26/03/2019

The dangers of this potent “man-made” opioid

In recent years, the media has been awash with information on the health benefits of exercise. Exercise is known to boost mood in adults. But what about younger members of society? Based on recent, high quality survey data, we can estimate that about 11% of adolescents are depressed. Sadly, this means that one in 10 adolescents between the ages of 12 and 17 experienced a major depressive episode during the year of the survey. These numbers should raise alarm bells for both parents and doctors.

Depression makes teens feel awful, but being depressed as a teen may also have life-long consequences, including being depressed as an adult. Depressive episodes in teens can contribute to poor grades, poor interpersonal relationships, and worse physical health. Depression can also increase the burden of care for parents. In a recent post, I discussed how a teen’s social network can impact his or her chances of becoming depressed. There, we explored how having friends with good spirits could exert a positive influence on a teen’s mood. We have also previously touched on some of the concerns with giving teens antidepressant medication. Today we will tackle the hot topic of exercise and depression in adolescents.
A carefully conducted analysis of exercise and depression in teens

A recent study attempted to delve into the data behind exercise as a treatment for depression in teens. The authors initially screened 543 studies and found 11 to include in their analysis. Of those 11, only eight yielded good data to use for more specific calculations. In general, although not always, these types of analyses are particularly powerful because the authors use rigorous criteria when deciding which studies to include.

The teens included in this analysis were 13 to 17 year olds, who did not have any major physical health problems, such as obesity. The data from the studies compared the use of exercise as treatment for depression against a psychosocial intervention, an educational intervention, treatment “as usual”, or no treatment at all. After combining data, the authors eventually concluded that exercise appears to lead to moderately improve depression in adolescents, particularly in those already receiving some formal treatment. But, treatment “as usual” was not well defined, and we don’t know, for example, how many of these teens were taking antidepressant medication.
Will exercise really help teens suffering with depression?

So, should we conclude from this study that all teens with depression should be treated, to some extent, with exercise? It is tempting to say yes. However, concluding that all teens with depression should be treated with exercise would over-simplify the results of this study.  A person (adult or teen) with depression will likely find that exercise helps improve symptoms to some degree. However, this study doesn’t support the statement that exercise is the best cure for depression. Instead, it would be more accurate to say that in teens who are already undergoing treatment for depression, exercise appears to be a strategy with modest benefits and little downside. This particular study is a wonderful addition to our knowledge base, in that it puts another tool into a doctor’s toolkit to help treat patients with depression in clinical settings. Every day, about 10 people die from drowning — and two of them are children. Not only that, for every child that dies from drowning, five more are treated in emergency room for injuries from drowning, which can include permanent and severe brain injuries.

Here are the five things all parents and caregivers need to know about drowning:

    Drowning can be silent. When we think about drowning, we think about flailing arms and calls for help, but that’s not how it usually works. What usually happens is that people take the biggest breath they can and go down — and don’t come back up again. They can’t flail and they can’t yell. You could miss it. To learn more about this, check out the great post, “Drowning Doesn’t Look Like Drowning.”
    Drowning can happen where there are lifeguards. In 2011, a woman slid to the bottom of a guarded public pool in the Boston area and drowned — and her body wasn’t discovered for two days because the water was murky. While that may be an extreme case, people drown where there are lifeguards all the time. Lifeguards can’t always see everything, especially when drowning can be silent — and they can get distracted just like anyone else. Just because there is a lifeguard doesn’t mean you don’t have to watch your child.
    Drowning can happen in very little water. All it takes is enough water to get your face in. Children can drown in a kiddie pool, a bathtub, a bucket of water, or a toilet bowl.
    Good swimmers can drown. They can get tired, they can get a cramp, they get can caught in a rip current or in something underwater — or they can bump their head. Just because your child is a good swimmer doesn’t mean something bad can’t happen.
    Drowning is preventable. Here’s what you can do:

    Teach your child to swim. Sign them up for a swimming class — look for one that teaches water safety skills, too.
    Learn CPR. It’s easy to learn, and saves lives.
    If you have a pool, make sure it is completely fenced all around — and has a self-latching or self-locking gate.
    Use lifejackets whenever you go out on the water, on anything.
    Teach your children what to do if they get caught in a rip current: instead of fighting it and trying to swim back to shore against it, swim parallel to shore and ease your way out of it.
    Keep your eyes on your child at all times when they are in any kind of water. This includes bathtubs and kiddie pools; if you need to take your eyes off them, take them out of the water. At the beach or pool, keep your eyes on your children even if there is a lifeguard. You can read or look at your phone later. Nothing is more important than your child’s life.
In July, the Centers for Disease Control and Prevention announced that a woman in Miami-Dade County in Florida had tested positive for the Zika virus. Follow-up to this case led health officials in Florida to report a total of 15 cases in the area. These weren’t the first people in the United States, or even in Florida, to contract Zika. But these cases were unique in one important way –– they were likely caused by mosquitoes in the United States.

The CDC promptly issued a travel warning for pregnant woman and their partners, warning them not to visit the small community of Wynwood, just north of Miami, where these Zika cases first occurred. This is the first time the CDC has ever issued a warning to pregnant women about traveling to a place within the United States because of the threat of infectious disease.
It’s no surprise that local mosquitoes carry Zika

For many health officials it wasn’t a question of whether Zika was going to get to the United States, but rather when it would arrive. Currently, there are more than 1,400 travel-related Zika cases in the United States, and U.S. territories like Puerto Rico are grappling with more than 3,800 cases. Also, parts of the United States are home to the Aedes aegypti mosquitoes that carry the virus, with southern states like Texas and Florida bearing the greatest risks for outbreaks due to their warmer climates.

The news that mosquitoes in the United States have been found to carry Zika is certainly concerning, but experts say that Zika likely won’t spread here as it has in countries in Central and South America. “Our housing is generally better here, and since we’re more likely to have AC, we can keep our houses sealed off better,” says Dr. John Ross, an infectious disease expert and professor of medicine at Harvard Medical School. “We also tend to have more robust healthcare in the U.S. than in other places, so we can track and treat these cases more effectively.”
How do you know if you have Zika…and how can you avoid it?

The CDC reports that only about 20% of people who get the virus go on to show symptoms, which are usually mild and typically include a low-grade fever, sore or aching joints, conjunctivitis (“pink eye”), and a rash. However, the virus does pose a greater danger to pregnant women and their unborn children, as studies have shown that Zika may cause microcephaly. Microcephaly is a birth defect in which a baby’s head is unusually small. Often, the brain has not developed properly, which can result in neurological and developmental problems. Current research estimates that 1% of all pregnant women with Zika will give birth to a child with these neurological issues.

In addition to their travel advisories, doctors at the CDC have also provided information about how to prevent mosquito bites and decrease the risk of developing Zika:

    Avoid areas with Zika. Women who are pregnant or who are trying to become pregnant should avoid areas with known Zika cases.
    Use insect repellant. It’s a simple and maybe obvious step — using insect repellant helps deter mosquitoes and prevent bites.
    Wear clothing that provides coverage. Long sleeves and long pants protect your arms and legs from mosquitoes and help prevent bites.
    Practice safe sex. Zika can be spread through sex, so it’s important to use a condom to prevent sexual transmission. If you have been anywhere with an outbreak of Zika, doctors recommend that you use a condom for 8 weeks after your return if you don’t show symptoms of Zika, and for 6 months if you do show symptoms in order to prevent transmission to you sexual partner.
    Travel safely. If you are traveling to an area with known cases of Zika, take the proper safety precautions and watch for travel advisories. Doctors may recommend vaccines or other medications.

Although it’s concerning to see cases of Zika in the United States, they don’t necessarily signal the beginning of a widespread epidemic. “We always need to be vigilant,” says Ross. “The good thing is that people are aware of the dangers of Zika, and we have the tools we need to limit and monitor its spread.” As we watch the devastation of the opioid crisis escalate in a rising tide of deaths, a lesser known substance is frequently mentioned: fentanyl. Fentanyl’s relative obscurity was shattered with the well-publicized overdose death of pop star Prince. Previously used only as a pharmaceutical painkiller for crippling pain at the end of life or for surgical procedures, fentanyl is now making headlines as the drug responsible for a growing proportion of overdose deaths.
So what is fentanyl and why is it so dangerous?

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Its potency also means that it is profitable for dealers as well as dangerous for those who use it, intentionally or unintentionally. Increasingly heroin is being mixed with fentanyl so someone who uses what they think is heroin may in fact be getting a mixture with — or even pure — fentanyl. More recently, pills made to look like the painkiller oxycodone or the anxiety medication Xanax are actually fentanyl. This deception is proving fatal. It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol. While many people don’t know they are getting fentanyl, others might unfortunately seek it out as part of the way the brain disease of addiction manifests itself into compulsively seeking the next powerful high.
Helping people who use fentanyl

The way to help patients who are using fentanyl is the same as for other forms of opioid use disorder: to provide effective addiction treatment. However, the first and most important step is helping patients stay safe and stay alive until we can get them that treatment.

It’s worth remembering that dead people don’t recover.

To stop the deaths, we must provide immediate access to lifesaving treatment on demand. While any opioid use is risky, fentanyl has raised the stakes. Every single episode of fentanyl use carries the risk of immediate death. This highlights the need to change how we think about treatment. Many of the traditional models of addiction treatment were designed for alcohol use disorder. Misuse of alcohol can be fatal, but it usually takes many years or even decades to kill someone. In contrast, opioid addiction is imminently fatal, so waiting for treatment is and should be considered unacceptable. We must try to initiate treatment at every opportunity — in the emergency department, at the hospital bed, or even on the street. The best evidence we have shows that a combination of medication and psychosocial treatments is most effective for opioid use disorder. A study of MassHealth patients found that patients on medication treatments like methadone or buprenorphine are 50% less likely to relapse. Other studies have shown that patients treated with these medications are 50% (or more) less likely to die. And yet significant stigma and misunderstanding still exists around these medications. We have treatment programs (and doctors) that don’t offer these medications and patients who are doing wonderfully in recovery thanks to them, but who are also scared to speak out and say they are on medication because the stigma is so pervasive.

Even with our best efforts, it can take time for some people to be open to treatment. In those cases, our priority is to keep them alive and to keep working with them on their readiness to consider treatment. This requires access to naloxone, the antidote to overdoses. But it also includes other education and harm reduction services. People who have loved ones who are actively using and those who are using themselves need to know how to stay safe. There is very concrete education that can reduce the risk of overdose and we need to ensure it is getting to those at the greatest risk.
Moving forward

In Massachusetts alone, deaths due to fentanyl overdose have risen to 57% between 2015 and the first half of 2016. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

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