The Medical News Report
October, 2019, #93
Samuel J. LaMonte, M.D., FACS
October, 2019 Subjects
a) Too many people believe cancer can be cured without traditional treatment!!
b) FDA drug approval process—a need for change!
c) Blood clots known to occur prior to developing cancer
IMPORTANT REMINDER!!!! PLEASE READ!!!
I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.
The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns. You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.
Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.
Thanks!! Dr. Sam
One of the unintended consequences of immigrants coming to our country (legal and illegal) are certain infectious diseases that American doctors are having to become more aware of because American medicine has curtailed or prevented these diseases over the past decades. having not had much experience in previous decades, Most of these patients are being seen in the emergency rooms and urgent care facilities. Symptoms and signs are common to other illnesses but diseases from third world countries must be included in the differential diagnosis. Just as important is ever increasing exposure of American children and adults to these diseases.
Vaccination is a real problem in most of these immigrants (although legally they are supposed have them from the country they originate from). Hygiene and living behavior in many of these people are very different from the U.S.. Crowding of immigrants in small houses and apartments are a real recipe for disease spread.
Some of the most common diseases seen not uncommonly are 1) tuberculosis 2) measles (viral rash) 3) whooping cough (pertussis), 4) scarlet fever (streptococcus rash, 5) mumps, and 6) bubonic plague.
Tuberculosis has had a rise in rates because people who take biological agents for cancer and autoimmune disease are at risk. A TB skin test is required now before taking these drugs. However, it is a common disease in many countries, but now there only about 20,000 cases annually but 13 million Americans have latent TB. For people coming into this country, a TB skin test is a must, because there are few symptoms (called latent TB) for some time and only about 10% will have full blown disease which kills 50% of the patients. However, thousands every month come in illegally and have had no testing. Also any one exposed to a patient with TB should be skin tested.
The Mycobacterium tuberculosis bacteria primarily invades the lungs, and is an airborn transmission affecting immunosuppressed people (HIV, LBGTQ, cancer patients, organ transplants, drug users, etc.) more than healthy ones.
Symptoms of clinical disease are chronic cough with blood tinged sputum, fevers, night sweats, and weight loss. Treatment of TB include Isoniazid, Rifampin, Stretomycin, Ethambutol, and Pyrizinamide.
Above X-rays show an infiltrate in the right upper lobe on the left and the cavities that form in the lungs on the right drawing.
Those who are skin test positive must have sputum tests to look for the bacterium and a chest X-ray to rule out disease. Most will need to take preventative anti-TB drugs (Isoniazid, Rifampin) for a year and be retested. There is a BCG vaccine available in endemic countries (Africa, Russia, Carribean, Latin America, and Asia).
In the last 3 decades, 31 million foreign born residents now live in our country (immigrants, refugees, illegals, asylum seekers, and parolees). During the Obama years, enormous immigration was approved from Middle East countries (Syria, Iraq, Iran, Pakistan, Afghanistan, Saudia Arabia, etc.), Africa, and South America. Now Central America is flooding our borders as our Congress is at odds with immigration reform ideology. Because of our Congress, many other countries are immigrating to Central America and are now crossing our borders.
Other diseases brought in by immigrants now seen are river blindness (affects skin and eyes caused by a tiny worm spread by the black fly), malaria (fever and other symptoms caused by Anophelese mosquitoes-not transmitted from human to human), Guinea worm (caused by a parasitic worm that enters a foot blister or sore transmitted by water fleas to others), Chagas disease ( transmitted by the trypanosome parasite causing heart and neurological symptoms), Dengue fever ( transmitted by Aedes aegypti caused by the dengue virus; causes hemorrhagic fever; a vaccine is available in some countries), Ebola (a deadly virus with outbreaks in NYC nd Dallas), and Leprosy (caused by a bacterium similar to tuberculosis, only mildly contagious-airborne, not by touch) causes nerve damage and skin bumps, leading to loss of fingers and toes, the nose, etc. because of the neuropathy causing numbness. It can be cured today
Leprosy (Hansen’s disease)
No federal agency is reporting the actual number of these diseases coming across our borders as refugees from most of the world. Wonder why? Most of these diseases had either been eradicated or controlled in our country, and many of the diseases just were not seen here because the disease was carried by vectors (parasites, mosquitoes, etc.) that did not thrive in our country.
Sanitation and health conditions from migrant workers have impacted our food (E.coli, Hepatitis A, Giardia diarrhea). Our own homeless population is adding another layer of extreme public health concerns, even the bubonic plague, thanks to trash, feces, and sick people being bitten by rats carrying the plague. We have outbreaks of Hepatitis A in Florida thought to be caused by human fecal contamination of our food from migrant workers that pick the crops.
Unaccompanied children coming across our borders have created a major childhood disease issue, not to mention displacement of families, and the psychological impact of the youngsters.
All these medical issues for illegal immigrants come at a cost--$18.5 billion in 2016. After the explosion of illegals the past year, I would not surprised it has doubled.
A major factor comes from our country not enforcing our own health regulations in migrant workers and now in illegal immigrants. There are major U.S. companies who ignore health and other regulations for the migrants they employ.
Our country must crack down on these companies to play by the rules. And some of the Democratic nominees are supporting open borders! When our Congress ignore the laws, why should the people feel compelled to follow the laws?
Refugee resettlement is a concept that most of my readers are not aware of. This program is run by the UN and supported by our government. It has been in place for 33 years according to securefreedom.org
Refugees are being sent to smaller communities in our country with little input from the affected community. Minnesota has major resettlement groups from Somalia (100,000), Afghanistan, Iraq (102,000), Iran (2 million), and Syria (64,000). These communities are overwhelmed with a variety of issues especially language barriers, public health issues including a variety of diseases the doctor have never seen. Schools are challenged because most do not speak English. It is beyond me that the city councils, mayor, health department, etc. do not have a say in dealing with the assimilation of these people. I am sure many of the immigrants from the southern border are also being challenged with minimal work for these people. Most of us live in larger communities, so we are not aware of this going on right under our nose, but it affects the health of our American citizens, and I wanted to bring this to your attention. If you are interested, I suggest that you watch this video https://www.youtube.com/embed/6PzT8vEvYPg
The CDC reported that in 2015, 1 million immigrants obtained legal permanent residency in the U.S.
In 2016, 6 million people entered the U.S. as non-immigrant, non-visitor status (students, temporary workers, exchange visitors staying longer than 6 months). These people are supposed to have medical screening prior to coming to our country, however, what percent are really screened?
The system is just being overwhelmed and the American citizen is suffering because of it being exposed to many diseases. Immigrants are required to be tested for STDs, have a chest X-Ray to rule out active tuberculosis, and verify vaccinations as stated by the CDC. Obviously that isn’t happening as illegals flood our borders, and while some U.S. Congressman criticize their living quarters while they are being processed.
The Department of Homeland Security reported that 45 million foreigners with visas, and 420,000 have overstayed their time allowed in 2016. Canadians lead the number of those who overstayed.
The CDC recommends the following screening tests for new arrival immigrants receiving medical care—TB skin test, HIV, hepatitis B, STDs (gonorrhea, syphilis, and Chlamydia,etc.), CBC (complete blood count), serology for parasites, malaria, and lead levels, chicken pox antibody, and a urinalysis.
Medical tourism is defined as seeking medical services outside our country. 15 million U.S. patients annually go out of the country creating a $50 billion industry in 2017. There are many factors which have increased the magnitude of this industry. And now a new twist…..U.S. doctors going out of country to operate on U.S. citizens.
Ashley Furniture Store has been sending doctors and their employees to Cancun, Mexico, to have surgery because it saves the company so much money (as much as 60-80% of the medical cost. Patients are given stipends by Ashley Furniture ($5000) and pay all their expenses to have surgery in Galenia Hospital in Cancun, Mexico. Surgeons from the U.S. are paid by Ashley Furniture as much as 3 times the amount Medicare would pay them for the procedure plus expenses.
This story is occurring for thousands of Americans who are choosing to go to the Caribbean, South America, and Central America to have surgery because the cost is so much less than in the U.S. (but most are being treated by foreign doctors).
Consider when there are no lawyers, no federal regulations, no red tape, running up the cost of healthcare in the U.S. Hidden costs, middle men, insurance costs, high drug and medical device costs are getting out of control, because we live in a country who take advantage of our freedom to charge what the public will bear which is part of the capitalistic, free enterprise system. Safety may at extreme risk in many of these foreign country due to the lack of regulations and laws. 90% of the lawyers in the world live in the U.S.!!!!
North American Specialty Hospital, known as NASH based out of Denver, has organized treatment for dozens of patients at Galenia Hosptial since 2017. 40 orthopedic surgeons from the U.S. have signed up with NASH and are traveling out of the country to perform joint replacements, back surgery, etc. in Cancun.
They perform these procedures on their time off from their practices in the U.S., and are paid all expenses plus much more money for their surgical talents than insurance in the U.S. would pay them. NASH uses American surgeons which, they are betting, will alleviate some of the fears of Americans having surgery in a foreign country.
NASH pays for extra malpractice insurance for the doctors if complications occur. Now patients can sue their doctors if they get a bad result. This is one of the biggest concerns Americans have about going out of country for medical procedures because they have little to no recourse if they have a complication. In this situation, there is legal recourse, something not possible in most cases with Americans having procedures outside the U.S.
Of course, patients must trust the local nurses and hospital staff for sterility of surgical instruments and operating rooms, cleanliness and infection control in hospitals, and even safety and security from outside people in a foreign city.
How does the language barrier between surgeon and staff work? Also nursing care, response to a surgical complication or medical emergency, other medical consultants if needed, anesthesia quality, etc. all are legitimate concerns. And who takes care of them once back in the states?
In Cancun, a knee replacement cost $12,000 and in the U.S. over $30,000. The standard charge for a night in the hospital in Cancun is $300 compared to $2000 a night on the average. The implant for a knee replacement cost $3500 in Cancun and in the U.S., $8000. Why is there a difference?? Free enterprise, capitalism, lawyers, etc.?
Ashley Furnture has sent 140 employees to Costa Rica and other places that have saved the company $3.2 million in healthcare costs since 2016. They have a travel manager that handles all the travel arrangements for the procedure, hotel rooms, transportation, etc..
Patients stay an extra day in the hospital for surgical procedures, and then stay in a local hospital for a certain specified number of days before flying home. Delayed complications and final results are an issue. Reference
The legal implications outside CONUS are quite unclear, however, the savings keep these patients travelling to spend as little as 4% of the cost at home. There has been a $30 billion dollar increase in revenue between 2012 and 2017 for foreign medical facilities.
The cost savings is enormous and the savings have created the desire for this industry to increase in the future. However, there is little legal recourse when complications arise, but finding American doctors to accept the medical and surgical complications from an outside the country procedure can be challenging. Also, a patient’s U.S. insurance may not cover treatment for these complications, which would require cash payment to physicians and medical facilities.
Patients with poor insurance coverage or with no insurance may take the chance and go out of country.
Thousands of patients annually go to countries where unproven methods are often sought with unknown results. Many times these patients don’t even seek standard therapy and seek “miracle cures” as close as Tijuana, Mexico, which is one of the quackery capitals of bogus medical treatments. These patients spend their savings, retirement funds, life insurance, and loans which put them into medical bankruptcy, an increasing problem even for those who stay in the U.S.
Immigrants with strong ties to their native countries have added to the medical tourism ranks. Seeing so many foreign medical graduates practicing in the U.S. increases confidence in seeking care from foreign countries.
Cosmetic surgery can be obtained for 50% less in developing countries. A heart valve can be replaced in India for 6% of the cost in the U.S. A knee replacement in Thailand is 20% of what one would pay in the U.S. An angioplasty in Columbia cost a ¼ the cost. Breast implants in Jordan for a 2/3 the cost; a facelift in Mexico for 40% of the cost.
In 2007, the Medical Travel Association was established as a not-for-profit organization to facilitate healthcare providers, government, insurance companies, and buyers of healthcare.
Some reputable institutions such as Johns Hopkins and the Cleveland Clinic have become involved as credentialing bodies for certain foreign medical facilites. Not only do they employ many foreign medical graduates in the U.S., and have attempted to be the chief connection on a global basis. Of course, it is a major recruiting tool for foreigners who want to come to the U.S. for medical care.
The Rich get richer
They cover themselves legally by not being agents of these providers with waivers to protect themselves. These mega healthcare facilities also recruit patients from around the world to come to their facilities for treatment, so they win both in patients being referred to them, but by letting these foreign hospitals use their name for marketing purpose, they increase their reputation (it is happening all over the U.S.).
Right or wrong, it increases patient’s comfort in going to these countries for much less expensive treatments. Of course, these facilities have coordinating contracts with many major medical centers here in the U.S. including Johns Hopkins, Cleveland Clinic, Mayo Clinic, MD Anderson Cancer Institute, to name a few. University meical centers create coalitions with outlying hospitals all over this country, but it does not mean they have specialists from those facilities. They act in a consulting basis only, but can give false confidence to local patients about the quality of the doctors staffing the hospital.
The U. S. Joint Commission on Accreditation (the main accrediting agency in the U.S. for hospitals and clinics) opened an international office in attempt to raise the standard of care in an unregulated market. The Joint Commission has a number of approved sites from from 78 sites in 2005 to 985 in 2017 specifically focusing on Mumbai, Dubai, Malaysia, and China.
Needless to say, medical organizations in the U.S. are concerned about this trend, and the American Society of Plastic Surgery has launched their own website to influence and educate potential travelers on the dangers of going out of the U.S.
Federal oversite is virtually non-existent. Malpractice cases have failed in most cases in cases outside the U.S. This is an unregulated industry.
Getting U.S. physicians to care for complications of non-U.S. care is hard to come by and would be out of pocket expense anyway.
Regardless, medical tourism will continue to grow in an attempt by these medical tourists to curb their personal healthcare costs. In the end, “buyer beware”.
Medscape, from the Journal of Plastic and Reconsructive Surgery, 2018
a) Why do so many Americans believe cancer can be cured with alternative (unproven) methods?
As a physician, it is somewhat amazing to me that 39% of American adults “somewhat” or “strongly” believe that cancer can be cured “solely” by alternative therapies such as oxygen therapy, diet, and herbs, etc. without standard cancer treatments, according to a national survey by the American Society of Clinical Oncology (ASCO) conducted by a Harris poll in 2018.
Respondants included 4038 participants and 1001 participants who currently had cancer or previously had cancer. 22% of patients currently dealing with cancer or had cancer believed alternative treatments alone could cure cancer and 38% of a group of family caregivers for cancer patients felt the same. I have already reported on the significant percentage of cancer survivors that take marijuana for side effects of chemotherapy (nausea and vomiting). There are many more taking it in some form along with their traditional cancer treatments. The key is to tell the oncologist the survivor is taking it.
One of ASCO’s missions is to prevent widespread misunderstanding about cancer treatments, especially those that are unproven. The best way to prove the long term effectiveness and safety of drug or treatment is repeated independent FDA clinical trials.
Why do people choose unproven methods?
Side effects of standard treatment can be serious and yet deemed acceptable by the medical community, but when patients are facing death, they will go to extremes including unproven methods. Knowing the risks, it is easy to see why people choose “less invasive methods”, but unfortunately they die any way, because the unproven method was not a “proven treatment”.
It is not surprising that there is a massive amount of bogus ads, testimonials about magical cures, and well meaning friends and family that hear of fantastic treatments often out of country. There are cancer treatments that are approved in other countries, but do not have the vigorous regimen required by the FDA to approve a treatment in the U.S.A. These treatments may infact be valuable, but until we have a better idea than having the FDA, we are stuck with their rules.
A study reported by ASCO found that patients who underwent unproven methods exclusively had overall a 2.5 fold higher risk of death. These patients refused standard therapy and instead had some type(s) of alternative treatment compared to patients who received conventional therapy. For patients who had breast cancer and refused conventional treatment for alternative methods had a 6-fold increased risk of death and 4.5-fold increased risk for colon cancer patients.
As alternative or complementary therapies are being more readily accepted for treating a variety of pain issues, people’s acceptance of these methods can cross over to serious diseases such as cancer.
Price is also a serious issue when traditional and even the newer immunotherapies are being used. In this study, 57% of participants facing a cancer diagnosis viewed the financial impact on their families as their number one concern. 54% were concerned about dying and cancer-related pain and suffering. Many of these treatments cost $thousands a month and not always covered by insurance or the copay is enormous. Those who are looking for a cheaper route are extremely vulnerable to alternative treatments.
88% of respondents wanted Medicare (the U.S. Congress) to negotiate prices with Big Pharma (they already did for Medicaid). Easier said than done, since the drug companies have a right to set prices in our free enterprise country. 77% stated they should be able to buy cancer drugs from other countries at much reduced prices.
Younger and middle aged people (18-53 years) are the most vulnerable according to this ASCO study. Nearly half surveyed were the most likely to believe that alternative methods alone can cure cancer, which is extremely disturbing.
Dr. David Gorski of Wayne State University Cancer Institute in Detroit, Michigan, feels that acceptance of conspiracy theories (having become commonplace as the internet sites multiply) about a host of issues by younger readers has led to seeking alternative treatments. The internet is full of conspiracies that the government, the medical profession, and the pharmaceutical companies are keeping the cure for cancer from the public just like they lied about flying saucers, etc.
These people are not unintelligent. When the CEO of Apple Inc. (Steve Jobs) chose alternative treatments for his very curable pancreatic malignant insulinoma and died unnecessarily because he chose unproven treatments that did nothing to shrink the tumor. His cancer continued to grow and he died of it. Why would a man of his intellect do this, when money was no object? Fear of the standard treatments for one. Why would Steve McQueen, the famous actor, go to Tijuana for treatment of his mesathelioma of the lining of the lung? Of course he died.
This study by ASCO also asked about the satisfaction of cancer care. 89% and 88% of cancer patients were satisfied with their care and its quality repectively. It is critical to discuss any alternative treatments with the trusted physicians to keep them on the right track.
Well known alternative and unproven cancer treatments
Some of the most common alternative methods mentioned are ozone therapy to increase oxygen to the body. The only problem is cancer selectively steals blood and oxygen from the body, therefore, increasing oxygen to the body by any method is feeding the cancer cells which are growing much faster than normal cells. There are clinics that use ozone throughout the country under the name of holistic medicine.
Magnetic field treatments have been around for decades and can be found along the border of Mexico. No proven value as an isolated treatment for cancer, however, I recently reported on clinical trials using magnetic fields to increase the concentration of chemotherapy into brain tumors. Electrical fields have also been touted as curative and has no scientific basis.
Laetrile comes from seeds of the apricot and has been touted as a cure for cancer for decades as well with no proven value. The seeds do contain amydalin (vitamin B17), which has no scientific evidence for value in curing cancer and breaks down to cyanide, which has killed some of these patients.
Often so called cancer clinics use lower doses of chemotherapy when treating with some of the quack methods and then tout the unproven method as the cure. I know it is not politically correct to call them quack treatments, but that is what they are.
Whether it is a special diet full of carefully prepared proteins, fruits, and vegetables, there is no evidence they can cure cancer. Healthy balanced diets with less meat, less processed deli meats, and bad fats will help prevent cancer along with many other healthful behaviors but not cure it. The macrobiotic diet was in vogue for decades and creates malnutrition, and yet thousands were converts.
Cancer patients shoud seek the help of a certified nutritionist to help the body combat the millions of dead cancer cells trying to get out of the body after success with radiation and or chemotherapy (and other immune targeted therapies—biologic therapy). Hydration is key for the liver and kidneys to rid the body of these dead cells.
Edgar Casey (1877-1945) proposed that alkaline diets were curative for cancer, among other totally unproven treatments. To this day, there are numerous brands of alkaline water on the shelves of most grocery chains. Alkaline diets are becoming popular and have many unproven uses. They may be valuable for people with inadequate saliva, who have increased tooth decay because so many of the foods are acidic.
Although any form of relaxation therapy or exercise can be very valuable to cancer patients while undergoing treatment, it is only to be used as a complementary treatment (adding to traditional cancer treatments) but only with the oncologist’s approval. That goes for those pushing high doses of vitamins which can interfere with certain types of chemotherapy.
Chelation therapy is another quack method in the treatment of cancer. Although a known treatment to remove heavy metals from poisonings of mercury, lead, etc., it has no place in treating cancer. Medications such as EDTA (ethylene diamine tetracidic acid) will draw out these heavy metals. However, it is being used by certain practitioners world wide to pull the calcium out of the body just because calcium is seen in arterial plaques. As yet, there is no evidence of its value, even though the well known Dr. Andrew Weill promotes it.
Many forms of treatment come under the heading of holistic medicine, and there is no evidence any of these treatments cure cancer, although they have a place as a complement to standard treatments.
Much of Eastern medicine falls under this category, but remember, many of these therapies do not have adequate or acceptable evidence based research to provide the patients that it is FDA approved or at least an acceptable treatment used off-label.
Complementary therapy in addition to standard medical therapy is called Integrative Medicine and in many cases is becoming a standard of care.
I reported on Integrative medicine in the 75th report,
It is now a very acceptable method, but to be clear, it is addition of complementary treatments to standard acceptable medical treatments. This is not an alternative method, and certainly not one of absolute quack methods.
Aromatherapy, acupuncture, massage, meditation, music therapy, Tai chi, yoga, hypnosis, and all forms of herbal treatments have no curative evidence but have a place in the treatment of many neuromuscular diseases. However, under supervision, they can be very valuable to the cancer patient (survivor) to relieve pain, stress, depression, hopelessness, sleep problems, fatigue, and nausea and vomiting.
b) FDA process for drug approval—a need for change
Process for approval:
1- Investigational new drug application—apply to test a drug on humans.
2- New drug application—introduce a drug across state lines.
3- Review designation—need this designation to provide a timeline, goals for an application can be reviewed under the Drug User Fee Act.
4- Standard or Priority review to allow the FDA to determine if they will approve a drug. Standard time is 10 months and priority review time is 6 months. Of course, the FDA also has a process to allow a drug company to pay a fee to accelerate the process. Priority reviews require the drug to show unusually promising results for serious illnesses.
5- Breakthrough therapy designation—allows for accelerated development and review of a drug for life-threatening or very serious illnesses.
6- Fast Track designation—is allowed for those drugs which impact survival, day to day functioning, or the likelihood, if the disorder is not treated, will progress to a more serious state.
7- Accelerated approval—used for drugs that may fill and unmet need. Drug companies still must perform research on the drug even though the drug is being prescribed. If it proves to be effective, the drug is given traditional approval.
8- Prescription Drug Fee User Act—The drug company can pay a fee for the FDA to boost FDA resources and speed up the approval process. Maybe, I am naïve, but this sounds like money talks…….
There is a need for streamlining the process. Most countries have drugs being used 10 years before they are considered for approval. If it was not for the legal profession, this would not be so complicated here in the U.S. But unsafe drugs being approved prematurely is also a healthcare consideration, so we can’t have it both ways.
Provided by Cure Magazine, January, 2019.
c) Blood clots prior to the diagnosis of cancer—a need for screening
Up to 10% of patients develop a blood clot as long as 1 year prior to a cancer showing up (called an occult cancer). It has been known that venous blood clots (especially from the legs with emboli to the lungs) can occur before a cancer is diagnosed. What has not been studied as well is that arterial blood clots also can occur before a cancer becomes known. Heart attacks and stroke are the most common events that occur.
Certain cancers can secrete chemicals that increase blood clotting, especially lung, breast, and gastrointestinal cancers. Blood clotting is a very complicated process and certain chemicals can stimulate and accelerate the clotting process.
The point of this article is to have an increased index of suspicion for people who develop vascular events whether venous or arterial especially after the age of 70, and should be screened for an occult cancer.
This will fall on the shoulders of the primary care doctor, but I am bringing this to the attention of my readers, since most doctors are not aware of this connection. There is an increased risk for a person who is a smoker, overweight, had cancer in their families, had weight loss or loss of appetite. Patients should bring this subject up to their doctor for consideration of screening tests for cancer if these events occur. NEJM, Journal Watch, 2019
As doctors are trying desperately to prescribe less opioids for patients with acute and chronic pain, every attempt is being made to handle pain with multiple modalities, many physicians are suggesting or prescribing medical marijuana (CBD oil) or forms of THC.
Medscape Medical News reported on a study in Milwaukee that cited 450 patients with chronic pain who were already being prescribed opioids were, in addition, given cannabis products. It was found not to improve pain relief and did not help the patients reduce the amount of opioids. In fact, those using it daily were found to increase levels of depression, increased their use of alcohol, tobacco, and cocaine. This goes against the prevailing social media internet sites.
Many people believe that cannabis is a wonder drug for cancer, other diseases, and all types of pain, however, the evidence to date is just not there. Personal experiences, testimonials, etc., are easy to come by, but it is my responsibility to report evidence from research projects, not “the word on the street”. For those who swear by cannabis as a reliever of a multitude of complaints, I can only say, welcome to the placebo effect (which is real for those that believe).
This study reported surprise that scores in standard testing who take marijuana regularly showed increased levels of anxiety and depression, and substance abuse. This study coincides with other studies published in the Lancet Journal, July, 2019.
WWII facts about Hitler’s opioid and amphetamine addiction--FYI
A little known fact by the public was that Adolf Hitler was injected with opioids (Eukadol very similar to oxycodone) and amphetamines during the day and barbiturates for sleep at night by his personal physician, Dr. Theodore Morel, for severe abdominal pain for over a year, This was validated in the doctor’s personal records on Adolph Hitler overlooked for decades. German, British, and American troops were given methamphetamine to withstand many WWII battles much to my surprise. You may also not know that Hitler slept through D-Day invasion because of these drugs. His doctor would not let any of the Nazis disturb his sleep (created by barbiturates). He killed himself with 2 cyanide pills. Reference—The History Channel
ALERT FOR PATIENTS SEEING PAIN MANAGEMENT DOCTORS (and perhaps other doctors)
Having recently seen my pain management doctor for an epidural for a chronic back pain problem, I was surprised that he had a flyer sitting next to the sign-in. It stated:
“Many people are taking CBD (cannabidiol—the non-euphoric chemical in the marijuana and hemp plants) in one form or another. What patients do not know is that CDB can legally contain up to 5% of THC-(tetrahydrocannabinol—the euphoric substance in marijuana). This enough to test positive in a urine test. If a person tests positive for THC or any illegal substance, I will not write any prescriptions for pain”.
The variety of CBD products include gummy bears, cosmetics, foods, oils, creams, and is now available for animals too. It is pretty crazy, but people are buying it like candy.
This should be a wakeup call to pain patients that doctors are not going to allow their patients to mix THC and opioids. There are going to be some upset patients, but the opioid crisis has put an enormous burden on doctors to decrease the number of opioid prescriptions (and it is happening—40% less in 2018). This has created a tremendous anxiety in patients who are in need of pain control. Until the feds legalize marijuana and its products (it makes no difference what individual states are doing), many doctors, who now require a urine test before a pain med can be prescribed, are not going write pain scripts unless a patient has a certified medical marijuana card. Florida is looking hard at legalizing cannabis from medical use to recreational use. God help us!
Can cannabis help certain patients with sleep, relaxation, and better tolerance of pain? Many say it does. There is some sound scientific basis for cannabis to potentially be valuable. Prior to the last 80 years, cannabis was widely and legally used as a medicinal herb. CBD products will become legal country wide in very little time. Workers and professional athletes, etc. are quitting their regular jobs and opening up CBD stores. It remains to be seen how abused and misused it will be, but when marijuana is legalized, CBD will likely fade, since THC is so much more potent. Until research can give us the answers, we will not know its true value until that research is performed and approved by the FDA. Get ready for everything from soap to foods to be laced with CBD.
THC oil on the black market (the streets) is being implicated in causing the deaths and pulmonary diseases landing patients in the ICU. We now have 7 deaths and 508 deaths. Oils are not meant to be sent into the lungs.
The State of Florida has made possession of 20 gms. of marijuana a misdemeanor, essentially a parking ticket. $100 fine and 10 hours of community service and education. In my mind, unless a person is caught performing a crime, law enforcement won’t even waste their time writing the person a ticket. It remains to be seen how the legalization and minimization of possession will affect crime, auto accidents, creating a gateway substance legal, and mental and cognitive status of people.
The ECS—Endocannabinoid neurological system
There is scientific evidence that there is a system (ECS) in the body that produces its own cannabinoid-like substances that biologically bridges many of the body’s physiological locations that involves hunger, sleep, relaxation, immunity, memory formation, mood, energy, brain health, and etc. This involves known chemicals in the body such as endorphins, serotonin, and the immune system. The ECS regulates pain, inflammation, bone health, and new nerve cell formation. It is thought that cannabis provides therapeutic benefit through this system. This is the theory. Journal of Oncology, Navigation, and Survivorship, May, 2019
My advice would be to discuss this with your doctor and if you decide to try cannabis (of any kind), please let the doctor know if it is helping and how it is helping. Is it causing other side effects such as depression, increased use of alcohol, or use of of other substances. Physicians need feedback from their patients and a real honest assessment. The research does not support the benefit, but I think the final word is still yet to come. The American public deserves these questions be answered about the value of marijuana and its contents in pain management.
Alternatives to opioids--Gabapentins (pregabalins) overprescribed and sometimes dangerous
Doctors have been forced to prescribe non-opioids for chronic pain and have been desperate to find other medications that help. A class of drugs that are being overprescribed at record levels is the gabapentins (Neurontin) and pregabalins (Lyrica) and they are of little value as reported in journal articles.
These medications were originally developed and are of some value for post-herpetic neuralgia (shingles), but have been of little value in many other forms of neuropathy even including acute shingles pain. Diabetic neuropathy, back pain with sciatica, regional pain syndromes, etc. all have been tested to find the value of these medications and the JAMA-Internal Medicine Journal reported minimal to weak evidence that there is value in these conditions.
A recent report stated that there are increased numbers of suicide, traffic accidents, overdoses, and injuries in younger people (15-24) taking pregabalin (Lyrica)-not gabapentins (Neurontin). It is a risk in anyone taking this medication, and alcohol is absolutely not allowed because it accentuates sedation. If this is prescribed for you, please talk to your doctor about these risks. British Medical Journal, June, 2019A few words on Kratom
Kratom is being used by many people who want to relieve pain and get a buzz at the same time. That sounds like opioids doesn’t it? In fact, Kratom, an actual tree has become a common recreational drug that needs to be controlled. Kratom contains mitrogynine, a chemical that stimulates the same sites in the brain that opioids do. And yet, it is not illegal (it is in some states due to its safety concerns). The FDA warns people not to use it because of serious side effects including hallucinations, seizures, liver damage, withdrawal, and death. Withdrawal can be serious and make it very difficult to get off the recreational substance that should be called a drug and controlled. But as long as it is not declared a drug by the federal government and only a dietary supplement, it can not be controlled by the FDA.
I am aware that in Florida, at least, there are bars that sell Kratom cocktails (totally legal). Between the increased use of marijuana and now Kratom use (used as tea), the young people are going to be in a lot of trouble with substance abuse. If one believes these are gateway drugs, be very afraid!
This is readily available in vaping shops, “head shops” that sell paraphernalia for smoking marijuana, etc. Kratom has been used for pain relief in Eastern Medicine for centuries. It does work but buyer beware.
In conclusion, there is little evidence that any other category of medications including anti-depressants, anti-anxiety (benzodiazepines), muscle relaxants, and cannabis products are much help in improving pain levels with or without opioids. However, there are people that swear by these medications. It is my responsibility to report only medical literature articles (not heresay).
We are faced with using opioids wisely as they really are the only form of medicine to help acute and most chronic forms of pain. Relying on opioids for chronic pain, however, invites abuse and addiction. But when the companies stop making it (they are going bankrupt because of lawsuits), who will provide it to those in need?
On the other hand, there is good evidence that many forms of complementary therapies are of value including, chiropractic, physical therapy, regimens of exercise, massage, yoga, meditation, acupuncture, etc. and should be tried. Getting insurance companies to cover these therapies continues to be a challenge. Congress must get involved and the public must encourage them to support insurance coverage, which would accelerate the use of these non-opioid therapies. If the government is serious about getting the opioid crisis under control, these therapies must be part of the solution.
We desperately need new research on new medications to help treat pain. And more study on products sold legally that have the same effects as opioids, like Kratom.
WebMD; JAMA; Journal Of Oncology, Navigation, and Survivorship, 2019
1 in 3 seniors dies of some form of dementia!! While the incidence of dementia has decreased the diagnosis of Alzheimer’s Disease (AD) has increased
Risk Factors that create risk for early dementia
There are many factors that increase the risk of dementia including aging, hypertension, previous stroke and heart attack, hearing and vision loss, social isolation, depression, diabetes, and smoking which account for about 35% of dementia cases whether Alzheimer’s disease or not.
Other risk factors for early dementia include:
Medication side effects, genetic risks, physical inactivity, not sleeping, eating a diet high in salt, fat, sugar, and red and processed meat, overeating, obstructive sleep apnea, excess alcohol intake, head injury, chemotherapy, head radiation, Down’s syndrome, Parkinson’s disease, metabolic, nutritional deficiency, and brain diseases.
Not getting enough sunlight, living in a polluted environment, cooking with aluminum pots and pans, and people who don’t drink enough fluids (dehydration) increase their risk. Even having surgery with general anesthesia may increase the risk of cognitive decline. Although not yet proven, exposure to herpes virus may increase the risk.
In other words, any unhealthy lifestyle and many diseases seem to increase the risk, and with the average American overweight and having several of these risk factors, it appears dementia will be increasing in the next few decades. There are statistics in Alzheimer’s disease, and since about 70-80% of dementia is diagnosed with AD, one could extrapolate from these statistics:
1) 5.8% of older adults have AD (currently 5.4 million Americans)
2) There will be a 40% increase in AD over the next 10 years barring some medical breakthrough.
3) By 2026, there will be 7.1 million and by 14 million in 2050.
4) The death rate for people 85 or older has doubled since 2000.
5) AD is still 100% fatal, and of the top ten causes of death is the only one that there is no cure.
6) 85% of dementia is diagnosed initially by primary care doctors.
7) 16 million family members provide 18.5 billion hours of unpaid care with an economic value of $233.9 billion dollars. 30% of AD patients are on Medicare or Medicaid. AD could bankrupt the Medicare and Medicaid by 2050.
8) The cost of care (healthcare, longterm care, and hospice) for AD is $277 billion (2018) in the U.S.
9) The amount of revenue allotted by the U.S. Government for AD needs to be greatly increased considering the impact of disease burden and death. FY2018 $1.9 billion for AD research by the NIH* (*NIH=National Institute of Health9).
10) Average cost per patient of AD=$ 287,000, Cardiovascular disease= $175,000, Cancer= $173,000. *NIH=National Institutes of Health
Preventative techniques (recent research)
Hypertension during midlife followed by low blood pressure (hypotension) when older also seems to increase the risk, even over having sustained hypertension into the late life. JAMA, August 13, 2019
Patient with long standing anemia have a 43% greater chance of dementia and polycythemia (too much blood) increases it 24%. Anemia reduces oxygen to the brain, and too much blood thickens the blood clogging blood vessels.
Dementia in patients who undergo surgery
More scary information! 1 in 14 (7%) older Americans undergoing elective non-cardiac surgery will develop an undetectable stroke (diagnosed by MRI in this study), which clearly increases the risk of dementia. Cardiac surgery has been known to increase the risk of cognitive decline for many years. 42% at one year of those who had a undetectable (covert) stroke) scored more poorly on cognitive testing, leading the authors of the study to state that these patients had double the risk of developing early dementia. Lancet, August, 2019
Dementia’s symptoms can include memory loss, difficulty in communication and concentrating, anxiety, loss of social skills, hallucinations, difficulty concentrating, and mood swings.
Medications can cause dementia—anti-cholinergic drugs
Medications can be a risk for cognitive difficulties at an earlier age than the average person might experience dementia.
Recent reports point to anti-cholinergic drugs. These medications block the neurotransmitter acetylcholine in the central and peripheral nervous system. This group of 56 strong anti-cholinergic drugs which include antihistamines, bladder antispasmodics, anti-nauea, anti-vertigo, anti-parkinson’s drugs, anti-arrhythmia meds, anti-depressant, anti-psychotic, and anti-seizure meds.
Some of these drugs can have short term side effects such as confusion and memory loss in older people. But the long term consequences of these medications has not been well studied.
The Geriatric Society 2012 Beers Criteria provides a list of meds that increase the risk of dementia. You can search on GoodRx for common drugs that can potentially cause dementia. www.goodrx.com/blog/-these-drugs-could-increase-your-risk-of-dementia
Patients 55 and older previously diagnosed with dementia who took these medications 1-11 years prior to the development of dementia. This group was compared with a similar aged group of controls who did not take these types of drugs. JAMA-Internal Medicine, 2019
Only certain groups of anticholinergic drugs were found to have increased risks for early dementia. Those with the strongest association with dementia were anti-depressants, bladder anti-spasmodics, anti-psychotics, and anti-seizure medications. There were no associations with antihistamines, gastrointestinal antispasmodics, certain bronchodilators, arrhythmics, skeletal muscle relaxants.
It is estimated that these drugs alone could be responsible for up to 10% of dementia cases. This study that included a large number of patients in the study. It was estimated that if a patient took one or more of these drugs every day for 3 years, that there would be a 50% increased risk of developing early dementia. Whether these patients might develop dementia later in life anyway was not studied.
Other major factors causing dementia
It was stated in this article that the risk of developing dementia from hypertension was 5%, 3% for diabetes, 14% for later life dementia, and 6.5% for physical inactivity. This was a European study. Lancet, 2017 The Alzheimer’s Association is currently doing a similar study in the U.S.
Androgen deprivation therapy for post-treated prostate cancer patients were found to have a 19% increased risk of developing dementia according to a JAMA journal article in July, 2019. However, this therapy is very successful in preventing the recurrence of prostate cancer, so don’t jump to automatic conclusions. Talk to your oncologist.
Genetic factors alone account for about 2% of dementia cases. However, if a healthy lifestyle is followed, even with high genetic risk that risk can be dropped by 50% to 1%. A healthy lifestyle is defined as no smoking, a healthy diet, minimal alcohol intake, daily exercise (walking).
5.7 million Americans have Alzheimer’s dementia, the most common type (65% of the patients in this study that were diagnosed with dementia). However, there are other causes, especially vascular dementia (i.e. Lewy body disease) or from stroke. Rarer causes include the genetic causes such as Huntington’s disease, HIV, and severe infections.
Dementia is a serious issue for older people if faced with the need for these common anti-cholinergic drugs (anti-depressants, bladder antispasmodics, anti-psychotics, ant-seizure meds, and certain anti-Parkinson’s drugs). If a person is hypertensive, diabetic, a smoker, and do not exercise regularly, the risk rise exponentially. Genetic risks also increase dementia, but a healthy lifestyle will reduce dementia by 50% if genetics are the only issue.
It is likely physicians will not mention this side effect, but it should be obvious that when given a drug for the first time, side effects should be asked about.
Review your drugs for potential for increasing your risk of dementia.
The risk/benefits of any treatment must always be discussed, but with shorter doctor’s visits and less time for discussion, it is incumbent upon patients to be proactive and ASK. Also reading about side effects in the package insert is advised. If they are not given to a person at the pharmacy, request it. It is your right and their responsibility!
A number of tests are required to test for cognitive skills including a thorough neurological and psychiatric examination including CT and PET scans to look for abnormalities including amyloid deposits in the brain (Alzheimer’s).
Laboratory tests for deficiencies, and blood chemistry abnormalities are tested. A social history regarding sensory problems (hearing, eyesight), living alone, social isolation, lack of mental exercises, lack of exercise, disability is also critical as these factors increase the risk of dementia earlier. A complete report on Alzheimer’s disease can be found in my website:
Treatment of dementia
Obviously controlling diseases and disorders that create higher risk are the best medicine plus a healthy diet.
1. Cholinesterase inhibitors-these keep the neurotransmitter acetylcholine at high levels which help memory and cognition. Aricept, Exelon, and Razadyne are three medications that accomplish this task.
2. Namenda regulates the activity of glutamate, another neurotransmitter that helps the brain learn and memory.
3. Other medications treat specific individual symptoms of dementia such as depression, hallucinations, sleep difficulty, agitation, and even the physical symptoms of Parkinson;s disease. All these above drugs may be prescribed for Parkinson’s disease and other forms of dementia.
4. Memory care facilities are available to assist patients with daily challenges. This includes occupational therapy, counseling, and management of physical and emotional needs. Adequate vision assistance, hearing aids, mental exercises, physical exercise (has proven to lower the beta amyloid and tau deposits in brains of Alzheimer’s including preserving brain gray matter).
Drugs (antihypertensive and intranasal insulin) and Ketogenic diet may help dementia
Although, very premature, a study out of Johns Hopkins School of Medicine found in older adults with mild cognitive impairment experienced modest improvement switching their diet to a modified Adkins/keto diet. Adkins diet uses a low carbohydrate diet. These diets should be under the supervision of a physician.
Patients with early Alzheimer’s disease (AD) do not metabolize carbohydrates well, and therefore a faulty way to use foods for energy. Moving to a diet that increases metabolism with fats and the creation of ketones may be a good energy source.
If these studies hold up with other independent studies, it would be a game changer, since drug research has been a dismal failure to trying to prevent continued dementia. This study emphasizes once again the importance of our diet and health. Journal of Alzheimer’s disease, July, 2019
Anti-hypertensive medications may help dementia, especially ARBs (angiotensin receptor inhibitors—i.e. lisinopril, losartan, valsartan, etc.), by reducing blood pressure in hypertensive patients. Vascular dementia could be prevented inthose patients. Even Alzheimer’s has a vascular component.
In this study in 2010 in the British Medical Journal, researchers found that there was a 19% lower risk of developing AD and 24% lower for dementia. In fact, there are other studies that single out ARBs as a better choice for treating hypertension that with ACE inhibitors, beta blockers, and calcium channel blockers. It is interesting that the benefit was greatest at one year but no long term neuroprotection beyond 3 years. Moreover, those ARBs that crossed the blood brain barrier such as valsartan and candesartan were better than those which did not cross the blood brain barrier showing longer term neuroprotection and smaller whilte brain matter hyperintensities on MRI scan.
It is also known that other protective mechanisms for ARBs include faster metabolism of tau, the protein that deposits in the brain of AD patients and also lowers oxidative stress.
Current studies under way are evaluating the positive effects of exercise, the statins, losartan (ARB) and amlodipine (calcium channel blocker). This report appeared in Medscape, July 26, 2019
Intranasal insulin (daily) may be effective in slowing the progression of dementia including AD. It has been found that it can slow the rate of progression of cognitive decline by 1-2 years according to Medscape Medical News (Wake Forest School of Medicine) presented at the Alzheimer’s Association International Conference in July 17,2019.
Insulin is critical for normal brain and body functions to maintain proper glucose levels. It enhances communication between neurons, increases brain blood flow, and protects against beta amyloid and abnormal tau, both of which deposit abnormal amounts in the brains of AD patients. It appears, according to the investigators, that either patients with AD have low insulin levels or does not work effectively. Intranasal administration (20 units used in a special device) is the only route that seems to work. This information was determined using cognitive and behavioral tests and measuring amyloid and tau proteins in cerebrospinal fluid. Intensive research continues. An inexpensive blood test to diagnose AD is on the horizon with encouraging clinical trials ongoing.
The research must come up with real treatments that can reverse the symptoms of dementia, but for now we must do everything we can to live healthy, treat diseases and disorders that raise risk, and talk to your doctor about some of these new research findings.
JAMA-Internal Medicine and Neurology, July, 2019
Everyone knows about cholesterol and its effect on the cardiovascular system. There are good fats (HDL)* and bad fats (LDL)* measured in the blood. However, the other fat is called triglyceride, actually made up with 3 fatty acid molecules and 1 glycerol molecule.
*HDL=hign density lipoprotein cholesterol
LDL=low density lipoprotein choleserol
Until the last several decades, there was no clearcut medical evidence that triglycerides were harmful to our bodies. In the past few decades, research finally reported cardiovascular disease risks from high triglycerides. Plaque in blood vessels are filled with fats—cholesterol and triglycerides (if elevated). Now, it is customary to check for triglycerides especially if there is a history of fat abnormalities, such as a high cholesterol. The blood test is called lipid profile.
There is another test that may be valuable as it measures inflammation in the body, which is thought to be one of the primary factors in many diseases including cardiovascular disease. This protein is produced by the liver in response infection and injury. Above 2 mg/liter is considered a high risk factor for heart disease. It should be tested twice 2 weeks apart to be sure of the results. The test is not routinely recommended except in patients with heart disease. Cholesterol lowering medications (statins) may reduce the C-reactive protein.
Why are high triglycerides bad?
There are other medical diseases that accompany triglyceride elevation especially when the LDL is high including type 2 diabetes mellitus and accompanying increase risk for cardiovascular disease.
Triglycerides over 500mg/dl might indicate a hereditary triglyceride disorder. This hereditary hypertriglyceridemia increases risk in having serious cardiovascular complications before the age of 50 including heart attack and stroke.
When blood is drawn, the fat in the blood separates from the blood and looks like this vial of blood. The plasma is milky from triglycerides.
Basic science of lipid metabolism
Lipids are transported in the blood in a protein capsule called a lipoprotein. If lipoproteins are elevated in the blood they attach more fats than normal specifically the breakdown product of fats—fatty acids (and cholesterol).
There are 3 well known classes of fatty acids: a) saturated b) monounsaturated c) polyunsaturated. Trans-fat is not a naturally occurring fat. It is created industrially and should be avoided in the diet. Fortunately decent restaurants do not use it in cooking.
The body can store energy for longer periods of time in the form of fatty acids. These acids are carried in the blood by proteins (beta-lipoproteins). These are stored in fat cells as triglycerides or neutral fat, which are converted to glycerol for energy.
Triglyceride is a glycerol molecule attached to three fatty acid molecules. Different forms of fats are critical to body function. Phospholipids maintain cell integrity, cell signaling processes, and construction of cellular receptors.
Fatty acids provide a source of concentrated energy for cellular metabolic needs. Oxidation of fatty acids creates 9 kilocalories of energy per gram of fat.
Classification of triglyceride abnormalities
The major lipids are cholesterol and triglycerides.
The real abnormality is in the protein that carries the triglyceride complex molecule. Hence the abnormality is called hyperlipoproteinemia, because the lipoproteins are actually elevated in the blood in hereditary cases, and since triglycerides are carried in the blood by this lipoprotein, the triglycerides and the lipoproteins are elevated and perhaps cholesterol. These lipoproteins can also carry cholesterol and if these fats can’t be broken down by the body to fatty acids, the cholesterol and the triglycerides are elevated. When cholesterol is broken down, it is excreted as bile salts, which are broken down even further by the bacteria in the bowel.
As mentioned above, there are two types of hypertriglyceridemia-primary (hereditary) and secondary (caused by diseases such as diabetes, thyroid disease, pancreatitis, and certain medications including birth control pills and steroids).
Hereditary hypertriglyceridenemia is classified into 5 types (not necessary to include in this discussion).
Treatment of hypertriglyceridemia (or could be called hyperlipoproteinemia) regardless of type, hereditary or not.
1) quit smoking
2) lose weight
3) limit alcohol intake
4) cut back on sugars (refined carbohydrates) in sweets and sugary drinks
5) Eat more grains, vegetables, fruits, and food containing omega 3 fatty acids
6) Control any underlying diseases such as type 2 diabetes mellitus, hypothyroidism, pancreatitis (usually from alcohol abuse, pregnancy, or actually high triglycerides).
6) 4 grams daily of Omega 3s--1000 mg capsules (Vascepta, Lovaza), or similar amounts of 2 important types—EPA-eicosapentaenoic acid 900mg and DHA—docosahexaenoic acid 375mg in each 1000mg capsule. 4 capsules are recommended daily. It can be taken at one sitting or split doses twice a day.
If the cholesterol is elevated, a statin may be prescribed as well. It is optimal to lower the LDL-cholesterol and raise the HDL-cholesterol. If still elevated, Xetia (fat blocker) will assist the statins.
Scopeheal.com; WebMD, medicine.net, and Mayo Clinic
This completes the October report!
The November report will include:
1- Breast cancer screening; estrogen in postmenopausal women, BRCA gene testing
2- e-cigarettes—deaths, pulmonary disease, and explosions
4- Driving and aging-when to take the keys away
5- Drug crisis update
6- Peripheral neuropathy
Stay healthy and well, my friends, Dr. Sam