Category: Healthcare

“Take care of your people and they will take care of your customers.” – JW Marriott

Every busines offers a product. Offering the best version of that product is the main aim of any business..
A hospital is no different. It offers a product. It’s called “Patient Care”
Every hospital aims to offer the best patient care versus all the other hospital competing with it for business.
The most immediate face of patient care in any hospital aren’t the doctors, administrators or janitors. They are the nurses. They are the most immediate parameter used by patients to rate care in any hospital. The care they give will make or break a hospital.
So a hospital that aims to win business and be seen as great cannot afford to skimp on nurses. That hospital will aim to get the best and most experienced nurses. They will also get younger nurses who hopefully can take the place of the older nurses one day but they will not be the dominating group in the nursing pool. The older and more experienced nurses should be.
Then you come to the doctors. You want the best. If you have good ones, you strive to keep them. If they threaten to leave, you try to meet them halfway. If they are surgeons, you stroke their ego – you may need both hands! Then remember the product you offer is patient care and you need good nurses and doctors to achieve that.

Interestingly, there is a trend in the US that boggles the mind. Hospital administrators seem to have forgotten what the product is. They’ve forgotten what really matters. They are bogged down by the numbers so much that they have lost sight of what their product is – Patient Care!
So some lay off nurses, get rid of good doctors, seeing personnel cost as a liability instead of an asset and in the process, worsen patient care. They nickel-and-dime the quality of their product to death – no pun intended.Personnel costs may be a problem when one is dealing with the Post Office but in a hospital, that is the key for a great product.
Now this happens because a lot of hospital administrators honestly do not know and understand the ins-and outs of patient care. Running a hospital is not the same as running, say, UPS or Walmart. They are both businesses but one deals with people – sick people – and there is a high degree of unpredictability that the numbers do not always reflect. That is the problem classically-trained business minds have. It is no accident that physician-owned-and-ran hospitals do better than non-physician-owned ones. It is also interesting that the longer an administrator has been at a position in a hospital, they better the decision-making gets. This is because they are forced to develop relationships with the doctors and nurses and thus acquire a feel for that unpredictability.

Which brings me to my point – that hospitals should be run by physicians and nurses, supported by a finance team. This should be a physician who does clinical work not a desk-hugger. It is the only way that the product, patient care, will always come first and not some arcane numbers. Having a finance team will reduce any excesses that physicians are sometimes prone to when new medical technology or drugs are available. The vision of a hospital will also be more in line with the real needs of patients in a community and the future of medicine not the numbers. The other doctors and nurses in the hospital are more apt to find a listening ear in a physician CEO than a classic MBA daydreaming about numbers and spreadsheets.

Sure, not every physician can be a good administrator but honestly, looking at what is out there now and how physicians and nurses see being treated all over, what do we have to lose?

“When the Grim Reaper comes to call, words fail – they’re just too small.” – Dixie Lyle, To Die Fur

Harriet Tubman may be one of the most admired figures in all of American history. Her bravery is the stuff of legends. Besides my personal admiration for what she did, I’m also saddened that her ancestry goes back to the Akan people of Ghana. I am an Akan.
She will forever be remembered for her use of the underground railroad to free over 300 slaves after she escaped slavery herself. In about 19 trips, she never lost a single passenger.
I often think of Ms Tubman when life rears it’s ugly head.
I also find myself comparing what she did to what I do. To what doctors and nurses who take care of critically-ill patients in either the Intensive Care Unit (ICU) or the operating room (OR) do.
Please do not get me wrong. I am in no way setting the two jobs on the same footing. Not at all. I dare not. I wouldn’t survive for a minute in the conditions she thrived in.
What I aim to do is compare only an aspect of what she did to what we as critical care providers do.
Ms Tubman used her wiles, intuition, courage and the underground railroad to snatch men, women and children from the clutches of slavery.
Doctors and nurses who work in the critical care setting, either in the operating room or the ICU, use their acquired skills, intuition, advanced monitors and drugs to snatch men, women and children from the clutches of the Grim Reaper.
Whereas Ms Tubman never lost a passenger, we are not so lucky. Sure, modern medicine allows the most amazing stories of healing. A series of these successes makes one forget that, like Ms Tubman, we are really trying save people from a really powerful enemy.
Her enemy were the slave owners and the States . Ours is the Grim Reaper.
The fact that we succeed is often not so much due to our abilities but also to luck or chance or fate or providence, whatever you want to call it. Then every so often, just when you think you have reached a safe spot with your ward, the Grim Reaper shows up unexpectedly and snatches him or her back. That is when one realizes who really is the more powerful. That our knowledge, monitors, intuition and drugs are really feeble attempts to hold off the might of Mr Reaper.
So as the futility of the moment hits and chest compressions are halted, a flat line on a monitor screen is all we are then left with. In the silence that ensues, one can often hear his faint but powerful voice as he escapes with the soul of a patient who was alive only a few minutes ago. One can usually hear his chuckle as he asks, “Who’s is your daddy?”
No answer is needed, then those moments remind us all of the frailty of life and our powerlessness. One can then only sigh, get back the composure and march off to the next battle, hoping this time to get the upper hand. Then as old as life itself is this dance with the Grim Reaper. A truly macabre yet rewarding dance indeed. We get better at it each day and I’m sure Ms Tubman would be proud.

“A good gulp of hot whisky at bedtime—it’s not very scientific, but it helps.”
– Alexander Fleming

The practice of medicine demands that a doctor give the best possible care without knowingly causing the patient harm. A physician is supposed to have the well-being of his or her patients as the paramount issue of his or her practice. This position in the doctor’s hierarchy of care is never supposed to be affected by money, fame, glory or power. Yet, as the following story illustrates, doctors are only human and are swayed by money.
Until about the early 1940s, alcohol-containing beverages were seen as having medicinal properties. As far back as in ancient China, Egypt, Greece and Rome, healers treated everything from snake bites to pain with booze. Alcohol was recognized for it’s antiseptic and analgesic properties. Even during the American Civil War, field medics used whiskey and brandy to treat pain when they ran out of opiates. At the beginning of the 20th century, whiskey was being used to treat delirium, anemia, dyspepsia and snake bites. A common adult dose was about 1 ounce every 2-3 hours. Child doses ranged from 1/2 to 2 teaspoons every three hour. In some cases, alcohol could comprise as much as 40% of a patient’s daily intake!
Even today, we still hear of remedies like
rubbing a teething infant’s gum with whisky or drinking hot beer to treat the common cold.
Around 1850, scientific medicine started emerging in the US. With that, the therapeutic benefit of alcoholic beverages started to be questioned. By the early part of the 20th century, this anti-alcohol-for-medicine movement had gained traction. It also coincided with the Prohibition movement.
In 1916 whiskey and brandy were removed from the list of scientifically approved medicines in The Pharmacopeia of the United States of America.
In June 1917, even as the 18th Amendment to ban alcohol was slowly working it’s way through Congress, the American Medical Association (the AMA) voted to denounce the use of alcohol for medical purposes.
The resolution read:
Whereas, We believe that the use of alcohol is detrimental to the human economy and,
Whereas, its use in therapeutics as a tonic or stimulant or for food has no scientific value; therefore,
Be it Resolved, That the American Medical Association is opposed to the use of alcohol as a beverage; and
Be it Further Resolved, That the use of alcohol as a therapeutic agent should be further discouraged.
In 1920, Congress passed the 18th Amendment and with the Volstead Act, Prohibition was ushered in. However, the law allowed the use of alcoholic beverages (beer, wines, whiskey and brandy) for medicinal purposes and for the Holy Sacrament. I guess the cultural use of alcohol as a drug was too strong.
The next few years saw the prescriptions of alcohol skyrocket. Using prescription pads obtained from the Treasury Department, doctors could sell patients prescriptions for a pint of whiskey every 10 days for $3 ($40 today). For $3 more, a pharmacist would then fill it.
In Chicago, a pharmacist named Charles Walgreen grew his chain of 20 stores in 1920 to 525 in 1930 through these prescriptions.
In 1922, five years after passage of it’s resolution to denounce the use of alcoholic beverages as medicine, the AMA did a national survey – the Referendum on the Use of Alcohol in the Medical Profession. The results were interesting:
From alcohol not having any scientific value as a therapeutic agent just 5 years earlier, now doctors reported using alcohol to treat as many as 27 ailments including diabetes, cancer, asthma, dyspepsia, lactation problems, tuberculosis, pneumonia, high blood pressure and problems old age!
A group of doctors would even lobby Congress and eventually bring the case before the Supreme Court to be allowed to prescribe as much alcohol as they wanted and not the measly 10 pints every 10 days. Even though the group claimed that their motivation was not money bu the issue of independent practice and non-interference by the federal government, one could not help but think of the AMA survey.
Eventually, Prohibition would be repealed through the 21st Amendment in 1933 and a decade later, the practice of prescribing whiskey and brandy for ailments would slowly die out.
As doctors, we are asked to help or do no harm. Yet when money is in play, I wonder how many of us succumb and do things that may harm patients. Like the patients of yesteryear, yearning for their pint of whiskey, I wonder how many of us take a swig out of that exhilarating bottle of power, fame and glory and forget what we are supposed to stand for. I hope we of today are doing much better than those back then.

To undergo a surgical procedure, most people need some form of anesthetic.
If the procedure is small and does not involve a very deep incision, the surgeon can numb the area locally with local anesthetic and proceed. This technique is called local anesthesia and can be used even in a doctor’s office without the presence of a trained anesthesia provider.
The next level would be regional anesthesia. Using a local anesthetic, the nerve supply to a particular region of the body is blocked. This is great because not only does it allow the anesthetic to be localized but it also can be tailored to give pain relief for hours.
In instances where a local or regional anesthetic is not feasible or contraindicated, the other option is general anesthesia. Here, using either an intravenous or inhaled agent, loss of consciousness is achieved. This allows the patient to undergo surgery.
In a paper published in 2003, Vesna Jevtovic-Todorovic, an anesthesiologist then practicing in Virginia, exposed 7-day-old infant rats to a combination of two of the following – midazolam, nitrous oxide and isoflurane – for 6 hours. The exposure led to the death of nerve tissue in the developing brains of the rodents. Even worse, the rodents suffered long-lasting cognitive impairment in learning and memory, which worsened as they aged.
A few years later, the same phenomenon was observed when the same study was done using young monkeys.
This of course raised concerns in the anesthetic community, as many wondered if this phenomenon was possible in human kids.
Studies to correlate this in humans were lacking and retrospective analyses of data have given mixed results. This led to the F.D.A. and the International Anesthesia Research Society to form a group in 2009 to promote further research into this called SmartTots – Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots.
Even though there is still no human data, in 2012, the group recommended that elective surgery under general anesthesia be avoided in children younger than 3.
Late in 2014, they also stated that if an operation requiring anesthesia and sedation can reasonably be delayed, it “should possibly be postponed because of the potential risk to the developing brain of infants, toddlers and preschool children”.
At the moment, there is an ongoing study which has enrolled 700 children to study this phenomenon – A Multi-site Randomized Controlled Trial Comparing Regional and General Anesthesia for Effects on Neurodevelopmental Outcome and Apnea in Infants (GAS).
It is however not only children who seem to suffer possible negatives effects from general anesthetics on the brain. The elderly population seem to suffer from negative cognitive effects as well. Patients older than 60 seem more prone to develop delirium and some memory loss after general anesthesia and it is irrespective of the drug used. Patients with a history of dementia also fare worse.
Anesthetics cause their effect by blocking receptors in several regions of the brain (GABA, NMDA, Dopamine etc). Older patients may just have a harder time recovering from this block. There is the thought that anesthetics may induce neuronal changes that are harder to reverse in the elderly.
The use of regional techniques, when possible, prevents this problem.
One thing patients receiving general anesthesia worry about a lot is awareness. The fear that one would wake up during surgery and feel every part of the procedure. Awareness is a really rare occurrence. As the data is showing, anesthesia providers may actually be giving too much anesthetic when we use the classic definition of minimum alveolar concentration (MAC) to dose inhaled agents. This means patients are really “knocked out” and have a very slim chance of waking up. Even though explicit memory (conscious) is totally blocked, there is a chance that implicit memory (unconscious) may still be active and could lead to patients thinking they woke up. Also, chances are that as a patient emerges form anesthesia, he or she may erroneously think that they are still having surgery. Awareness is however possible during surgery of the very sick since those patients can hardly tolerate a deep general anesthetic.
So what does the future hold? The use of functional MRI during anesthetics may be a possibility in the future. We use the BIS monitor to gauge awareness but that might not be enough. Maybe the use of the EEG should be introduced. The introduction of newer drugs also hold some promise. It seems the best care in some case may be not to put patients to sleep.

The times leading to and after the passage of the Affordable Care Act aka Obamacare were tumultuous times in the US. There was the talk of death panels all the way to the fear of having a single payer system overnight.
Sure the law has had benefits in increasing the number of insured Americans but it is also dogged by financial problems. Just last year, several healthcare cooperatives, including one here in Kentucky, closed down. Several insurers, like United Health, have stopped offering plans on the exchanges and just this week, there are reports that premiums for maybe a million or more Americans might go up about 22%.
Probably the paramount reason is that most insurers underestimated how sick the uninsured population was. Also, the number of young and healthy persons who were forecasted to buy insurance and thus finance the program has been much lower. Most tend to pay the penalty and take their chances. Then is also the small issue of some state governors refusing to expand Medicaid to include more of the indigent population for political as well as fiscal reasons.
Beyond the financial issues, which have the ability to totally cripple the law, there are other unintended consequences. One of them results from the push by the law to consolidate medical providers into large groups.
In a piece published in the Annals of Internal Medicine in 2010, three of the leading healthcare advisors to the president then, and big proponents of the ACA – Ezekiel Emanuel, Nancy-Ann DeParle and Robert Kocher – wrote:
To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience.
And thus began the move to consolidate all health groups.
In 2015, there were 112 mergers, up 18% from 2014. Even the insurers are merging. The belief was that large groups are more efficient in sharing information, managing costs and reducing risks for the patient.
As I always say, the experts who tend to write healthcare policy are often those who hardly do any patient care and this push to consolidate groups is another prime example.
Anyone who does any direct patient care will tell you that bigger is not necessarily better!
The push to consolidate is creating behemoths that are inflexible and take eons to react to change. It takes these larger groups longer to implement new policy or even effect cost savings.
These larger groups that were being encouraged were named Accountable Care Organizations or ACOs.
McAllen, a small town in Texas, was one of the most expensive places for healthcare in 2009. All that changed when the physicians there formed an ACO to provide value-based (preventative) and not activity-based (tests and specialist referrals) care. That little ACO outperformed the John Hopkins system interns of cost savings and outcomes in 2014 according to data from the Centers for Medicaid and Medicare Services. Several papers published recently show that physician-led ACOs outperform the much larger hospital-organization based behemoths.
The reasons for that are not difficult to find.
A lot of these hospital-organization based systems are often healthcare businesses that have bought groups at myriad places. The hospitals and groups are often scattered over counties and even states. They tend to be run from a central office, often far-removed from the individual centers of care. Hence, decisions are made that do not reflect the conditions that may favor any particular hospital or group. This then has an adverse effect on care at the affected hospital or group, negating any cost savings or improvement in outcomes.
Further, small groups offer more personalized care, which is a priceless commodity in medicine. It facilitates follow-ups and the tailoring of care to patients needs.
Also, the ability to use data is faster in smaller groups and technology can be implemented quicker.
Lastly, the patient experience in small community hospitals are also more pleasant. They do not feel like they are lost in a sea of faces and are just another medical record number.
It is really a pity that the ACA has pushed a lot of small and wonderful physician groups into these large inefficient behemoths. As the unintended consequences of this law gradually unfolds and we learn to make the necessary changes, I hope a push to smaller healthcare organizations will be paramount.

In 2014, a group from the San Diego Medical Centre led by Eric Macy MD, published an interesting retrospective study. They looked at healthcare use and prevalence of serious infections among 51,582 hospitalized patients with penicillin allergy. They found that these patients with penicillin allergy had an increased exposure to more broad-spectrum antibiotic, suffered more infections and were re-admitted more.
Coincidence? Not at all.
For years, it has been known that even though about 10% of the US population reports an allergy to penicillin, only about 1% of these cases are true immune-mediated allergies. Also, in cases of true immune-mediated reactions, 80% lose their sensitivity after 10 years. This matters because when a patient reports a penicillin allergy, most hospitals do not test for the patient to prove the veracity of that claim. Instead, patients are placed on broad-spectrum antibiotics like vancomycin and the fluoroquinolones. The use of these more powerful antibiotics leads to higher healthcare costs, increased risk for antibiotic resistance, and suboptimal antibiotic therapy. As we all are realizing, the issue of antibiotic resistance is no joke. Heard of Colistin-resistant E. coli?
Overall in the US, the incidence of such false drug allergies is on the increase and the consequences can be dire, as exemplified in the case of penicillin.
Now an adverse reaction to a drug is seen as any unwanted and untoward effect of said drug. These reactions include allergic reactions as well intolerance to it. Even the inability of the drug to work falls under adverse drug reactions.
Now a true drug allergy is mediated by the body’s immune system through antibodies – IgE as well as the T-cells. Since these are immune reactions, a true allergic reaction is not seen the first time one takes the drug. The body must be sensitized first. Where IgE mediates the really fast reactions like hives and angioedema, the T-cell mediated reactions takes days and weeks to become evident.
Data shows that less than 5% of adverse drug reactions are due to true immune reactions – so true allergies.
Yet, we are seeing patients with the most interesting allergies everyday. We’ve all heard them:
“Epinephrine (adrenaline) makes my heart race!”
“Beta-Blockers make my heart beat really slow!’
“Bernadryl made me sleepy!”
“Predinisone made me jumpy!”
“Aspirin tore up my intestines!”
These pseudo-allergies hinder optimal patient care in a lot of ways. They prevent the use of the the best drugs for the patient.
Several factors are contributing to this situation. A common factor buttressing all of this, is that more Americans are taking more drugs daily. One is going to see more adverse drug reactions.
The causes then split into patient and provider-related factors. Let’s do some scenarios (based on true events);
A patient notices a “bad” event while taking a drug A. He/She makes the erroneous connection that she has an allergy to drug A. Next time she is at her doctor’s or the hospital, she is asked by the triaging or admitting nurse about her allergies. She states she is allergic to drug A. The nurse just records it without further questioning and it is part of her history.
The patient call her doctor to tell him/her that she had a reaction to drug A. The doctor unwilling to bore and really find out the cause of said reaction goes, “You might be allergic to it. Let’s try drug B.”
A patient in the hospital is in pain after surgery. She is also having nausea. The physician orders a dose of narcotics to be given with an anti-emetic. The nurse does that. Fifteen minutes later, the patient is found apneic but successfully resuscitated. A day later, the patient is told she had an allergic reaction to the anti-emetic.
Years ago, a patient received novocaine at his/her dentist reaction office. There was an adverse reaction. According to the patient, she lost consciousness. She was later told she was allergic to all local anesthetics. It doesn’t matter that it might not have been the drug but where it might have been injected. Or that novocaine is an ester-based local anesthetic that is allergenic but quite different from the amide-based ones like lidocaine that are not.
A patient receives a peripheral nerve block for shoulder surgery. She emerges from general anesthesia in pain and nauseous. Well, the block didn’t work so the patient had to be given narcotics intraoperatively. In recovery, she is given more narcotics to treat her pain and ondansetron to treat the nausea. She erroneously concludes afterwards that the combination of local anesthetic, narcotics and ondanstron made her postoperative course so uncomfortable. She must be allergic to all those drugs. They appeared as allergies on her next visit!
Allergies have become a screen that practitioners can hide behind. They use it to get out of figuring out what is really going on or protecting themselves from a possible lawsuit. Patients on the other hand are quick to jump to erroneous conclusion. Conclusions that affect their care negatively.
Maybe it is time for most hospitals to employ an Allergy Czar. maybe institute an Allergy Tribunal. Then frankly, I’m developing an allergy to all these allergies.

Many years ago, while spending some time in the lab, I had a part-time job in home healthcare. I had three patients. They were all over 85 years old. The only male patient among the three had had a stroke and his loving wife needed help taking care of him. She was an extremely loving woman but of a slight build so it was really hard for her to do all she had to do for her sick husband. They didn’t have kids but the love they had for each other filled the home.
The other patients – two women – provided an interesting case study. They were both in their 90s. One was a widower while the other never married. The widower had spent her life working with the homeless and needy the other used to be an attorney. They both never had children. However, the home of the widower was always warm and welcoming. The other not so. The widower got visits constantly from nephews and nieces. In the year that I took care of them, I met only one relative of the old attorney – a young nephew. He visited once. I gathered there was more family out there but they never visited. The widower was spry, active, witty and sharp. The old attorney not so much. Somehow, she was always ill even though she really had no debilitating chronic ailment.
Over time I wondered what role the family of lack thereof played a role in the health of these patients. The man who had had a stroke was sick but mending nicely from all the care from his loving wife. The widower was was always looking forward to a nephew or niece visiting and looked great for her age in spite of several chronic conditions. The attorney, well…
That year made me think of family a lot. It made me think of the support that family brings. It made me wonder about the warmth it can create and the health benefits.

Years later, I found myself in Kentucky. Now Kentuckians are very family-oriented people. Having my extended family in Ghana, they make me miss them everyday. Each morning in the preoperative area in the hospital, one can see several children and grandchildren waiting to give a grandma a kiss before she goes off for her new valve, fathers surrounded by kids before that knee replacement, mothers with sisters before that mastectomy – all celebrating family and the art of support.
Imagine my surprise one morning when I went to see a patient preoperatively and did not see a soul with him. Of course I had to bore. The man was in his mid-60s. I found out that he was divorced and not in contact with his former wife. He had no children but had one living brother who lived in another state. I asked if the brother was going to be there. He said no. The nurse asked if he had the brother’s number so she could call him and keep him up to date (During surgeries, there is one family member who is kept up to date on the progress of the procedure). He said he didn’t have a number and that they communicated by email! I was stunned. By email?
He went on to have his surgery and did well but all day that day, I couldn’t get him out of my mind. It made me think of family and support….again!
Facing surgery and anesthesia is a very intimidating prospect for most patients. Even tough men who have been through the rigors of war show cracks preoperatively. Having loved ones around helps one greatly through this time. The immediate expression of love and support reassures and raises one’s spirits. To imagine a patient going through this period alone boggled my mind.

Now sometimes family can be a hindrance. Family members can be disruptive and delay decisions on important procedures. Everyone in OB knows of the husband who passes out at the sight of the epidural needle, gets a concussion and unintentionally delays his wife’s care. In all however, family support in times of illness is indispensable.

It is not only in the perioperative period that family support is advantageous. Another important instance where family matters is in the care of people with chronic diseases. Patients with diabetes, cystic fibrosis, mental health problems and even addiction all do better when there is support at home. Several studies show that this support prolongs lives and decreases the incidence of complications. Family helps patient keep their medical appointments, monitor parameters like their blood sugar and blood pressure and take their prescribed medications. They provide the emotional support that is often so direly needed.
Even though the overriding theme in this piece seems to be about family, it is really about support in the time of illness and need. After all those years, I kept seeing the importance of support. Support through the tough times help emotionally but also seem to translate into more stable vital signs, faster healing and better outcomes. Even though it comes easier and more readily from family, in the absence of one, good friends can offer that support. It reminds me of the refrain from the old Bill Withers’ song:

“Lean on me when you’re not strong,
I’ll be your friend, I’ll help you carry on.
For it won’t be long ’til I’m gonna need
Somebody to lean on.”

Over the years one thing is become rather clear – that in the art of healing, support may be the part we physicians cannot control but is direly needed.

The week that started on Sunday, August 21, 2016 was probably significant in that it highlighted the extent of the opioid epidemic in the US.
On Tuesday and Wednesday of that week, there were over 60 overdose cases in Cincinnati alone. In 2 counties in southern Indiana, there were 14 overdose cases between Tuesday night and Wednesday morning. In Mount Sterling in Kentucky, a city of about 7000, there were 12 overdoses on Wednesday alone!
Drug overdoses are up significantly in the US and 60% of them are due to opioids. It is estimated that there are about 16 000 opioid overdose cases a year now. So how did we get here? How did the US come to occupy the non-enviable position of the world’s largest consumer of opioids and opioid deaths?
To understand that, one has to understand what opioids are.

These are natural occurring drugs derived from opium, like morphine, that work on the opioid receptors in the body to relieve pain or synthetic ones like oxycontin and fentanyl that do the same. Now another kind of opioid, heroin, derived from morphine, has been used purely for recreation for a while but it’s recently become the replacement drug for addicts who cannot get their hands on the synthetic ones like oxycontin. More about that later.
Before the 1990s, doctors used opioids rather sparingly. One can say that pain was undertreated. Narcotics were mainly given to cancer patients. Then in 1980, Hershel Jick published a study claiming that the use of narcotics in 11,882 in-patients led to only 4 cases of addiction. Six years later, Portenoy published his study looking at the use narcotics in non-cancer patients. He claimed that there were no adverse effects. He studied 38 patients! He based his claims on 38 patients!
Even though both studies were highly flawed, they dramatically changed medical thinking and then practice. Portenoy formed the American Pain Society and preached that the risk for opioid addiction was less than 1% – a number he would later confess that he grabbed out of thin air!
The society came up with “Pain as a 5th vital sign” slogan and it caught on.

Into this fray, jumped Purdue Pharma. It launched Oxycontin in 1996. With aggressive marketing, the company promoted this new drug and got all on board.
The Joint Commission got behind the “Pain is the 5th vital sign” movement and the 0 to 10 pain scale with smiley and “wincey” faces was born. By 2004, doctors who undertreated pain faced sanctions. Opioids were being prescribed to all, even outpatients. Later Endo Pharma and Johnson & Johnson would join the opioid party with their own portfolio of synthetic opioids.
Purdue Pharma claimed that oxycontin was a slow-release formulation and would never lead to addiction. Well, we know better now. They had to pay $635 million in fines in 2007 for misbranding and reformulate the dug but by then it was too late.
By 2012, sales of opioids were more than $9 billion a year and in 2013, opioid overdose surpassed car accidents as the number one cause of accidental death.
To combat the indiscriminate prescription of opioids, several states like Kentucky, have enacted laws in the last 2 years that have made prescription of these drugs more onerous. Overnight, all the pill mills which churned out prescriptions for opioids vanished. The poor addicted patients had to find the next best replacement.

Enter heroin!
To make things worse, dealers are now lacing the heroin with illegal fentanyl that is formulated with raw materials from China.
To get how dangerous this combination is, follow me here. The standard opioid for comparison is morphine. Let’s give that a potency of 1. Heroin is about 4-times as potent and Fentanyl 75 – 125-times as potent. Now combine heroin and fentanyl!
So the intricate web of opioids and addiction was woven by Big Pharma and the medical profession around the issue of pain. Pain. Let’s define it:
“A distressing feeling caused by intense or damaging stimuli”, like cutting yourself with a knife or breaking an ankle. It was designed by the body to tell us something is wrong and to find a fix.
Pain is further broken down into acute and chronic pain.
Acute pain is what I described earlier. It comes on fast and is usually from an injury. it is treatable and goes away in days or even in a few months.
Chronic pain is a different animal. It is it’s own disease state because there is really no one reason for it. It is intractable pain that exists for three or more months and does not resolve in response to treatment. It is affected by physical, environmental and even psychological factors. Now acute pain can turn chronic if not treated well.
Opioids should classically be used to treat really bad acute pain like surgical pain, burns and trauma. It should be tapered off and other modalities of pain management used. Opioids should not be used for chronic pain, where there is no end in sight. The only group of patients with chronic pain who should be on long-term opioids should be cancer patients. That unfortunately did not happen and we are in this mess.

A way out might be the use of marijuana. In 2014, Bachhuber et al published a study in JAMA that showed a drop of 25% in opioid deaths in the 3 states where marijuana use is legal. Another paper by Powell’s group supported this. It showed that medical marijuana dispensaries were associated with a 16 percent (and possibly as high as a 31 percent) decrease in opioid overdose deaths. Lastly a study from this past July shows that doctors in states with medical marijuana laws wrote fewer opioid prescriptions.
The use of marijuana for pain might be due to it’s effect of cannabinoid receptors in the brain that modulate pain perception and it’s effect on sodium channels that play a role in pain genesis.

Like the needle-exchange program that was initially frowned on by many, it might be the only way out of this opioid quagmire.
Hopefully we as physicians will learn from this to base clinical decision-making on sound science and resist the aggressive marketing of the pharma industry.

“No disorders have employed so many quacks, as those that have no cure; and no sciences have exercised so many quills, as those that have no certainty”.
– Charles Caleb Colton

The placebo effect is a powerful thing. The belief that a substance can alleviate an ill has the power to do just that in about 30% of the population. The more benign the ailment e.g. aches and pains, cold, the easier is this effect. Things get a little tougher when an ailment is more complex in nature. Throughout the years, there have been men and women who have exploited the placebo effect to sell “snake oil” to unsuspecting patients. Sometimes, they have been able to sell their worthless products sans even a placebo effect – all they needed was the force of their nature and the glibness of their tongue.

The original snake-oil salesman was Charles Stanley. In the 1900s, Clark Stanley was known for his snake-oil. He claimed his concoction was a blend of snake-oils and that the recipe was from an old Indian medicine man. He would draw crowds to his rattlesnakes-killing sessions, where he would then sell his snake oil for 50 cents a bottle (about $10 today). He claimed it could cure toothaches, ankle sprains, neuralgias and most other ailments. In 1917, the Feds seized a shipment of the snake oil and analyzed it. Well, they found it contained 99 percent mineral oil and 1 percent beef fat, with traces of red pepper and some turpentine to give it a medicinal smell. His business was shut down.
My favorite quack of all time was John R. Brinkley – a man who never went to medical school but somehow managed to buy a medical degree. One day, he observed two goats mating and marveled at the sexual prowess of the ram. He then came up with a theory – if one transplanted the testes of the ram into the human scrotum, the patient will acquire the sexual prowess of the ram. What? Well, he opened his first goat-testes-transplant clinic in 1918. Forget that he wasn’t a doctor, knew no good surgical or sterile techniques. Forget that the idea was stupid and ridiculous. Well, he was inundated with patients, opened more clinics all over the country and made millions. Later he touted the transplant as a cure for almost every ailment. His first patient even got his wife pregnant. He advertised on the radio. He entered politics. Finally in 1938, he was sued for malpractice, lost and later died in 1942 a pauper.

These days, with FDA oversight being the way it is, such concoctions and ridiculous procedures are tough to sell without approval. There are still lots of quacks in the world of alternative medical treatments, supplements and diagnostic devices. One of them is Elizabeth Holmes.
In 2003, at the age of 19, she dropped out of Stanford’s chemical engineering program. She had the nugget of an idea and she planned to use this idea to change the world. The idea was to build a machine that could use tiny drops of blood from pricking a finger to run blood test instead off the ‘gallons’ that those ‘draculic’ phlebotomist draw. She founded a company initially named “Real-Time Cures”. In February 2005, she bagged $5.8 million from a venture capitalist and another $9.9 million year later. She changed the company’s name to “Theranos”, an amalgam of “therapeutics” and “diagnostics”.
By the summer of 2014, she had raised $400 million and the company Theranos was valued at $9 billion. Since she owed 50% of the company, as of the of summer 2015, at the age of 31, she had a net worth of $4.5 billion! She also had her machine named “Edison”.
There was only a small problem with this Ms Holmes’ idea – it was not scientifically viable but her investors did not seem to know or care. Since she founded the company, she had refused to either discuss her ideas with anyone in the medical community or publish any papers on work done based on this idea or tests with the Edison device. In the medical community, there were great doubts about her work.
Outside this community though, Ms Holmes was being feted as the next big thing. She received one honor after the next. Her speaking engagements ranged form TED Talks to lectures at Harvard. She adorned the covers of Fortune, Forbes, and Inc. and others. She was profiled in The New Yorker. The Board of Theranos had people like Henry Kissinger, George Schultz and Bill Frist as directors. She was going to revamp how testing was done. She was going to build devices that could test for hundreds of diseases from a same sample of blood. The sky was the limit.
When she was asked about the technology and science behind her Edison blood-testing machine for the 2014 New Yorker article, this is what she said:
“A chemistry is performed so that a chemical reaction occurs and generates a signal from the chemical interaction with the sample, which is translated into a result, which is then reviewed by certified laboratory personnel.”
This got the attention of the veteran Wall Street Journal reporter, John Carreyrou. He started investigating the company. On October 16, 2015, the Journal published the article:
“HOT STARTUP THERANOS HAS STRUGGLED WITH ITS BLOOD-TEST TECHNOLOGY.”
It was the first in a series of articles that blew the lid off the scam. He found the Edison did not work so Theranos used the blood-testing machines made by Siemens and other medical device companies for it’s tests. The tests that were done with the Theranos machines in clinics that they had opened in Arizona had results that were way off. Incidentally, the FDA and
Centers for Medicare and Medicaid Service (CMS) were investigating Theranos around the same time. Earlier this year, the hammer fell. Ms Holmes was been banned by the CMS from operating any lab services for 2 years. The Edison machine was been banned by the FDA. Walgreen pulled out of an agreement with Theranos to open blood testing centers. Ms Holmes is being investigated by the SEC and some lawsuits are in the wings. That $9 billion valuation now looks like a pipe dream.

The practice of all branches of medicine lends to it’s practitioners a certain aura of authority that is the envy of many. Some also erroneously see the profession as a way to fame and fortune. Thus, the profession attracts not only the best and the brightest but also charlatans. These quacks also bleed into the pharmaceutical and medical device industries and can cause as much harm there. We in the profession can only hope and pray that the mechanisms in place can weed out these snake-oil salesmen pitching bad medicine.