Dealers Gotta Protect Their Turf

English: Vicodin tablets Italiano: Pillole di ...

English: Vicodin tablets Italiano: Pillole di Vicodin. (Photo credit: Wikipedia)

In New Hampshire, more people die of prescription drug overdoses than car accidents. CDC statistics report that prescription drugs are involved in 75% of all drug-related deaths in the United States. In 2011, the Centers for Disease Control estimated 14,800 deaths related to opioids (opioids or opiates defined as morphine, heroin, oxycodone, codeine, methadone, hydrocodone and hydromorphone.)  Note that with the exception of heroin, all drugs of abuse are available from your friendly healthcare provider.

Whether drug sales are illegal enterprises selling vials on the corner or a transaction that takes place in an exam room, it’s all about numbers and turf. Getting people hooked and keeping them coming back are the keys to a thriving business. For people with insurance, getting narcotics (opiates) from their local doctor or Emergency Room is easier and less expensive than going to the corner drug dealer, particularly since drug dealers don’t settle for a co-pay. Just as dealers rename their products to generate interest,  Big Pharma continues to feed the appetite of addicts with new medications and new formulations of old medications.

Narcotic painkillers have been combined with over the counter meds because of  the belief that the two medications together provide better pain relief than either of the medications taken alone. Unfortunately when people take two Vicodin (hydrocodone and acetaminophen) every 4 hours for pain round the clock (12 pills daily), they run the risk of liver damage because of the amount of acetaminophen bundled in the pill.  The makers of Tylenol (brand name acetaminophen) are so concerned about acetaminophen overdoses that they have decreased the recommended maximum daily dose from 8 pills daily (4000 mg)  to 6 pills daily (3000 mg). This change forces the makers of Vicodin to lower their recommended maximum dose to stay within the new guidelines and will result in Vicodin users having their daily dose decreased.  Sad that in the face of increasing numbers of overdose deaths due to prescription narcotics and the increasing number of prescription drug addicts,  the push to change labeling is due to the potential for a Tylenol overdose resulting in liver damage, rather than concern about overdose or addiction.

Of course the makers of Vicodin don’t want to see their business cut in half. They want to keep on selling the same number or more pills every year. Faced with the very real possibility that providers will decide to switch patients on Vicodin to a drug without any pesky daily maximums, the makers attempted the business affirming move of  trying to get approval for a pure hydrocodone pill. Luckily the FDA panel on pain relief voted against it.

The panelists agreed the higher dose of hydrocodone would be an effective pain reliever, but they felt uneasy providing another formulation of a drug in a class that is already widely abused. According to the Drug Enforcement Agency (DEA), hydrocodone is on the top of the list of most abused drugs in the United States. Sounds like a no-brainer.

Hopefully the FDA will agree with the panel and prevent a new dangerous drug from flooding America’s streets, school yards, and homes. In the war on drugs, our government has gone after the dealers of meth, pot, heroin, and crack. Somehow the legal dealers, Big Pharma, are allowed to thrive while they destroy lives.

opioid prescriptionsDo some people need narcotic painkillers to control their pain? Of course.  In the face of increasing narcotic use, do we need to add more potential drugs of abuse to the marketplace? I think not.  Big Pharma seems to be doing pretty well with what they have.

chart courtesy of the National Institute on Drug Abuse.

Beauty Contests and Cancer

Miss America contestant plans double mastectomy after competition

The above headline hit me hard. To see a beautiful woman, fearful of cancer, planning a double mastectomy AFTER the competition only reinforced my healthy distrust of beauty contests. The take away message seemed that having a double mastectomy would ruin your chances of winning a beauty contest.  Of course they couldn’t discriminate against someone with breast cancer genes, but perhaps there was some obscure rule about reconstructed breasts via “natural” breasts or a prohibition against prosthetic breasts.  I didn’t know for sure,  but in my quick view of her world, this young lady didn’t dare get a mastectomy until after she had been judged with her breasts intact. My prejudice against these contests demanded that I find the facts.

I surfed the Miss America site to get some insight into what was, and wasn’t considered beautiful by pageant officials. At first glance, their requirements looked fairly innocuous:

To compete you must

  • Be between the ages of 17 and 24.
  • Be a United States citizen.
  • Meet residency requirements for competing in a certain town or state.
  • Meet character criteria as set forth by the Miss America Organization.
  • Be in reasonably good health to meet the job requirements.
  • Be able to meet the time commitment and job responsibilities as set forth by the local program in which you compete. (source)

So perhaps putting off the mastectomy was driven more by the need to be “in reasonably good health to meet job requirements” than needing breasts to compete. Certainly surgery, a hospitalization, and recovery would impact the contestant’s availability.  My suspicion that there was more to the pageant requirements was driven by the lack of a weight and height requirement in the rules.  Since the armed forces and other positions, such as smoke jumpers, must meet  height and weight requirements, I thought  Miss American might.  I dug a little further, went to the New Hampshire web page, and found more requirements for contestants:

(Q) A contestant must be and always have been a female.

(R) Contestants must not now be and never have been married.

(S) Contestants are not now pregnant, and have never been pregnant. She is not the adoptive parent of any child.

(T) Contestants must be of good moral character and never been involved at any time in any act of moral turpitude.

(U) Other than minor or petty offenses, contestants must never have been convicted of any criminal offense and there are no criminal charges presently pending against the contestant.

(V) Contestants must never have performed any act or engaged in any activity or employment that is or could reasonably be characterized as dishonest, immoral, or indecent.

(W) Contestants must be in good health, and can, to best of their knowledge, participate fully and without limitation in any Program activities. Contestants must not use or consume any illegal controlled dangerous substances or abuse the use of alcohol or other dangerous substances.  (source)

Whoa! We’ve all heard of contestants being stripped of their titles due to moral turpitude clauses, legal violations, and drug and alcohol abuse.  I can understand those, but to ask contestants to certify that they “are not now pregnant and have never been pregnant”?  Obviously the pageant is against abortion, adoption, and single parenthood (because they’ve nixed marriage, too).  Is this to impart an air of virginity and chastity to the contestants or to preclude unsightly stretch marks?  Why not disqualify them if they’ve had a sexually transmitted disease as it is as much an indicator of sexual activity as pregnancy.

Still, no clause stating a contestant can’t have plastic surgery. Miss Universe/Miss USA rules come right out and say they don’t prohibit plastic surgery because of the difficulty in enforcing the rule.  Though I suppose they could require contestants to sign a blanket medical release and go trolling through their medical records and health insurance bills looking for surgery. You know, if it’s that important to the pageant.

And then I started thinking of how important the pageant must be to women willing to sign off on the requirements because if  the Miss America pageant was  a job interview, the questions on marital status and pregnancy would be against the law. To the women who enter these, putting aside marriage, children, and college parties to be a contestant is likely considered a reasonable trade off. I don’t understand their desire to participate in a beauty pageant, but it’s a decision I don’t get to make. It’s theirs, as is either having or delaying cancer risk reduction surgery to pursue a dream.

When all is said and done, I wish Miss America contestant Allyn Rose  the best of luck in the pageant and in her decisions regarding her genetic risk of cancer. I’ll never be a fan of pageants, but as long as women enter and people watch, they’ll go on.

Colonel Russell Frasz, 89th Airlift Wing vice ...

Colonel Russell Frasz, 89th Airlift Wing vice commander, poses with the 51 Miss America 2004 contestants and Miss America 2003 on the Andrews flight line as part of their tour of Andrews AFB, Md. (Photo credit: Wikipedia)

Cats Cause Suicide

Cats cause suicide. Surprised? I was. I always believed the sneaky, furry creatures were more apt to creep onto my face at night and smother me rather than drive me to suicide. This accounts for my scrupulous sobriety any time cats are in my vicinity. I can tell they’re plotting and waiting for someone to get drunk enough to pass out, rendering the victim incapable of responding when the cat-like smothering starts. But suicide?

And using an iPad at night can cause depression. Damn. I thought not having an iPad caused depression or, at the very least, envy.  My friends with iPads always act so happy.  Now I have to consider the joy of owning one may be the public face they’re showing while inside they’re crying.

In Britain, over 500 breast cancer deaths a year are believed to be caused by working the night shift. I worked the night shift for several years. I knew I was at risk for weight gain and insomnia, but no one explained the breast cancer connection. As more companies hire overnight workers, isn’t this a public health concern we should forcefully battle? Particularly as there are professions that demand night work such as police officers, fire fighters, air traffic controllers, flight attendants and hospital employees. Should we ban women from working those hours?

It seems every time I read the health section of a newspaper I find another unexpected and sometimes unavoidable risk factor for a disease I don’t currently have, but may get.  How worried should we be?

Well sexy headlines, like “cats cause suicide,” serve a purpose far greater than alerting the public to a potential problem. Consider that there were no health advisories after the cat-suicide connection research was published to have people with cats checked for evidence of T. gondii, the parasite allegedly responsible for the suicidal behavior. There was no public outcry to ban cats. Instead the researchers cautioned that there were limitations to the study, a larger population needed to be examined, and, even if a direct connection  was found, there were no drugs to treat T. gondii. The study recommendations were to practice hand hygiene and food safety, making prevention options for suicide in cat owners the same as prevention options for food poisoning. Helpful.

What did the headlines and publicity actually accomplish? Generate interest in further research.  Conducting research is expensive. Dollars for research face stiff competition. Sexy headlines attract focus which attract dollars.  Sort of like when a celebrity gets a disease and starts a foundation. Suddenly everyone is lining up to get involved.

Research is good, but attaching it to a controversial or provocative headline may be more about drumming up donors and discussion and less about conclusive results which can improve our health.  Being overly concerned about every newspaper story or article that comes along warning of early research findings that may harm our health is harmful to our health.

If we’re going to believe the headlines, let’s focus on the happy ones. Red wine, chocolate and sex all have reported health benefits. Enjoy those in moderation (and then you won’t have to worry about death by cat suffocation either).

Will you still need me, will you still feed me when I’m seventy-four?

When my daughter was younger, she said she loved me so much that when I was old she’d get a wheelchair and push me wherever I wanted to go. Her sister said she’d push me off a cliff. I was in my early thirties when this conversation took place and since then I’ve wondered who will take care of me if I become old and infirm.

As part of my nursing education, I spent a fair amount of time in nursing homes. Afterwards, as a new nurse, I worked in hospitals. Both of these experiences convinced me that the majority of the elderly were frail, sickly, and unable to live on their own. It depressed me.

In the nursing home, the patients with dementia were the most labor intensive. One birdlike woman practically lived at the nurse’s station. She’d yell to each passing staff member or visitor, “Hey, lady. Hey, lady. Get me out of here. I have to go home.” Her idea of home was the home of her childhood and she’d often continue with, “my father will be mad at me. I’m late. Get me out of here.”  Sometimes I’d want to loosen her restraint and take her to this home that was still alive in her memory. Other times I’d sneak around so she couldn’t see me and ask me to help her. What I remember most is that no one ever visited her.

In the hospital, dying patients needed the most resources. Mouth care, turning and positioning, constantly assessing their level of comfort and providing medication were all involved in “aggressive comfort care”  as opposed to “comfort care only.” We knew we were fighting a losing battle, yet wanted to be proactive in preventing further complications and keeping the patient pain free. Sometimes family members would stand vigil, many times the nurses were the only silent witnesses to the winding down of a life.

It wasn’t until I worked in outpatient care that I realized many older patients were self-sufficient, active in their communities, and living at home without assistance. They didn’t need the services of a nursing home and, if they were lucky, the end of their lives happened in their home rather than in a hospital or ambulance. It gave me hope.

As my parents inch past seventy-five, I’ve also realized how many of the elderly live in their own homes and struggle to maintain their dignity while dealing with limited resources. There comes a time when you realize mom or dad isn’t able to manage their own life as they once were. I think that realization, for most children, is slow in coming and it takes even more time before the children try to step in and help.

Why is that? I think on some level we’re ashamed to acknowledge our parent’s physical problems. Intellectually, I understand that the elderly have a decreased sense of smell, touch, vision, hearing and taste. They may not notice the smell of spoiled meat, not see the stains on the dishes they’ve washed, not be aware of the loudness of the television while they’re talking on the phone, and eat the same food day in and day out. Their mobility is limited due to  loss of muscle, disuse, and degenerative diseases like arthritis. Their bowels don’t function as regularly as before. Their skin is easily damaged and slow to repair.

And most of us are busy, damn it. We have children graduating from college or getting married or having their own babies while we try to pay off parent PLUS loans, boost our 401k’s,  keep our marriages or relationships strong and maybe even find time to fulfill our own dreams. All this is going on while our parents start a slow decline and insist they can take care of themselves. They don’t want to be a bother.

So where do we put our time and effort? Into the problems we can fix. Babysitting grandchildren, advancing our careers, spending romantic time with our significant others, doing the things we always meant to do that we now have the time for. And the more our parents say they’re fine, we shouldn’t bother,  it’s no big deal, the easier it is for us to defer to their fine judgement and leave them to their own devices. I mean, really, they’re our parents.

Until the day we go over to their house and realize that they aren’t doing okay. They need our help. All of the things they did for us and taught us to do for ourselves have come full circle. They need help to wash themselves up and keep themselves clean. They need someone to monitor their meals and make sure they’re eating enough high quality food. They need someone to dry them off and look for signs of skin breakdown and intervene early. They need someone to clean their house, check the outdates on their food, and drive them to appointments. Much as they helped us to transition from dependent child to independent adult, we must now support them as they transition from independent adult to dependent parent. It’s not fun.

And for me, and I feel shame as I write this but I suspect others feel as I do, it is hard. It is hard to remind a parent to shower, to go to the bathroom, to wear a depends pad, to take their medications. It is hard because we now become the parents of the person who parented us. It is hard because we know deep down inside that our parents would never want us to see them as weak and in need of help so we must thrust ourselves into their lives and do it matter of factly and decisively. And we must somehow reconcile the parent of our minds, the strong, vibrant, healthy person we remember, with the person they have become from no fault of their own other than the passing of the years. And then we must love them and help them, all the while protecting their dignity and sense of self.

It’s a damn hard dance to do.

But still, I see adult children who do it every day. They stand by their mothers and fathers in the most intimate and embarrassing situations with a grace that doesn’t come from socioeconomic status or education. It doesn’t come from religious guilt or dreams of inheritance. It doesn’t come from a sense of obligation or duty or even payback. It comes from love.

And every time I see an adult child performing the most personal care for their parents with a smile and the attitude that it’s not a big deal, I am humbled. The question isn’t who will take care of us when we age, it is how we can do the right thing for the people who have done so much for us

Pat, August 20, 2011 - Curb

Pat, August 20, 2011 – Curb (Photo credit: pat00139)



The Best Time to Get Drugs

If you’re a woman, the best time to get drugs (best defined as that which is the most excellent, outstanding, or desirable)  is, if you’re so inclined during childbirth. Really. When you’re having a baby.

Why you say? Because, in popular opinion, childbirth is incredibly painful. So painful that men, unable to compete in this pain category, equate kidney stones (universally acknowledged to be super painful) to the pain of labor. What do they give you for a kidney stone? Pain pills. What can you get while in labor? An epidural. The power of the epidural is well-known. Many woman ask for it by name, to the point where movies and tv shows have an obligatory scene where the laboring woman asks “is it time for my epidural yet?” as if that is the purpose of labor.

I will digress. Why do men have to equate kidney stones with childbirth as if it is some sort of contest?  When I look at medical technology, I see much care and diligence in ensuring the male healthcare experience is kept as pain-free as possible. The big indignity men suffer is the turn and cough (while pressure is applied to the scrotum) and the finger wave (in the rectum). By contrast, woman must endure a mammogram, which involves flattening the breast tissue  between two plates, and a pelvic exam, which includes the insertion of a  speculum, a metal instrument that looks like a duck’s beak).

English: Mammography in process: Shown is a dr...

Speculum Spectacle

Speculum Spectacle (Photo credit: cote)

Wow. Seems like men might want to compete with some of that pain. Perhaps testicular cancer screening via mammography technology? Let’s see men undergo a yearly squeezing of their testicles until flat. And finger wave? Perhaps the doctor really needs a speculum to get a good look at the prostate. It’s not that I want to see more pain in the world. I only wonder why men seem to get off easier. Is it only coincidence that men dominate the medical field and male-centered interventions seem kinder and gentler?

But back to epidurals. As a nurse who once worked in childbirth, I found my patients divided on the subject of epidurals or other drugs in labor. There were the “give it often and early” adherents and the “ignore my screams of pain because I’m having this baby naturally” proponents. Me? Hey, I tried natural childbirth through back labor, slow progression, and the eventual discovery that my 10 pound kid wouldn’t fit through the birth canal. By the time the decision was made that only a c-section would remove her, I wanted to be put out like a junkie wants another fix.  Fell in love with the anesthesiologist the second he put the mask over my face and told me in a few seconds I’d be asleep. Anesthesia is my favorite memory of that experience.

But some woman outright reject drugs for childbirth. They become fixated on the idea that the only “right” way to have a baby is without medication. They want to work through the pain, even though too much pain can slow down labor.  And, it’s not like anyone is keeping track of who had pain meds and who didn’t. (Well, we did, but only for statistical purposes. We had no access to our patient’s permanent record to add this information.)

And thought it might be a worthy and noble ideal to have a drug-free childbirth, taking something to help doesn’t make you weak or less of a mother. It makes you a normal human being.  Much better to fall back against the pillows, a happy smile on your face, and able to relax between contractions than to be bolt upright, red-faced, and screaming like a foul-mouthed harpy. I’m not advocating an epidural for everyone, but it’s strange how women  enter the labor process determined to turn down drugs no matter how bad things get. Why not see how things go and cut yourself some slack. If you need help, ask.Never having had a kidney stone, I don’t know if the pain is equivalent to labor pain. What I do suspect is that if men underwent childbirth, there wouldn’t be a big discussion about whether pain medications were appropriate or not.  They’d take them if it was painful, refuse them if it wasn’t, and not bother to assign a value to the act. Why didn’t we think of that?