Top ten causes of death, US, 2020, and doctor time pressure

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

There is an article about US doctors, that primary care would have to work around the clock to apply all of the guidelines, here: https://news.uchicago.edu/story/primary-care-doctors-would-need-more-24-hours-day-provide-recommended-care.

Yes, but this is not new news. There was a trio of articles twenty years ago that said the same thing. And the guidelines have only expanded. Primary care is doing the same thing it has always done: what it can. Meanwhile we go to “Continuing Medical Education” and the other specialists ALL say we are not doing enough, we need to do more. Makes a woman cynical, don’t it?

Family Practice is a specialty, did you know that? We do a three year residency. Internal medicine is also three years, but many then “sub specialize” — further training in cardiology or rheumatology or nephrology, and etc. Sometimes we get a primary care doctor who doesn’t do the extra years but gets interested in something and they learn to subspecialize. We had a pulmonologist on the peninsula here, best I’ve worked with, who had not done the fellowship but learned it on the job. She was excellent and is now retired.

So you as a patient need to be aware of the top ten causes of death and do some thinking. Heart is still number one, in spite of Covid-19. All the cancer deaths are number two, but that’s only a fraction of the cancers. You want cancer screening, to pick it up before it is lethal. Pap smears, colon cancer screening, get your skin checked. Covid-19 is number three in 2020. Let’s look at the list.

US top ten causes of death, 2020.

  • Heart disease: 696,962
  • Cancer: 602,350
  • COVID-19: 350,831
  • Accidents (unintentional injuries): 200,955
  • Stroke (cerebrovascular diseases): 160,264
  • Chronic lower respiratory diseases: 152,657
  • Alzheimer’s disease: 134,242
  • Diabetes: 102,188
  • Influenza and pneumonia: 53,544
  • Nephritis, nephrotic syndrome, and nephrosis: 52,547

The list changes. What has fallen out of the top ten, since Covid-19 was not on the list back in 2019? “Intentional self-harm” aka suicide, was number ten in 2019.

Let’s go through the list one at a time and give you some basic tools and ideas about prevention, since your physician doesn’t have enough time to deal with all of it.

  1. Heart: The people who have not seen a doctor for twenty years, um, go see a doctor. If you have high blood pressure for twenty years, you will also have heart failure, which means pump failure. This is bad and will kill you. Check in at least every three to five years. In the US currently, you are a “new” patient after three years, so it’s best to show up just before that three year mark. Call ahead, everyone is short staffed. Check blood pressure, cholesterol and quit smoking (that includes pot, also bad for the heart), cocaine is very effective at trashing the heart, alcohol is bad for it, so is methamphetamines, and any other silly and stupid substance “overuse”. Kratom? Bad. Fake pot? Also bad. Turn off the tube or computer and go for a daily walk. Outside. Without headphones or earbuds. Try to figure out the bird noises, ok? Eat more vegetables. Don’t be stupid.
  2. Cancer: do the screening tests. Get the HPV vaccine for your children. Get pap smears. Use sun screen. Get your colonoscopy when you hit that age. Want to read about a screening test? Go to this site: https://uspreventiveservicestaskforce.org/uspstf/home . This is the clearing house for the current guidelines AND THEY CHANGE. They get updated. The vaccines are all here too. Get them.
  3. Covid-19. If you aren’t vaccinated then I don’t even want to talk to you, unless you are seriously immunosuppressed and your docs told you not to. Otherwise your brain has been taken over by non-scientist crazy whackos. IMHO.
  4. Accidents have been rising up the list and currently number one is opioid overuse deaths. Do not buy pills on the street because even if they claim to be oxycodone they may actually be fentanyl. The drug cartels aren’t so good at diluting the fentanyl enough to not kill you. If you are on prescribed opioids you should have a shot to reverse it (narcan shot or nasal spray) and your family or friends should know where it is and how to use it. Next is guns and cars. Guns should be locked up with the ammunition locked up separately when you are not working as a policemen or hunting a deer or rhinoceros. Cars should not be driven under the influence and hello seat belts. Oh, let’s see, wear your helmet on the bicycle, roller blades, e-bike, jet-skateboard or whatever. Wear a life jacket in the boat. Don’t point Axe towards your face and try to light the spray on fire.
  5. Stroke. This is all the same stuff as heart. And also Covid-19 increases your risk of stroke.
  6. Chronic lower respiratory disease: this is mostly caused by tobacco, tobacco, tobacco, marijuana, tobacco, asbestos, tobacco and woodsmoke or firefighting. Smoke is bad. Vapor is smoke, ok? See your doctor to get help quitting smoking. My father quit after 55 years of 2 packs a day of unfiltered Camels, so don’t tell me you can’t. Also it takes an average of 8 tries or so to quit. Yes you can.
  7. Alzheimer’s: keep your brain active, eyes are important, ears are important, eat those vegetables and if you live where I do, vitamin D in the winter.
  8. Diabetes: sweet drinks are bad. Fake sweet drinks are bad. A coke has 32 grams of carbohydrate. A Starbuck’s mocha 12 oz has 60. Quit drinking sweet drinks. Your goal is no more than 15 grams of sweetener a day. Now, what exactly is a carbohydrate? It’s anything edible that is not fat or protein. However, there are lots of very low carbohydrate vegetables out there. A cup of kale only has 8 grams of carbohydrate. Sweet peas and sugar beets have a lot more. Diabetics and everyone else should have at least half of every meal be vegetables, green and yellow and orange. Fruit is sweeter and all of the portion sizes (except kale) are less than you’d like to eat. Prevention is good.
  9. Influenza and pneumonia. Get your flu shot. There are two pneumonia shots and the first is given at age 65 and the second at 66. Except in people with heart or lung problems, then they get the vaccine early and repeat at 65 and 66. I think we are going to have a group of people who always mask on planes. I am one of them.
  10. Nephritis and etc. This is kidneys. What can affect your kidneys? Pills and illegal drugs, mostly. All pills that are absorbed are metabolized (which means broken down) by either the liver or the kidneys. Kidney function goes down slowly over a lifetime with age. We are seeing a huge rise in kidney problems because of too many pills. Yes, supplements too. Natural does not mean safe and what the heck is natural about a pill anyhow? Take as few pills as possible. Take ALL the pills to show your doctor. Ok, your doctor might be clueless about supplements. We had one person nearly hit the liver transplant stage until she showed my partner her supplement’s new label “Can affect the liver.” Holy cow. Should say “Can kill you.” So back to prevention: my baseline was that people should have blood lab basic testing every five years before age 50 and every three years after that if they were on NO PILLS. If they are on ANY pills, I recommend yearly testing. Did you know that the supplement companies can change what is in the pill at any time without telling you? Isn’t that reassuring? Heck no.
  11. There are still a long list of other causes of death. Liver disease, intentional self-harm, and on.

Since your doctor does not have time to think about all of this every time you stop by, it’s partly up to you. I don’t trust Dr. Google at all, but the sites I go to are the CDC, the Mayo Clinic, NIH, AAFP (American Academy of Family Practice). I look at lots of quack sites too, to see what is being sold, but I am not advertising them!

Be careful out there.

The photograph is Elwha watching the four point buck and wondering if it will eat him or not. From last week.

Why care for addicts?

I posted this in November, 2015. I am reposting it.

_________________

Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

Herd

For the Ragtag Daily Prompt: herd.

I am reading Dopesick, newly out this year, by Beth Macy. I am wondering what make people try addictive substances. At what age and why? To be popular? Herd mentality?

I’ve interviewed my older smokers for years, asking what age they started. Most of them say they tried cigarettes at age 9. Nine, you say? Yes. Parents then look horrified when I say that they should start talking about drugs and alcohol and tobacco by the time their child is in third grade. Recently a woman told me that she tried cigarettes at age 7.

It’s not just talking to your kids, either. It’s modeling as well. What do you model for tobacco, for alcohol, for prescription medicines, supplements and over the counter medicines? Do you say one thing but do another?

I am 100 pages in to Dopesick. The most horrifying new information is that more people under age 50 have died from opioid overdose then died in the 1990s from HIV and AIDS. Also the failure of history: we have had morphine available over the counter until addiction swept the country. Then heroin. This round is oxycontin. And I checked the index: no mention of kratom, sold from southeast asia. It is related to the coffee plant but it works as an opioid. It has been illegal in Thailand since 1943. I think they figured out that it too is addictive a long time ago.

I was an introvert, a smart girl, a geek before there was a word. I did not party and was not invited. I went to Denmark as an exchange student. I tried a cigarette there and decided that I couldn’t afford it and it tasted awful. I drank beer there, but was careful. I did go to a party where I was offered a bowl of pills: no. I was cautious and became even more cautious when I returned to the US.

When and what did you try first? And WHY? What makes us try these addictive substances? The evidence is piling up that the younger we try them, the more chance of addiction. And certain substances addict very very quickly.

Who chooses not to be part of the herd and why?

Tobacco Use Disorder

With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

from: https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200)

We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.

I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.

The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…

disaster and withdrawal

When I watch the disaster news, what I think about is withdrawal.

Everyone who is on a substance that causes dependence or addiction is withdrawing.

They don’t seem to ever discuss that, but think…. if you are in Houston or Florida when everything floods, are your cigarettes dry? I don’t think so. And put multiple people in close contact in a shelter, with many withdrawing… I am not surprised that tempers flare.

Let’s look at numbers.

Tobacco: in 2013, 21.3% of the US population age 12 and older, smokes tobacco. Disasters are a reason to quit. It’s hard enough to quit tobacco, but imagine going cold turkey if we have our Pacific Northwest really massive earthquake. Quit smoking now, don’t wait for a disaster. And think about being in a stadium with one in five of the people over age 12 withdrawing from tobacco. Is that fun?

Alcohol: “In 2013, 30.2 percent of men and 16.0 percent of women 12 and older reported binge drinking in the past month. And 9.5 percent of men and 3.3 percent of women reported heavy alcohol use.” Ok, that’s rather vague. If you have a drink or two after work every day or with dinner, will you notice the lack? Yes, I think so, but maybe only 10% of the adults are really going into alcohol withdrawal. That’s a conservative estimate. 30% are probably grumpy.

Illicit drugs: 4-8% of the 40-70 year olds used something in the past month. Are they addicted? Well, some are. And the 18-15 year olds are the most active, around 20%. Methamphetamines, cocaine, crack, crank, heroin, eeee-yuk.

Prescription drugs: “More than half of new illicit drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens).” So let’s see, what percentage of the population is on prescribed opioids, benzodiazepines and barbituates? Ooooo, 1/3 of the US population has been prescribed opioids (2). Chronic opioids are prescribed to 3-4% of the US population, but of course, that is the prescribed chronic pain ones, not the illicit ones. Now, those can have a withdrawal. Alcohol and benzodiazepine withdrawal are the most dangerous for the patient, but in opioid withdrawal the pain receptors go absolutely crazy, like a volcano blowing up. And the tweakers withdrawing from methamphetamines. The sleep medicines like sonata and ambien avoid the issue of whether they are addictive by saying they are for “short term use” — 6 weeks for the former and 2 weeks for the latter, but some people have been on them for years. And marijuana daily, I have seen great difficulty with anxiety and sleep when people are trying to quit.

Marijuana: 7.5% of the population over age 12. How many of those are addicted? I see varying numbers, ranging from 10% to 50%. If you use marijuana regularly, check. Stop it for a week. See if there is a problem. I’d try it before a disaster, because it would add to the stress during….

Caffeine: Ok, I would withdraw from caffeine. 90% of US people are addicted to caffeine. I get a massive headache for 24 hours and then I am ok. I have gone off it more than once….

With ADHD medicines for children, a “drug holiday” is sometimes recommended. If you are regularly using any potentially addictive substance, try a “drug holiday” of your own.

And I think it’s the best motivator ever to quit smoking. Friday I had a couple of dedicated smokers and when I talked about flooded cigarretes, they blanched. Quit now, before you quit in circumstances…

And prayers for everyone in the disaster areas.

1. https://www.drugabuse.gov/publications/drugfacts/nationwide-trends
2. https://www.cbsnews.com/news/more-than-one-third-americans-prescribed-opioids-in-2015/
3. https://www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html  Hey, 80% of the world opioid supply is eaten by the US population! Why are US citizens in so much pain? Or are we under the impression that we shouldn’t have to feel pain and by gosh, we can afford the drugs….
4. http://www.nejm.org/doi/full/10.1056/NEJMra1507771#t=article Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies.

So WHY doesn’t the news talk about this? Because the cigarette and alcohol and prescription drug companies would yank the advertising?

At what age should we talk to our kids about drugs?

I am a rural family physician and my recommendation: before age 9. Before third grade.

WHY? Your eyes are popping out of your head in horror, but my recommendation comes from surveying my patients. For years.

The biggest drug killer is tobacco. However, it takes 30 years to kill people. It is very effective at taking twenty years off someone’s life, destroying their lungs, causing lung cancer, heart disease, mouth cancer, breast cancer, uterine cancer, stomach cancer, emphysema, heart disease….

I ask older smokers what age they started smoking. This is informal. This is not scientific. But most of my male older smokers say that they first tried cigarettes at age 9. I think parents need to be talking to their children about cigarettes by age 9.

And then start talking about alcohol and illegal drugs and the terrible dangers of pills.

“My innocent child would never….” Unfortunately my daughter said that as a senior in high school in our small town, there were 4-5 kids out of the 120+ that were not trying alcohol and marijuana. But there are kids trying far worse substances. We have methamphetamines here, and heroin, and pain pills sold on the street.

The perception that pills are safe is wrong too. Heroin is made from the opium poppy and it’s rather an expensive process, not to mention illegal and has to be imported from dangerous places. But teens take oxycodone and hydrocodone, bought on the street, to get high. And now drug sellers are making FAKE oxycodone and hydrocodone and selling that on the street. It contains fentanyl, which is much much stronger. If the dealer gets the mix wrong, the buyer can overdose and die.

Talk to your children young! NEVER take a pill from a friend, never take someone else’s medicine, never take a pill to party! YOU COULD DIE! And if you have a friend that is not making sense, that you can’t wake up, DON’T LEAVE THEM! Call an ambulance. Your friend may have used something illegal, and may not want you to call an ambulance. But if you think they are too sleepy….. don’t take a chance. People can get so sleepy, so sedated, that they stop breathing.

And parents, you are the ones that have to set a good example. Don’t drink alcohol every night. Don’t use pot every night. Take as few pills as possible. Pills aren’t necessarily safe because they are “supplements” or “natural” — hey, opium and heroin are plant based! Stop using tobacco and if you have a hard time doing it, tell your children you are struggling. It takes an average of eight tries to quit smoking. Get help.

Lastly, we talk about childhood innocence, but we let kids babysit at age 11. That is the Red Cross youngest age. My daughter took a babysitting course at age 11 and babysat. If we think they are responsible enough to do CPR, call 911 and do the heimlich maneuver, shouldn’t we also be talking to them about addictive substances by that age?

Talk to your children about addiction young… so that they can avoid it.

I am submitting this to the Daily Post Prompt: calm. I am not calm about this topic, but the photograph is calm…. and if we can help more children and families…..