willing to follow such orders. Even a few resisters, even if they were jailed and silenced, would wreak havoc with military cohesion and brand the United States as a war criminal (not that some people are not ALREADY calling the US war criminals.)
Donald Drumpf doesn’t normally change his positions, even sotto voce. This change, while quietly made, is somewhat surprising. It suggests that there are people to whom Drumpf listens who are giving him advice to tone down his message, a little; fact-checking is apparently not a priority for them. Who are these people? Well-heeled supporters? Mr. Cheney? Whoever they are, we need to be aware that Drumpf is following the advice of those who are at least marginally wiser than him and more importantly, strategically more disciplined. They hold the same racist, classist, anti-humanitarian views that Trump holds, but they are more realistic, much smoother in their delivery, and they know the limits of power. They probably contribute most of the money that the Republican Party uses.
This is not a good insight. It makes it more likely that Drumpf will win at the Republican Convention. There is still only a small possibility that Drumpf could win the presidential election because he has already alienated two or three crucial voting populations beyond any recoverability: women, Latinos and Mexicans, and blacks or Afro-Americans. Blacks have not become the central minority force that was predicted forty years ago because their percentage of the population has not increased as expected and because they still do not vote in sufficient percentages to sway elections decisively (except when they have a black, charismatic candidate like Barack Obama to vote for.)
Latinos have become, almost without anyone noticing, the decisive “minority” group (Europeans, or “whites”, are becoming the real minority) in this election: they are now highly motivated to become citizens in order to vote against Drumpf and people like him. Republican strategists once entertained a fantasy that they could win over a significant portion of the Latino electorate, but that fantasy is gone.
Women are over half of the electorate and we can guess that ninety percent of them will vote against Drumpf, regardless of who his opponent is; this represents the deciding factor in this election and there is nothing that can change that in the next eight months.
The importance of this factor (the hint that there is someone behind Drumpf to whom he is listening) lies in the effect it will have on the Republican Party, especially after the election. After losing to Hillary Clinton, Drumpf will be the leader of the party and will install his sycophants in responsible positions. He will also hold the allegiance of elected Republican politicians, who will most likely continue to hold the House and probably the Senate. The money that Republican supporters supply will be used, before and after the election, to fund propaganda that slanders and belittles the Democratic leadership and promotes attacks on human rights and social values, such as equality of education, opportunity, health care, and nutrition, that even citizens who vote Republican still uphold.
There is an indication that Drumpf really wants to be President, and that he is delusional enough to think that he has a significant chance of winning this post; the people behind him are probably realistic enough to know he will lose in November. Even in a head to head contest, Drumpf has no chance against Clinton and only a fair chance against Sanders. None of the other candidates has a chance either; Bush was the only one who had a measurable possibility of winning.
If Drumpf becomes the Republican nominee and a splinter group of “true conservatives” fields a third party candidate, then Drumpf is dead in the water. This is why all the other Republican candidates for President, despite denouncing him as a fraud and a con man, say that they will support Drumpf if he wins at the Convention. They sound like robots, faithfully following their conservative programming, marching together to defeat.
This is the real danger of Drumpf: he is a charismatic leader who will take the Republican Party much deeper down the rabbit hole of paranoia, self-aggrandizement, and blind nationalism, and he will take a significant number of economically defeated, disenfranchised, under-educated white Americans with him. If you thought the wild slanders and vile insults that have come from Republicans against Hillary Clinton and all important Democratic and non-political leaders were disgusting, you haven’t seen anything yet.
