nebulous

For the Daily Prompt: mnemonic.

I know lots of mnemonics. The first that I learned is “Every Good Boy Does Fine”, for the lines of the staff of the G clef, for playing my flute. Medicine is full of mnemonics. An out of date one: Shock, shock, shock, everybody shock, big shock, little shock, shock, shock, shock. This used to be the order of shocks and the medicines for cardiac arrest. It has changed…

…but I would rather look at the photograph than think about mnemonics. It is not a nebula, but that is a star. I took this with my cell phone when it was almost too dark, so the nebula like shapes are the tops of trees, a block from my house.

opioids international

The US is not the only opioid crisis.

Reblogging:

https://www.groundup.org.za/article/woman-battles-escape-whoonga-park/

Living in the hell of Whoonga Park

Murder, rape, crime, homelessness, abuse by police … daily life for whoonga users

Photo of a woman holding a beaded South African flag
Nobuhle Khuzwayo doing bead work during life skills training at the Denis Hurley Centre. Photo: Nomfundo Xolo
By

“Siqalo used to be the most promising child in our house … the last born. He got the best of everything. We took him to better schools than we did his younger sister and brother. He did well for the better half of high school.Then he met up with the wrong friends, and never even got to matric,” Fanele Ngcobo tells GroundUp about his son.

Siqalo is 22. He has been a whoonga user since 2015. By 10am, he has already smoked his second fix. Without the drug he struggles to function. Withdrawal effects – which people refer to as “arosta” – include stomach cramps, vomiting, and extreme anxiety.

Whoonga is a mixture of marijuana and heroin and rumoured to contain anti-retrovirals, detergents and even rat poison. Active addiction has spread in KwaZulu-Natal townships such as KwaMashu and iNanda. Hundreds of people now live in Durban’s ‘Whoonga Park’,

Siqalo was a keen soccer player, says his mother, Sizakele. Now his worn, black soccer shoes peek out from under the bed in his old room at home in iNanda, Durban.

“He always went for practice with his friends at the local playground. But after a while, soccer wasn’t the only thing he and his friends were playing with; he was also experimenting with dangerous drugs,” she says.

Siqalo lives in so-called Whoonga Park, under a bridge next to the Berea railway lines in Durban. The park has become a den for whoonga users. They have bright beach umbrellas to protect them from the heat and black plastic bags for shelter. The activities under the bridge are in plain view. People trade and smoke. In the afternoons and at night, many take to the city streets to hustle for food and the money they need to buy their fix.

“There are no beds here. Even if you can get a blanket or sheet to sleep in, it doesn’t last a week. The police will burn it,” says Siqalo. “So it’s easier just to use cardboard and plastic as it is easy to find in the streets. Although I miss home, I cannot go back home like this. I need to be clean. My family doesn’t trust me around the house and for good reason because I’ve stolen their money and appliances too many times. I tried to be clean when they first fetched me, but arosta is too painful – nobody can understand. But I still want to go home.”

Cooked meals, showers and clean clothes

Nobuhle Khuzwayo from eMpangeni, KwaZulu-Natal, is one of those trying to get off whoonga. She attends the iSiphephelo Centre housed at the Denis Hurley Centre in Durban, where she gets cooked meals and clean clothes three times a week. For a few hours she is free of whoonga.

Co-founder of the centre Sihle Ndima says it is a place of safety for young girls and women living on the streets of Durban. It offers meals, counselling, clean clothes and showers.

“Many of them return back to the streets soon after classes, and the work we do seems like failure, because in the end they go back to using whoonga,” says Ndima. “We work with a rehabilitation centre in Newlands East, Durban, and they offer free help.”

Khuzwayo, who is 30, came to Durban seeking a job in 2014, but after numerous failed attempts, she was left homeless and desperate.

“The shoe factory I was working for closed down after a month. Thereafter it was difficult to get employment. I had been staying at the Dalton hostel with some friends, who later introduced me to smoking. They would tell me it was marijuana, but after becoming a frequent smoker … I would get headaches, pains and stomach cramps when I hadn’t smoked. I just could not cope without it. When I confronted them, they told me it was in fact whoonga. I was already deeply hooked,” says Khuzwayo.

She could no longer live at the hostel. She moved to Whoonga Park. To get money she would have to resort to sex work, crime or selling cigarettes. She found a boyfriend who sold cigarettes at taxi ranks to help get them food and the R30 a day they needed to buy whoonga.

“To survive on the streets, I got myself a boyfriend because you can’t survive a day alone under the bridge as a woman. There are men known as amaBhariya, who claim to own the spots in Whoonga Park. They do not smoke or deal the drug; they do not speak local languages or even English. They are ruthless. They rape and kill women under the bridge and make sure the park functions the way it does. They wear blue workmen’s clothes and hats and use the underground drains to move around. So if you don’t have a man to protect you, they will always take advantage of you,” says Khuzwayo.

Merchants outside the park sell whoonga for R30. “They are usually in the streets or in nearby flats but not many sell whoonga under the bridge,” she says.

Hundreds now live in Whoonga Park beside the railway lines in Berea, Durban. Photo: Nomfundo Xolo

Khuzwayo has now moved to a local shelter, paying R20 a night. Her closest friend had TB and when she died it was a turning point.

“I am tired of this life. I am determined to change. I don’t want to die a senseless death without dignity,” she says.

She is now a part-time cleaner at iSiphephelo. After attending all counselling and life skills classes she will qualify for rehab. “After rehab, I am going to go back home and stay with my sister in eMpangeni. You cannot stay away from whoonga in the city,” says Khuzwayo.

Siqalo and Khuzwayo say whoonga users are known as amaPhara. “Because we look like zombies. We’re dead people walking. We sleep standing. We stab you for your phone and sell it for a fix. Plastic and rubble is our shelter, faeces and rubbish are everywhere, and we run from police who destroy our things and chase us away every week. But we always come back. We can’t survive anywhere else,” says Siqalo.

Khuzwayo says she has seen people high on whoonga killed by trains.

“You can’t save them, because it’s like the railway shocks you, and you’re unable to move … seeing the train come at you but unable to run. I’ve seen some getting crushed in half and some losing their limbs. Even a security guard, who was chasing us one time, got stuck and the train crushed his foot.”

“One way or the other, you’re lucky to survive under the bridge.”

reblogged from: https://www.groundup.org.za/article/woman-battles-escape-whoonga-park/

Illness Anxiety Disorder

“Please write something from a medical perspective about anxious people who worry every little thing is some serious disease.” — reQuest 2018

This is quite a brilliant and timely question.

Here: https://www.anxiety.org/hypochondriasis-replaced-by-two-new-disorders-in-dsm-5.

The DSM V was published on May 18, 2013. This is the Diagnostic and Statistical Manual of Mental Disorders version 5,  and it redefines various disorders. For example, opiate dependence has disappeared and so has opiate addiction. Instead, there is one diagnosis: opiate overuse syndrome. Which really combines both opiate addiction and opiate dependence and makes it a spectrum.

The DSM V drops hypochondriasis. Wait, you say, that diagnosis no longer exists? Well, yes, correct. So the diagnoses are made up? Yes, as my daughter says, “All the words are made up.” So psychiatry changes and the diagnosis definitions change and some diagnoses disappear. Medicine is like the Oregon Dunes, really. The information is changing daily. I went into medicine thinking it is like a cookbook, where I just have to learn all the recipes. Nope, sand dunes: the wind and waves and new information change the contours daily. It drives my patients nuts. “My insurance won’t cover the medicine I’ve been on for 26 years.” Um, yeah, sorry, work for single payer and shut down the insurance companies, ok? “This combination of medicines has never killed me yet.” Um, yeah, sorry, but you are in fact getting older and we no longer think that combination is safe and first do no harm: I can’t prescribe combinations that I think may kill you.

Hypochondriasis has been replaced by two diagnoses: Somatic Symptom Disorder and Illness Anxiety Disorder.

From the Mayo Clinic website: https://www.mayoclinic.org/medical-professionals/clinical-updates/psychiatry-psychology/diagnostic-statistical-manual-mental-disorders-redefines-hypochondriasis.

“Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.”

“To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.”

So, subtle difference. Broadly, the illness anxiety disorder people are sure they have SOMETHING and are worried about ALL THE SYMPTOMS. The somatic symptom disorder people are worried about A SPECIFIC SYMPTOM OR SYMPTOMS and WHY HAVEN’T YOU FIXED ME.

Some of the people complaining of weird symptoms do have a medical diagnosis that has not been sorted out. Take multiple sclerosis for example. The average time from the start of symptoms to diagnosis is 4-5 years.

Here: http://biketxh.nationalmssociety.org/site/DocServer/Facts-about-MS.pdf?docID=54383).

Also here: https://www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-Tools.

Another one is sarcoidosis: https://www.mayoclinic.org/diseases-conditions/sarcoidosis/symptoms-causes/syc-20350358. It’s hard to diagnose, can affect different parts of the body, and it’s still pretty mysterious. Add to that list chronic fatigue, fibromyalgia, chronic pain, and numerous other diagnoses.

With multiple sclerosis, you may be thinking, well, if they had just done the brain MRI sooner, the diagnosis would be made. Not necessarily. I did find a patient with a bunch of MS brain lesions: made the diagnosis. She had had a brain MRI 3-5 years before because of suspicious symptoms during pregnancy. At that time her MRI was entirely normal.

The DSM V does not have a diagnosis called psychophysiological disorder. This is an ongoing discussion:
1. https://pdfs.semanticscholar.org/7f7f/21a9b524fb677d575428bea11aab4c8d70c5.pdf
2. https://thoughtbroadcast.com/2011/01/21/psychosomatic-illness-and-the-dsm-5/
This site: http://www.stressillness.com/ is my current favorite about psychophysiological disorders. I heard a lecture from the physician who runs the site. He is at OHSU in Portland and gets the gastrointestinal patients where “they can’t find anything wrong” from all over the state. He is really good at this. He and I are in agreement: the symptoms are real. However, the symptoms may come from emotional suffering and from emotional trauma in the past and present.

It is clear that fibromyalgia is a “real” disorder: functional MRI of the brain shows the pain centers lighting up more with a standardized pain stimulus than “normal” patients. PTSD is “real”. It is interesting that there is more stigma surrounding fibromyalgia and chronic fatigue than PTSD: is that because the former two are more often diagnosed in women, and the latter is legitimate (finally) for male (and a smaller number of female) veterans?

And what do I, your humble country doctor, think? I think that chronic fatigue and PTSD and fibromyalgia and illness anxiety disorder and the others all may be variations of the same thing. Our body will handle and “store” or “stuff” emotions that we cannot handle or are not in a safe situation to handle it. Eventually our body decides that we are now safe enough and will notify us that we have to handle the emotions. Currently our culture is terribly unsupportive of this and there is huge stigma attached to dealing with it. We are all supposed to just be nice.

In the end, we can’t judge how a friend feels or whether they are well or not. We have to treat them with respect and kindness.

The photograph is me on my grandfather’s lap. He became a psychiatrist and I am a family physician. Taken in 1962 or 3. We are at cabins in Ontario, Canada. What a pair of grubs, but happy…..

Make America sick again: diabetes

The trend in diabetes treatment is clear: keep Americans sick.

The guidelines say that as soon as we diagnose type II diabetes, we should start a medicine. Usually metformin.

A recent study says that teaching patients to use a glucometer and to check home blood sugars is useless. The key word here is teach, because when I get a diabetic transferring into my clinic, the vast majority have not been taught much of anything.

What is the goal for your blood sugar? They don’t know.

What is normal fasting? What is normal after you eat? What is the difference between checking in the morning and when should you check it after a meal? What is a carbohydrate? What is basic carbohydrate counting?

I think that the real problem is that the US medical system assumes that patients are stupid and doesn’t even attempt to teach them. And patients just give up.

New patient recently, diabetes diagnosed four years ago, on metformin for two years, and has no idea what the normal ranges of fasting and postprandial (after eating) are. Has never had a glucometer.

When I have a new type II diabetic, I call them. I schedule a visit.

At the visit I draw a diagram. Normal fasting glucose is 70-100. Borderline 110 to 125. Two measurements fasting over 125 means diabetes.

After eating: normal is 70-140. Borderline 140-200. Over 200 means diabetes.

Some researchers are calling Alzheimer’s “Type IV diabetes”. The evidence is saying that a glucose over 155 causes damage: to eyes, brain, kidneys, small vessels and peripheral nerves.

Ok, so: what is the goal? To have blood sugars mostly under 155. That isn’t rocket science. People understand that.

Next I talk about carbohydrates. Carbohydrates are any food that isn’t fat or protein. Carbohydrates range from simple sugars: glucose and fructose, to long chain complicated sugars. Whole fruits and vegetables have longer chain carbohydrates, are absorbed slowly, the body breaks them down slowly and the blood sugar rises more slowly. Eat green, yellow, orange vegetables. A big apple is 30 grams of carbohydrate, a small one is 15, more or less. A tablespoon of sugar is 15 grams too. A coke has 30 grams and a Starbuck’s 12 ounce mocha has 62. DO NOT DRINK SWEETENED DRINKS THEY ARE EVIL AND TOOLS OF THE DEVIL. The evidence is saying that the fake sugars cause diabetes too.

Meals: half the small plate should be green, yellow or orange vegetables. A deck of card size “white” food: grains, potatoes, pasta, whole wheat bread, a roll, whatever. A deck of card size protein. Beans and rice, yes, but not too much rice.

For most diabetics, they get 3 meals and 3 snacks a day. A meal can have up to 30 grams of carbohydrate and the snacks, 15 grams.

Next I tell them to get a glucometer. Check with their pharmacy first. The expensive part is the testing strips, so find the cheapest brand. We have a pharmacy that will give the person a glucometer and the strips for it are around 4 for a dollar. Many machines have strips that cost over a dollar each.

I set the patient up with the diabetic educator. The insurance will usually cover classes with the educator and the nutritionist but only in the first year after diagnosis. So don’t put it off.

For type II diabetes, the insurance will usually only cover once a day glucose testing. So alternate. Test 3 days fasting. Test 1-2 hours after a meal on the other days. Test after a meal that you think is “good”. Also after a meal that you think is “bad”. I have had long term diabetics come in and say gleefully “I found a dessert that I can eat!” The numbers are not always what people expect. And there are sneaky sources of carbohydrate. Coffeemate and the coffee flavorings, oooo, those are REALLY BAD.

For most of my patients, the motivated ones, they have played with the glucometer for at least a week by the time they see the diabetic educator. I have had a person whose glucose was at 350 in the glucose testing. The diabetic educator called and scolded me for not starting metformin yet. The diabetic educator called me again a week later. “The patient brought their blood sugars down!” she said. “She’s under 200 after eating now! Maybe she doesn’t need the metformin, not yet!” Ah, that is my thought. If we don’t give people information and a tool to track themselves, then why would they bother? They eat the dessert and figure that the medicine will fix it or they can always get more medicine.

Type I diabetes has to have insulin. If a type II diabetic is out of control, high sugars, for long enough, they too will need insulin. The cells in the pancreas that make insulin are killed by prolonged high blood sugars.

I went to a lunch conference, paid for by a pharmaceutical company, at the AAFP conference in September. The drug company said start people on metformin at diagnosis and if they are not in control in 3 months, start a second medicine, the drug company’s new and improved and better and beastly expensive medicine!!!

Yeah, I don’t think so. All of my patients are smart and they all can figure it out. Some get discouraged and some are already on insulin, but they are still all smart.

Fight back against the moronization of US citizens. Keep America healthy, wealthy and wise.

hypertension: The 2017 Clinical Guidelines

A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”

“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?

First of all, these guidelines are NOT JNC 9.

What is JNC 9, you ask?

One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.

And do you think some of it is driven by money? Well, it’s the US.

JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.

They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.

Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.

The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.

But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.

So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.

It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.

How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”

Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.

It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.

Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”

I reply, “Let’s talk about strokes.”

They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.

One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..

JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
JNC-8: https://jamanetwork.com/journals/jama/fullarticle/1791497
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/

teens high risk for addiction

What teens are at high risk for addiction?

Would you say inner city, poor, abused, homeless?

This study : Adolescents from upper middle class communities: Substance misuse and addiction across early adulthood. which I first saw in WebMd, says that the privileged upper middle and rich children are at higher risk  for addiction than many of their peers.

350+ teens in New England were studied.

Drug and alcohol use was higher than across country norms, including inner city.

Rates of addiction diagnosis by age 26 were
19%-24% for girls
23%-40% for boys
These rates are two to three times the norms across the country.

Rates for addiction diagnosis by age 22 were
11%-16% for girls
19%-27% for boys
These rates are close to the same in girls, but twice as high in boys as peers across the country.

The teens were often popular high achievers who are A students. Parents tended to drink more in those cohorts than the norms.

Also: “Findings also showed the protective power of parents’ containment (anticipated stringency of repercussions for substance use) at age 18; this was inversely associated with frequency of drunkenness and marijuana and stimulant use in adulthood.” That is, parents who sent a clear message that consequences for illegal and underage substance use including alcohol and marijuana would be serious, provided protection for their teens.

A second article: Children of the Affluent: Challenges to Well-Being says this:

“Results also revealed the surprising unique significance of children’s eating dinner with at least one parent on most nights. Even after the other six parenting dimensions (including emotional closeness both to mothers and to fathers) were taken into account, this simple family routine was linked not only to children’s self-reported adjustment, but also to their performance at school. Striking, too, were the similarities of links involving family dining among families ostensibly easily able to arrange for shared leisure time and those who had to cope with the sundry exigencies of everyday life in poverty.”

Other children’s perception of parenting examined included:

felt closeness to mothers
felt closeness to fathers
parental values emphasizing integrity
regularity of eating dinner with parents
parental criticism
lack of after-school supervision
parental expectations

This aligns with my observations both in my town and with patients. I see parents “check out” sometimes when their children are in their teens. “I can’t control him/her. They are going to use drugs and alcohol.” I told my children that if they partied I would NOT be the parent who says, “Oh, he needs to play football anyhow.” I would be the parent who would be yelling “Throw the book at him/her. Bench them.” And I saw parents of teens going out to the parking lot to smoke marijuana at a church fundraiser when it was still illegal. And saying “Oh, our kids don’t know.” I thought, “Your kids are not that dumb.” They invited me along. I said, “No.” And I really lost respect for that group of parents. What example and message are they sending to their teens? Yeah, cool, do illegal things in the parking lot, nod, nod, wink, wink.

Meanwhile, my children keep me honest. “You are speeding, mom.”

“Yeah,” I say. “You are right. Sometimes I do.” And I slow down.

bust

I took this in 2011, as a Mad as Hell Doctor, traveling around California talking about single payer.

We are losing more and more physicians. Our three counties, 450,000 people, are down from 8 neurologists ten years ago, to 2. The last one standing in the county of 350,000 says that he is really tired.

Single payer, medicare for all….. because I dream of other countries, civilized countries, countries where there is one set of rules, I can take care of any person who comes to me, I know what is covered and what is not, and I actually get paid….