Inhaled Insulin: Will Life be Sweeter?

It was announced today that the FDA has approved insulin for inhalation to be marketed by Pfizer and Nektar Therapeutics under the brand name Exubera. The drug is indicated for both type 1 and type 2 diabetes, to be used in place of short-acting insulin at meal times. It can be used in conjunction with long-acting insulin or oral, non-insulin pills that help to control blood sugar.

Hmmm. If you have diabetes and are on insulin therapy, have you read between the lines yet? What about those who have to take long-acting insulin? I don't know about your diabetes management, but I can't think of one individual that I know who uses insulin to manage their diabetes and only takes short-acting insulin.

Information in the popular culture magazines over the last few years have been exclaiming over the day when inhaled insulin would replace the needle stick injection of current insulin therapies. People living with diabetes have been waiting for this day! Now we find that it will replace some of the insulin that those on injection therapy use, but not all of it.

And wait! There's more news: there are concerns about the toxicity that may be awaiting your lungs from inhaling Exubera, and worry that the drug won't be able to achieve a reduction in hemoglobin A1C levels to below 7%, the accepted gold standard in good diabetes care.

Well that's no surprise, since it isn't made to replace all of the insulin that one should take, and there has been too little opportunity to work with it together with other diabetes medications long enough to learn how to optimize it's effectiveness.

The FDA reports that safety and effectiveness were demonstrated in trials involving approximately 2,500 individuals with type 1 and type 2 diabetes. Based on these trials, there are significant restrictions to Exubera's use, including that it should not be used by smokers, or those who quit smoking in the previous six months. It is also not indicated for patients with asthma, bronchitis, or emphysema. Because of this potential for lung damage, the FDA recommends baseline lung function tests before an individual begins to use Exubera, and repeat testing at 6 months, and then annually.

Given the track record for recent drug approvals and their subsequent problems, as well as the significant questions I have regarding the number of individuals who will develop lung problems after the drug becomes more widely used, I have to wonder if this is a drug that will be readily accepted by providers and individuals with diabetes alike. Since anyone managing their diabetes is very likely on at least one or two long-acting insulin injections a day, and most have come to realize that insulin injections cause little to no discomfort, will they be excited about replacing other daily injections with inhaled insulin?

I don't know, but I won't be in a hurry to recommend it until we have more safety data from those who do use it.

Related Topics: Diabetes and Your Sex Life , New Diabetes Treatments Show Promise

Technorati Tags: diabetes, inhaled insulin, Exubera

R & R

Sometimes you just have to take some time to yourself.

In Rhode Island there is this wonderful place that is part of the state university called the Environmental Education Center at the W. Alton Jones Campus. It's in a more remote section of the state, and is used for teaching students in the environmental education program. It is also used for camps, including summer and school vacation camps for kids, environmental field trips for schools, and a great program called "Women's Wilderness Weekend." also known as "WWW."

I've been attending WWW for many years, and have always found this to be a great way to recharge; I have friends there that I only see at the weekends, we get fed fabulous food, and we don't have to do the dishes afterward. What more could I ask for? Well there are great workshops to participate in, and I always learn something new, like how to make jewelry, or how to orienteer in the woods with a compass. I didn't go to the weekend this time, but I yesterday I went out to teach a class on pairing food and wine. We had a lot of fun, and it was good to visit with friends for the afternoon.

If you aren't too far from Rhode Island consider the option of a vacation for your kids or yourself (there is a men's weekend too) in this beautiful place. Here's a picture to make you want to visit:

There is a technique in Zen meditation where you pay very close attention to whatever simple, ordinary task you are doing as a way of helping you to maintain focus. This type of training exercise for the brain can assist you to stop the racing, "what if" thoughts that cause many of us so much anxiety in life. Cooking is a perfect way to practice this technique, because there are so many colors and textures to focus on. It also helps you to keep from cutting off the end of your finger!

If you are a person who needs an opportunity to learn to manage stress better, I would recommend books by Jon Kabat-Zinn, and the resources available from the Center For Mindfuless at UMass Medical Center.

Laurie


There is no need to go to India or anywhere else to find peace. You will find that deep place of silence right in your room, your garden or even your bathtub.

Elisabeth Kubler-Ross

Heart for Medicine

I've been blogging since December and trying to find the right mix of information and interesting, maybe a little bit controversial, posts to keep people interested. Since I'm blogging for WebMD, you can be sure that I have some concern about not offending anyone outright. That wouldn't be appropriate, and it's not really me, for the most part.

There are some things that tick me off in medicine, such as the problems with professional liability and the need for tort reform, and I have alluded to them. Another is discussed in my last post, the idea that people should come to see me expecting to "buy in" to a plan of treatment.

Currently I'm thinking about lousy health care providers, and how passionate I am about doing the right thing for people. That means that when I spout off about patients needing to do what I'm asking of them when they come for my advice, there is a flip side: I owe them an obligation to be thoughtful about what I chose to have them do. I have to choose tests, medicines, and treatments with care and a purpose. There are a lot of providers out there who are "fishing" for their medicine. These people order a lot of needless tests, including blood work, or try medication after medication until something works, hoping to hit on a workable solution.

There is supposed to be a method to medicine; after a history is taken the provider develops a list in their head of possible causes of the person's complaints. The provider then performs a physical exam and comes to an educated conclusion about what he or she thinks is wrong and what the treatment options are. Only then are additional tests ordered to support the diagnostic conclusion that the provider has already determined to be the likely cause of the complaint.

I'm interested in what experiences my readers have had with this type of medical care. This is the part where I hope to stimulate some comments! If there is anything a blogger lives for it's comments about their posts, and I'm told that I have to be a little more patient about that as a newcomer to weblogs. That's easier said than done! But I'm hoping to get a big boost in traffic since I have been honored by being the lead off post at Grand Rounds today. Yippee! A great big thank-you to Kevin, MD for this honor.

Laurie

An honor is not diminished for being shared.
Lois McMaster Bujold, "Shards of Honor", 1986
US science fiction author

Related Topics: Diagnosing Your Doctor: What Should You Know?, How Much Does Health Care Truly Cost?

Technorati Tags: Medicine, Medical Blogosphere, ethics, Medical Practice

Why Do you Come...

Why do you come to my office to see me?

At least once a week I see someone who comes to me for my opinion about what's wrong with them and what to do about it. We always have a discussion before that person leaves the office about what I think is wrong, why I think that, and what I think should be done. Sometimes, like many health care providers, I'm not absolutely sure what's going on, but I've got a differential in my head. This is a list of possibilities about what's wrong, prioritized from most likely to least likely.

If I'm a little torn, I may think out loud to them, and say, "I think it's this, but here's why I'm not 100% sure. We're going to do X, Y, and Z, and then I'm going to see you again in a very short time to see if this has helped. If you're better, we'll keep up this plan. If you're not as well as I would expect at that point, we'll reassess and make another plan." People are Ok with that. They know you're being thoughtful in your approach, they know you're not throwing them to the dogs, and they know that you care enough to check on them again.

Egos aside, I don't honestly think that anyone expects me to be 100% right, 100% of the time, the first time I evaluate a problem. Before they leave, I always say to them, "I've given you a lot of information; do you have any questions for me?" We talk about any questions or concerns that the individual has and I send them on their way, with a plan for when the person is to come back. They leave knowing when and why I want to see them again, and they have stated that they agree to follow that plan.

At least two or three times a month I see one of those people back for the follow-up. Sometimes it is for the scheduled visit that is supposed to occur from the visit described above, but often it goes like this...

Me: "So, when I saw you last you were having symptoms 'A,B,C' and we made a plan for you to do 'X,Y,Z' and come back in two weeks to see how you were doing. Here it is three months later and you're back with the same symptoms, only now it seems as though they may be worse. Tell me what happened."

The Patient: "Well, I started to feel better, and by the time I finished up the medicine that you gave me I felt so good that I thought I didn't need to come back."

Me: "Do you remember me saying that this medicine would take a few weeks/months to completely heal your problem?"

The Patient: "Well, yeah, but since I felt better, I thought maybe I just healed more quickly than you thought."

Here's another one:

Me: "So, I see that last year at this time you were here for an infection and we noticed that you had very high blood pressure. We talked about how you might lose some weight and get a little more exercise. When I saw you the next time a couple of months later you had not had much luck with losing weight or getting out to walk. We talked about how it was pretty tough at that time for you to meet those goals. I recall that we agreed that you would take medicine until you were actually able to exercise and lose some weight. We were both worried because you didn't want to have a stroke like your dad did. Is that about how you remember it?"

The Patient: "Yeah, well I took that medicine for awhile, but I didn't like the way it made me feel."

Me: "Well what brings you in today?"

The Patient: "I've been feeling really tired, and having a lot of headaches, so I thought I better get that checked out."

Me: "How long has it been since you took any blood pressure medicine?"

The Patient: "A couple of months now."

Me: "Well your blood pressure's pretty high today, 240 over 136. I think if we get that under control you'll feel a whole lot better. But we need to do some blood work today, because I'm concerned about what your high blood pressure may have done to your kidneys." (Because I see that he really hasn't had a medication refill in 8 months, and I know that we found his hypertension when he was in for a sick visit, so at a minimum he's been a year with high blood pressure, probably more). "So tell me about how that medicine made you feel, and I'll see what I can do to pick one that won't give you those side effects."

Which brings me back to the question, "Why do you come?" If you think medicine is a one-way street, where you don't have to let me know that something isn't working for you, think again. You're an adult. Take some responsibility for your health. There are a lot of medicines out there, lots of other options if you don't feel well on the first choice prescribed for you. When I tell you that I need you to come back, I'm serious. Even if you feel better, it doesn't mean you're cured. You might actually need several months of medicine, or you might think you're better, and not actually BE better. When you get your license to practice medicine you can decide that. Until then, I'd appreciate it if you'd follow my advice regarding medication and treatments and come back to see me when I ask you to. Either that or don't bring your problems to me for my advice.

Laurie

Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.

Thomas Szasz, The Second Sin (1973) "Science and Scientism"

Related Topics: WebMD Survey: The Lies We Tell Our Doctors, Managing Hypertension

Technorati Tags: healthcare, preventivemedicine, hypertension, heartdisease

Another Opinion on Pain Management

If my post about pain management by primary care providers interested you then check out another opinion on the subject over at DB's Medical Rants; the post is from January 13th, 2006.

Take care, Laurie

Technorati Tags: pain, primarycare

Bypass Surgery: Medical Fraud?

Over on the Heart Disease Support Board at Web MD, "Vlad" reports that his dad recently suffered a heart attack, and that there is now controversy in his household about whether or not his father should undergo the recommended coronary artery bypass and mitral valve replacement surgery; his dad has 3-vessel disease and a leaky mitral valve.

Vlad shares that his dad is frightened at the prospect of having surgery, and his mom, who has read a book called "Heart Frauds" by obstetrician-gynecologist Dr. Charles McGee, thinks that there is no benefit to his having the surgery. According to Vlad's post, the premise of McGee's book is that there has never been any actual proof that CABG surgeries extend a person's life. Vlad writes that he is "terrified of pressuring my dad into a potentially life-threatening surgery if he could survive without it" but on the other hand, he's also afraid that his dad will have another heart attack if he doesn't have the surgery.

Vlad asks an interesting question, especially to those of us in medicine who have become accustomed our patients being referred to have bypass surgery. First of all, in this day of evidenced-based medicine, I really doubt the surgeons would continue to perform a procedure that had no merit whatsoever. Second of all, cardiovascular disease has been proven to be progressive; if a person chooses not to have surgery, they will eventually have the opportunity to make that choice again, although no one can predict how soon that will happen. According to the American Heart Association, in an analysis of seven studies of individuals who had chosen medical management rather than open-heart surgery, a range of 37-50% in had crossed over to have bypass surgery in the 10-year follow-up period.

There are a number of factors that effect surgical outcomes and life expectancy post-bypass, and for those who are interested in the details I recommend that they read the ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive Summary and Recommendations, published in 1999 in the journal Circulation. One of the interesting points made by this article is that their analysis is being made on studies from the 70-80's. These studies were completed before the current trends in medical management of heart disease were known, such as the consistent use of drugs like beta-blockers, ACE-inhibitors, and lipid-lowering agents.

Since I haven't read Mr. McGee's book, it may be that his premise is exactly this: we don't know what changes in medical management will do to the surgical versus medical management arguments. But the surgeons get to argue on the flip side: bypass surgery is being made safer by procedures that allow them to open the chest only minimally or to work on a beating heart, and moving to the consistent use of the internal mammary artery for grafts has increased graft success rates. These procedures, like the newer medical management techniques, have not yet been put through the same comparative analysis. My guess is that analysis is underway now, knowing something about how the American Heart Association (AHA) works.

Where does all this leave Vlad's dad? Well, there are certain things that we are still sure about when considering an individual for open-heart surgery. There are health conditions that can affect a person's surgical outcomes; these include:

• Age: patients over 70 are at a slightly higher risk for complications.
• Gender: women have a slightly higher risk.
• Previous heart surgery puts a person at a higher risk.
• Having another serious medical condition: diabetes, peripheral vascular disease, kidney disease, or lung disease.

There are also possible risks in having coronary artery bypass grafting (CABG), which include:

• Heart attack, which occurs in 5% of these surgeries.
• Stroke, which occurs in 5% of these surgeries (the risk is greatest in those over 70).
• Blood clots.
• Death, which occurs in 1-2% of those who have the surgery. That also means that 95-98% have no serious complications.
• - Sternal wound infection, which occurs in 1-4% of these surgeries (this complication is most often associated with obesity, diabetes, or having had previous CABG).

Addressing question of long-term survival, the AHA reports on a collaborative (with the American College of Cardiology) meta-analysis of 7 trials with a total enrollment of 2649 patients, which has allowed comparison of surgical versus medical outcomes at 5 and 10 years. Among all these patients, the extension survival of CABG surgical patients compared with medically treated patients was 4.3 months at 10 years of follow-up. That doesn't seem to be much, but it's in the breakdown of the subgroups where the differences really show. For example, in patients who had a diseased left main coronary artery, the median survival for surgically treated patients was 13.3 years versus 6.6 years in medically treated patients.

Based on Vlad's description of "three-vessel disease," it is likely that his dad left main artery is involved in his disease process. According to this report, "the benefit of surgery for left main coronary artery disease patients continued well beyond 10 years. By 15 years, it was estimated that two thirds of patients originally assigned to medical therapy and who survived would have had surgery. The 15-year cumulative survival for left main coronary artery disease patients having CABG surgery was 44% versus 31% for medical patients." Additionally at 5 years two thirds (66.6%) of the bypass patients had no symptoms, compared with 38% of the medically managed patients. At 10 years symptoms were about the same and the authors attributed this to the use of vein grafts in the bypass patients as well as the crossover of medical patients to having bypass surgery. Again, this outcome points out things that will be evaluated in the future analysis of studies from the period between the late 80's and the early years of 2000, when use of the internal mammary artery had become the norm in bypass grafting.

Paul Prudhomme, chef-owner of the famous K-Paul's Restaurant in New Orleans and heart patient, tells a story about how he came to write the book "Chef Paul Prudhomme's Fork in the Road: A Different Direction in Cooking." Having developed heart disease, Chef Paul decided to turn to healthier cooking, and to produce a book for individuals with health concerns. He talks about how he came to his own "Fork in the Road," where he had to make healthier food choices. I have been told that he notes in this story that we all make the best possible choices with the best available information given to us at the time that our choices are made.

Eventually we each will reach a personal fork in the road. We'll take the best information available to use, combined with the recommendations of the professionals that we are paying to advise us, and if we trust them, we will feel comforted that we have made the best possible decision for that moment. Vlad's father is being advised to have bypass surgery and a repair of his mitral valve. I think if I were in his shoes, I'd have the surgery.

Laurie

Convinced myself, I seek not to convince.
Edgar Allan Poe (1809 - 1849), Berenice

Related Topics: Repair or Replace Mitral Valve?, Nonsurgical Treatments for Heart Disease

Technorati Tags: mitralvalve,heartbypass,surgery,webmd

Knitting Nurses

Here's something you don't know about me; am a self-taught knitter. I also need another life of time so that I can spend more of it knitting. I decided to learn to knit because I fell in love with all the beautiful yarns in the shops. I made my daughter the most beautiful sweater, and now I want one, but I can't seem to find the time to get the yarn and get started.

Over at Lion Brand Yarns there's a blogger named Mandy, who's also a nurse. For those of you who like a good yarn about knitting or who enjoy a happy story, check her out.

Laurie

Creativity is a drug I cannot live without.
Cecil B. DeMille (1881 - 1959)

Technorati Tags: knitting,nurses,yarn,webmd

Why I didn't Go to Medical School

I had a really great grandmother, who was a nurse. She was born in 1900 and became a nurse in the mid-40's when she got displaced from a job inspecting planes on a Sea Bee base. She'd started there as a waitress in the canteen at the beginning of the war, then scored this job as the last of the men went off to fight, and the women filled their jobs. It's funny; I never talked to her about the plane inspections, yet I am so proud of her for being a woman in a nontraditional job at a time when women had to rapidly learn to consider unusual options. You might say think "outside the box," but I hate cliches.

When the war was over and the men came trickling home, women like my grandmother had to make other plans. The state began offering job-retraining programs, and through them she became an LPN. I still have her textbooks from school and as far back as I can remember I can recall reading her nursing textbooks when we went to visit on Sunday afternoons.

When I graduated from high school I was working as a certified nursing assistant (CNA). I started college at the "number one party school in the nation," but to tell the truth it wasn't the partying that made my grades rotten. It was just like high school; too many high school friends on campus and no real passion for anything. I left home and went to Virginia where I had family, and got another CNA job. On a ‘lost soul' phone call home to grandma, she said to me, "I don't know why you don't go to nursing school; you love what you're doing, and apparently your patients love you." It was like getting hit in the head! Why didn't I think of that?

It's really interesting how fast one can get through school when food has to be put on the table! Grandma and I would chat regularly, and she'd tell me stories about being a nurse in a mental hospital in the 40's and 50's. Sorta like Cuckoo's Nest, you know? It made us close, and because I admired her so much, I wanted to be like her. I developed into the kind of nurse I believed she was, caring and compassionate, a person who'd often go around the rules a bit to make things work for humans that needed her care.

My grandmother was bigger than life to me. By the time I graduated with my Bachelor's Degree in nursing she was nearly 84 years old; we were still living 500 miles away from one another and I missed her so! Two years later my (now) husband and I moved home because I wanted to live near her again. She lived two more years and she passed on right after trout season "opening day" in April. She loved to fish, and lived for opening day. When I was a kid she'd take me fishing and impress me with her ability to recognize, and repeat, bird calls, so that they would "talk" back to her. When she died at the hospital where I worked I was "on duty," as she used to say. She'd been ill for a while, and had made herself a "no code." I remember the nursing supervisor coming to tell me, and I sat down right there in the hall and cried. Then I went to her room and opened the window as she'd told me she'd always done, to let her soul fly away.

When my father and uncles made arrangements for her burial one of my uncles decided that she should wear a certain dress; I objected on the grounds that she never wore that dress except on special occasions, and she was an individual who lived for comfort, not dress-up. No one would listen to me, and I got so frustrated that unbeknownst to the others my sister and I went to her house and got all her fishing gear: rod, hat, vest (complete with hand-tied flies), and waders, and took them to the funeral parlor (BTW, what kind of name is funeral parlor, or funeral home? Someone needs to explain that one to me). The director, a family friend, balked a bit, telling me that she was already in a dress! I told him to put the gear on over the dress if he needed to, but put it on. When funeral day came my sister and I had a bit of a time keeping a straight face in the receiving line, but it was worth it. Her casket was closed, with her "gone fishing" sign hanging on the outside.

Today, when people ask me, why did you become a nurse practitioner, why didn't you just go medical school? I tell them it's because nursing is in my bones, and it connects me to one of the most special women I have ever known. Here's to you grandma, thanks for watching out for me.

Laurie

Related Topics: Many Patients Prefer Nurses to Doctors, Caregiver

Tags: grandma,tribute,webmd

Strong Bones, Weak Memory

Anyone have trouble remembering to take their medications? I volunteered (read: I actually ASKED my doc for it) to take something for bone strength (Actonel), because there is osteoporosis in my family, and I have early bone thinning. Just a little thin, but I can see the handwriting on the wall. If I don't take care of this now, I'll have osteoporosis and be at risk for broken bones before I know it.

So back in July I got this prescription and I'm supposed to take the medication once a week. Do you think I can remember? I am the QUEEN of telling people how to remember to take their meds. "Put them with your toothbrush," I say, or "set them next to the coffee pot." Well it doesn't make me remember. None of it works. I put them next to my computer, where it feels like I spend every waking moment when I'm home. I put it in the kitchen with my tea. That worked great while I was walking every morning, but 6 AM walking hasn't happened since the light changed a few weeks ago. I’m hoping after the daylight savings time change I can go back to walking in the morning, because this end of the day walking is a pain at the end of a long workday. I bet you know. There's never a good time to exercise, is there?

Anyway, this med has to be taken on an empty stomach. I arrive home starving at the end of the day, so there's no way I'm going to take this pill and wait a half hour before eating dinner! So I'm working on this. Let me know if you come up with any ideas….

Laurie

Related Topics: Women and Calcium, Pomegranates for Osteoporosis

Technorati Tags: osteoporosis, boneloss, calcium, medicationreminders

Carbs Aren't the Problem

Ok, once again, repeat after me, "carbs are not the problem, carbs are not the problem."

The Women's Health Initiative, a multi-year study of 48,000 post-menopausal women has once again proven that losing weight is as simple as calories in and calories out. Face it, who has a harder time losing weight and keeping weight off than post-menopausal women? We 40-somethings can whine all we want, but remember how much worse it got as we shifted from or 20's to our 30's, and then into our 40's? Well add another decade and and the loss of hormones and whoa baby, you ain't seen nothin' yet!

Here's the nitty gritty: the Women's Health Initiative Dietary Modification trial was a long-term study designed to see whether diets low in fat and high in fruits, vegetables, and whole grains could help protect postmenopausal women from cardiovascular disease, breast cancer, and colorectal cancer.

From 1993 to 1998, a total of 48,835 post-menopausal women were randomly assigned to either a low-fat, carbohydrate-rich dietary intervention, or a dietary control group of their own choosing. Women in the low-fat diet group attended individual and group sessions focused on promoting the low-fat intake and increasing vegetable, fruit, and whole-grain (complex carb) consumption. They did not receive any instruction on weight loss, nor were they asked to restrict calories. The control group received diet-related education materials only. The researchers then collected data on body measurements and nutrient intake through August 31, 2004, with an average follow-up of 7.5 years. A total of 19,541 (40%) of the participants were randomized to the low-fat, complex-carb diet and 29,294 (60%) were assigned to the control group. Women in the low-fat diet group lost an average of 4.8 pounds compared to virtually no loss for the control group in the first year. Additionally, the low-fat, carbohydrate-rich group kept more weight off over the study period, although the difference narrowed over time, from 4.1 pounds at one year, to 0.8 pounds at 7.5 years. The researchers noted, "Weight loss was greatest among women in either group who decreased their percentage of energy from fat. A similar trend was observed with increases in vegetable and fruit servings..."

So as you're contemplating those New Year's resolutions to lose weight, the take home message from this study is that caloric restriction, rather than a focus on individual diet components is the only sure-fire way to achieve weight loss through dieting. Since my mom participated in the low-fat, carb-rich arm of this study and lost at least that average amount of weight, I guess I better go talk to her now...

Happy New Year, Laurie


Walking is the best possible exercise. Habituate yourself to walk very far.
Thomas Jefferson (1743 - 1826)

Related Topics: The Atkins Diet: What it is, South Beach Diet: What it is

Tags: carbs, diet, exercise, 2006resolutions, webmd

Does Your Health Care Provider Treat Pain?

Over at Kevin, M.D.'s Medical Weblog there is discussion of the choice of some physicians not to apply for a Federal Drug Enforcement Agency (DEA) licenses to prescribe Schedule 2 drugs (potentially addictive drugs with critical medical use, such as opiate-based pain medications). One case that he describes is that of a patient who becomes very ill and requires pain medication (see Thursday, 1/6/06 blog). The patient goes to his primary care doctor only to find that he does not have a DEA license to prescribe narcotics. The patient was forced to find a new provider to manage his cancer pain while he was in the crisis of illness.

This weblog discussion is based on a current article in the New England Journal of Medicine (NEJM) regarding the potential for the DEA to become involved in examining physician's practices for writing pain medications for individuals at the end of life. This article points out, "Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians' fears of regulatory oversight and disciplinary action remain a central stumbling block" for prescribing Schedule 2 drugs. Well, I'm not buying that; I think for many providers the overblown fear of regulatory oversight is an excuse not to do the hard work of pain management.

I find the choice of any provider not to prescribe appropriate pain medications unthinkable, and their excuses for not doing a portion of the job that is critical to patient's comfort morally reprehensible. If, as the NEJM article points out, the individual provider feels inadequately trained to provide pain management, then seek out the education needed. This is important to patients: poorly controlled or uncontrolled pain and other distressing symptoms are the greatest fears of patients facing serious illness. According to research, greater than 90 percent of the pain associated with severe illness can be relieved if providers adhere to well-established guidelines and seek help from experts in pain management or palliative care as needed.

I have been in a physician-NP practice for 2 years; like any practice, we have our share of folks looking for narcotics to take away the pain of life for a bit. In my opinion, if a provider is thoughtful and consistent in their practice, a chart audit will indicate that there is no reason to suspect their prescribing practices. There are specific steps that can be taken by a provider to protect themselves from both DEA criticism and the drug-seeking patient.

For example, each pain management patient should be seen on a regular basis (for me it's quarterly at a minimum or their prescriptions aren't refilled) to evaluate and document their pain and level of functioning on their current regimen. If it's appropriate all of my pain management patients are also going to physical therapy or to pain management specialists for other modalities, such as steroid injections. Ongoing participation in these consults is a requirement for them getting pain medications renewed.

It is also important to create certain expectations with the individual patient to keep a provider from being marked as a pushover when it comes to obtaining a narcotic prescription. For example starting off with the stated anticipation that a certain acute injury will need roughly "x" amount of healing time, that the provider expects a prescription to last the person at least a certain number of days and wants to hear from them earlier if the medication isn't "holding them," (rather than calling 4 days early because they're all out of pills), and stating an expectation that they will have started PT by their next visit are all possible appropriate options. These statements set the individual up knowing that the provider sees a time limit to the need for narcotics and that you are working together to get them well and back to full functioning. This scenario of course presumes that the injury is capable of healing; certainly the discussion is different when an individual is terminally ill.

In two years we've built a busy practice and I can count on one hand the few people who've really been a problem. Those individuals sign a pain agreement, which requires them to use a single pharmacy and get all their narcotic prescriptions from our office. It takes very little time to weed those problem individuals out after that, because a call to the pharmacy board got me a report on all their filled prescriptions since our agreement was signed. Those individuals were then told that our office would continue to manage all of their medical problems and that we would refer them to a pain management specialist for this particular issue. We also offered referral to help for their addiction, if the over use problem was theirs.

Do these practices potentially foist the narcotic abuser off on someone else? Yes. But doing them and documenting them in the patient's chart also keeps an individual providers butt out of a sling if a chart audit occurs. More importantly to our patients it also allows providers to safely offer a critical service to individuals in pain.

No one ever told me practicing medicine would be easy; in fact it isn't easy. The decisions that health care providers make every day can mean life or death, comfort or pain. The decision to prescribe narcotics safely and effectively is as important as any other treatment decision I make, and I believe that my patients with pain deserve to have access to this care from the provider who knows them best. I didn't start out with the knowledge to prescribe narcotics in this manner, but I sought the needed education that is available to any provider who chooses to avail themselves of it. So the next time you are seeing your health care practitioner, ask if they prescribe narcotics when they are necessary. You don't want to find out they don't when you're in pain.

Laurie

The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.
Sir William Osler (1849 - 1919) British (Canadian-born) physician

Related Topics: Care at the End of Life, Cancer Pain

Tags: cancer,NEJM,painmanagement,webmd

Siblings With Heart Disease?

The National Heart, Lung, and Blood Institute, a division of the National Institute of Health, has been following a representative sample of the residents of Framingham Massachusetts since 1948, in a study called the Framingham Heart Study. This study has contributed a large volume of knowledge about what causes heart disease to begin, evolve, and to end fatally in the general population.

In 1971 the Framingham Offspring Study began a spin-off of the original study that follows 5,124 of the original participant's children, 28-62 years of age. These individuals have been tracked using standardized, twice yearly cardiovascular exams, daily surveillance of hospital admissions, death information and information from health care providers outside of the study clinic. Researchers hope to understand what differences exist between those who develop heart disease and those who don't over a long time period.

The latest information from the Offspring Study is that if you are middle-aged and have a sibling with heart disease, your risk of developing heart disease is 45% higher than that of people whose siblings have not had heart disease.

Joanne Murabito, M.D., Sc.M., of the National Heart, Lung, and Blood Institute's Framingham Heart Study reported these findings in the December 28 issue of the Journal of the American Medical Association. Dr. Murabito and colleagues analyzed the data of 2,475 participants in the offspring group, aged 30 and over, who did not have heart disease at the start of the study. Participants were followed for 8 years and cardiologists or neurologists verified all cardiovascular events.

During this time there were 329 cardiovascular disease events, including 11 heart-related deaths, 8 other cardiovascular deaths, 99 nonfatal cases of myocardial infarction or coronary insufficiency (unstable angina), 106 cases of angina (stable), 59 strokes or transient ischemic attacks, and 46 cases of intermittent claudication (leg pain related to arterial blockages). After adjusting for age, sex, and heart disease risk factors the researchers found that the risk for cardiovascular events is 45% greater for those whose siblings have vascular disease than those who do not when compared to the general population.

The sibling factor was also a stronger predictor of the development of cardiovascular disease than having a parent with premature heart disease, which is a routine screening question that health care providers use to determine an individuals risk of developing heart disease. This research implies that sibling cardiovascular disease is a useful marker of family members' vulnerability to cardiovascular disease. The fact that increased risk remains after adjusting for age, sex, and heart disease risk factors suggests, "a significant proportion of risk is explained by factors other than the traditional risk factors," concluded the researchers. Dr. Murabito noted that the one limitation of this study is that the Town of Framingham's population is primarily white, and therefore these results may not apply to individuals of other ethnic backgrounds.

These results are certainly intriguing and will cause me to ask individuals about their siblings' history of heart disease as I interview them as part of a chest pain evaluation.

Laurie

All generations experience change. You cannot predict the future, so don't waste any time worrying about it. The challenge you must accept, right now, is to make yourself better every day.


Jeffrey R. Immelt
Business executive

Related Topics: Heart Disease in Siblings Doubles Your Risk, Real Stories: Living With Heart Disease

Tags: heartdisease,siblings,webmd

Get Paid to Quit Smoking??

Here's an interesting concept: a web site that pays you to quit smoking. Jeff Schell, Founder and CEO of Smokers Brokers writes that the idea for this incentive to help smokers quit came during a road trip among four college friends, two of whom were smokers. Apparently the smokers drove the nonsmoking passengers crazy with their need to stop for smoke breaks, and Mr. Schell bet one of the smokers that he could help him to quit and make money. A year later he reports that the friend has "cut down" significantly on his smoking and has made enough extra cash through investing his cigarette money to plan a trip to Cancun. I'm all for anything that will help smokers quit, and I wonder if any of the smokers I know will trust this guy enough to invest in his service. I'm concerned that because this business is not the actual broker there is no assurance that this guy won't take your money on a trip to Cancun himself. I wrote to him to ask him to discuss my concern; we'll see if he replies.


Laurie

Reputation is what you are in the light;
character is what you are in the dark.
--American Proverb

Related Topics: Smoking Cessation, Motivating Yourself or Others to Quit

Tags: quitsmoking,Cancun,smokersbrokers,webmd