PHILADELPHIA visual artist E.C. had been coughing for a few weeks— before the coughing intensified over two more weeks, with the addition of intense chills during the second week.
Admitted through the ER, the 68-year-old frequent mountain biker stayed 12 days in the hospital with a regular turnover of specialists proposing different diagnoses and treatments—along with regular Covid testing. Ultimately blame fell on Advil, too much over too many years—based on testing and doctors’ consensus, but without self-reported abuse of the drug or definitive laboratory proof.
To treat the first diagnosis of pneumonia, E.C. received I.V. antibiotics; a nasal cannula to provide supplemental oxygen; and Tessalon Perles, or benzonatate, a numbing agent that subdues the cough reflex. When airways become raw and irritated—following a cold or, in this case, half-hour long coughing “fits” — invading bacteria or viruses can cause pneumonia, as well as acute bronchitis, inflammation of the large airways; or asthma, which causes excess mucus and wheezing and can cause permanent narrowing of the airways—or both conditions at the same time.
When antibiotics failed to improve E.C.’s still-worsening cough and chills, treatment switched to steroid medications, in this case prednisone—which decreases inflammation in the bronchi, relaxes the surrounding muscles and can help with persistent coughing. Steroids often provide the ultimate relief in cases of acute bronchitis, acute asthma or when the two exist together.
Extensive testing throughout E.C.’s hospital stay found none of the usual causes of pneumonia— viruses or bacteria, such as legionella—but instead identified two difficult-to-explain clues. The first was nodules on the lungs—also called spots or shadows—which are round and denser than normal lung tissue, and usually consist of scars from healed infections or irritants in the air, though these can be early signs of cancer. While a few had shown up on an X-ray of E.C.’s lungs taken years earlier, these had now multiplied—but with no discernible cause.
The other clue was elevated eosinophils, a type of white blood cell that aids in the body’s immune response, notably to parasites, and are active in the respiratory tract. Mild or moderately elevated eosinophil levels for most people are transient and require little to no treatment, although they can indicate asthma.
Possible causes of the “very high” eosinophil count in E.C.’s lungs included infections, allergies and inflammatory disorders, along with a host of different drugs. According to an Israeli study, in cases of the rare eosinophilic pneumonia (EP), “almost every family of medication was implicated…a higher prevalence among a few pharmacological families” — that included non-steroidal anti-inflammatory drugs (NSAIDS).
The researchers hypothesized some “connection between the pathogenesis of EP and the mechanism of action of those commonly used medications.” (Eosinophilic asthma can also make patients “highly sensitive” to the effects of NSAIDS —which can “inflame your airways and cause serious growths in the lining of your nose called nasal polyps,” according to Web MD.)
On the other hand, “defining a medication as the cause of eosinophilia requires clinical judgment, because no laboratory test alone can confirm the role of a specific medicine,” write Harvard immunologist and infectious disease specialist Peter Weller and colleagues. E.C. had taken Advil during limited periods over the years for pain due to injuries and arthritis, but eosinophilia has many other possible causes, including chemicals, air pollution and infection.
NSAIDS used to treat inflammation and alleviate pain —often that caused by headache, lower back issues and arthritis —include dozens of medications, but not drugs that are purely pain relievers, such as acetaminophen (Tylenol). NSAIDS can take up to two weeks to build up to a “blood level” of effectiveness—and may not help much before then or if taken irregularly.
The most common NSAID side effects are gastrointestinal symptoms, including stomach irritation and sensations known as heartburn. In severe cases, NSAIDS can irritate the stomach lining, resulting in an ulcer or small erosion and can cause internal bleeding. Taking NSAIDS at the end of a meal can reduce the risk of irritation and stomach ulcer, as can adding an antacid—with combinations available in newer drugs like Duexis, a mix of ibuprofen with famotidine.
Acetaminophen can be safer than NSAIDS, especially for people with ongoing gastrointestinal issues. For pain related to arthritis, combining acetaminophen with an NSAID such as naproxen —at medical doses (usually twice those recommended on the packaging) —can offer relief while avoiding side effects.
E.C. may be better able to pinpoint Advil as the culprit after months of no longer taking it, or future health problems may suggest different offenders—notably chemicals used in art supplies or Philadelphia air pollution, as well as whatever infection spurred his long illness. Alternatively, future chest X-rays may offer new information about those nodules and lead his doctors on entirely new diagnostic trails. At the last report, E.C.’s cough was gone; he had mostly recovered from bed sores and other effects of the long hospital stay; and he reported feeling “near 100%.”
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
NEW attention on “the abortion pill”—in anticipation of the Supreme Court overturning Roe v. Wade—has cast a brighter light on telemedicine and drug prescribing, especially that conducted across state lines. Under the public health emergency (PHE) of the pandemic, federal regulations granting more flexibility to providers removed most requirements of in-person visits for obtaining prescription medications, including for medical abortions (using medication to end a pregnancy), but this already-extended flexibility is likely to end in July.
Telemedicine, however, also falls under state law, and at least half of the states have already retightened licensing rules. Patients of Maryland’s Johns Hopkins Medicine can no longer receive remote care; and Mass General Brigham has cut off telehealth services to thousands of patients. University of Utah Health alone conducted about 100,000 out-of-state telemedicine visits in 2020.
Prior to the pandemic, individual states’ laws had not caught up with the “new techno-geographic realities of 21st century medicine…the legality of everyday clinical practices, such as calling in a prescription for a patient in another state, remains problematic,” according to the American Academy of Psychiatry and the Law. Many states required “an in-person encounter with a physical examination.”
Patients residing in Virginia, for example, may obtain prescriptions only from doctors who reside in that state. In Missouri, a phone call from a New York physician for a vacationing patient “constitutes the practice of medicine and ostensibly requires full licensure” of both doctors—that is, the New York doctor needs licensure in Missouri—without which that phone call “appears to constitute a crime.” Advice to traveling patients includes checking with state rules about how often you must be seen by your out-of-state prescriber, or how much time you have to find a doctor in your new state.
For medical abortion, 19 states currently prohibit prescribing the two-pill combination of mifepristone and misoprostol by telemedicine or delivering the pills via mail. (For surgical abortions, many states require two- or three in-person visits as well as an ultrasound examination.) While FDA protocol allows the pill regimen up to 10 weeks after the first day of a missed period, many states ban medical abortion after five or six weeks—and Alabama makes abortion at any stage a felony offense, with no exception for rape. Medical abortion comprises 39% of all abortions in the U.S.—but “if Roe is overturned, about half of states are expected to ban abortion altogether.”
Another contentious issue in telemedicine prescribing involves controlled substances (CS)—notably pediatric medications, such as Adderall, for attention deficit disorder and buprenorphine, used in medication-assisted therapies for substance-use disorders that are regulated by the Drug Enforcement Administration (DEA). In 2008, the Ryan Haight Online Pharmacy Consumer Protection Act (named for an 18- year-old who died from an overdose of Vicodin prescribed via a telemedicine consult) required practitioners to conduct an in-person medical evaluation before prescribing CS medications —with different guidelines on buprenorphine for patients residing in a DEA-registered facility.
With pandemic-inspired flexibility, practitioners could prescribe most controlled substances via telemedicine communication, “using an audio-visual, real-time and two-way interactive communication system.” (The most strictly regulated Schedule 1 drugs do not fall under this temporary flexibility, and include marijuana and heroin, as well as most psychedelic drugs, deemed to have no medical value and high risk of abuse, although Schedule 2 drugs include, for example, PCP, cocaine and meth.)
In an early study of substance-use-disorder providers, the greater flexibility expanded treatment for their patients. For all telehealth visits, a CDC study found that these increased by 50% during the first quarter of 2020 compared with the same period in 2019; while another study found that, of more than 2,000 patients receiving at least one telehealth visit during the pandemic, 79% expressed satisfaction with the visit, and 73% expect to continue receiving virtual health care services after the pandemic.
For medical abortions, still-unresolved questions include whether out-of-state providers of abortion services to people in restricted states can be prosecuted and whether there are “actions policy makers in states that allow telehealth abortion can take to protect clinicians in their state,” according to the Kaiser Family Foundation Women’s Health Policy site. Other questions arise around distribution issues, such as whether providers can mail medication across state lines or whether patients would need to travel to access the medication.
Meanwhile, new startups specializing in telemedicine abortions, such as Hey Jane and Just the pill, have begun offering services in states that allow them. And manufacturers of abortion medication are submitting proposals to the FDA to further relax dispensing rules, such as those that require doctors and pharmacies involved in abortion-pill dispensing to be certified by the manufacturers.
On the other hand, Louisiana Republicans want to rewrite the state’s homicide statute to protect unborn children from the moment of fertilization —enabling criminal prosecution of women, not only those who get abortions, but also those using in-vitro fertilization, intrauterine devices and emergency contraception (the morning-after pill, levonorgestrel). Other states may ban birth control altogether.
The greatest burden of current and anticipated restrictions falls on the poorest women and women of color, who are the least able to travel or afford to get safe abortions and thus most likely to give birth when they can’t afford it, which in turn threatens those families with the fewest means. For women across class and race, the emotional challenges of deciding to abort and then of obtaining an abortion, which are already challenging, may become overwhelming.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
THE RAPID heartbeat that woke Lake Tahoe medical writer D.P. in the middle of the night, insisted her doctor, must have come from nightmares she didn’t remember. D.P. wrote in an email that it took two more years before she received a diagnosis of potentially life threatening AFib (atrial fibrillation—irregular or very fast heartbeats, over about 100 beats per minute), after which she had two ablation surgeries to create scarring that can block abnormal electrical signals.
For Florida golfer G.D., her doctor dismissed reports of chest pains because all the usual tests showed a healthy heart. For Paris-based clothes designer L.K., her athletic appearance and good test scores made her long-time internist pooh-pooh any concerns. On annual physical exams, both women had good cholesterol “ratios”—the comparison of worrisome LDL (low-density lipoprotein) cholesterol levels with those of healthy HDL (high-density lipoprotein) —long considered to indicate good heart health.
Both also scored low on the heart-risk calculators relied on by many cardiologists, which tally responses to lifestyle questions such as smoking along with data that include the cholesterol ratio. But when the women obtained CT scans of their coronary arteries—known as calcium scans or CAC screening—these showed calcium deposits that can narrow the arteries, leading their doctors to prescribe cholesterol-lowering statin medications.
The lesson in these cases may be the limitations of current tools for assessing heart health, suggested D.P., who trained and worked as a nurse before spending 40 years as a writer and editor of medical articles and books. All heart tests have some shortcomings, she explained, and new assessments, such as the CAC scan, can take many years to be added to guidelines.
Another issue with heart health is that most patients are unaware of their personal risks or of what symptoms might look like if they occur. For AFib, few people know about the condition, and its symptoms can be silent. And even when experienced individuals feel their hearts speed up, they can be unsure whether to push unwilling doctors for more tests—despite AFib officially affecting some 10% of people over age 65, a number that could be much higher because of unreported or silent symptoms.
D.P. herself ignored early flutters until snowshoeing made her dizzy. And even after her surgeries and getting a heart rhythm app on her smartwatch, she heard the app’s alarm go off one night as she was lying in bed, watched her heart rate climb from 130 to 139 to 150— and still wasn’t sure if she needed to call for help, partly due to fears of the high costs of emergency care. At D.P.’s next checkup, the nurse practitioner told her: “Call 911!” explaining that EMTs should check the heart rate and only proceed with additional care if necessary.
Before obtaining her AFib diagnosis, D.P.’s ECG and exercise stress test were both normal, as was a second stress test from a heart rhythm specialist who “cranked up the treadmill incline as high as I could manage.” But as D.P. sat recovering afterwards, she mentioned the feeling of fullness in her chest and pressure in her neck that usually happened about half an hour after she plunged into icy Lake Tahoe or snowshoed up to a high mountain ridge. As a result, the doctor repeated the ECG both 15 minutes and a half-hour after the treadmill test. “Lo and behold,” D.P. wrote, “there it was: the occasional too-close-together peaks on the graph.”
Some people who report occasional heart palpitations receive a wearable heart monitor for a week or two. And AFib can also show up on a routine ECG or on smart watch heart rhythm apps, although the accuracy of the Apple watch varies among individuals, and in one study detected abnormal heartbeats only about one-third of the time. But AFib can be dangerous. Those with AFib have a risk of stroke 4-5 times higher than in people without the condition, and their strokes are generally more severe —though the highest risk occurs among those with other conditions as well, such as diabetes and high blood pressure.
In the cases of the women who had CAC screenings, the presence of coronary artery calcium “provides insight into the patient’s level of cardiovascular disease risk and is helpful for guiding interventions,” according to a National Library of Medicine report. But because CACs still have not made it onto many guidelines, most patients must first request a referral from their doctor and then pay for the test themselves, which usually costs between $40 and $150.
Calcium scans are “very useful if there’s uncertainty about a person’s risk of heart disease or the need for statins,” Brigham and Women’s Hospital cardiologist Ron Blankstein told Harvard Health—but not for anyone who already has coronary artery disease or has a low risk of heart disease, including most people under 40. Good candidates come from the “immediate-risk group…people ages 40 to 75 whose 10-year risk of heart disease or stroke ranges from 7.5% to 20%.”
Ten-year risk determinations using heart disease calculators, however, fail to add important considerations such as family history, diet, exercise and ability to control stress. As a result, according to Sanjay Basu, Stanford University researcher and author of an NIH-funded study, results from these calculators are often “way too high or low for some patients.”
As early as 2013, a study showed “that coronary artery calcium screening…should play a more prominent role in helping determine a person’s risk for heart attack and heart disease-related death,” according to a Johns Hopkins statement. But physicians continue to argue about the usefulness of CAC screening.
Even L.K.’s cardiologist said his decision to prescribe statins was based not on her CAC results but on the need to lower her LDL cholesterol, stating that reliance on cholesterol ratios is unproven and unreliable. According to the Mayo Clinic, “For predicting your risk of heart disease, many doctors now believe that determining your non-HDL cholesterol level may be more useful” than the ratio. (The non-HDL level, which should be below 130 mg/dL, comes from subtracting the HDL number from that of total cholesterol.)
For all three women, their recent treatments have promised better heart health—though all have remaining questions about the future, and these are the hard ones: what happens next, what are their ongoing risks, what more can they do to prevent future problems? Writes D.P, “what I really want to know is how long do I have? And that question, as it turns out, I don’t have the nerve to ask.”
Despite my good cholesterol ratios and healthy risk calculator scores, I will try to get a CAC screening to help with ongoing uncertainty about whether I need statins because my non-HDL cholesterol levels are high. I have tried Lipitor, which created not-uncommon alterations in liver enzymes, followed by pravastatin; and both caused muscle aches, a common but unproven side effect of statins. With any new indication of increased risk to my heart, however, I would certainly be willing to take them again.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
“UMAMI foods increase saliva production,” according to Cleveland Clinic HealthEssentials. “Literally they make your mouth water, which improves the way food tastes.” The taste called umami—based on glutamate, or more familiarly MSG, and other chemical compounds—has recently joined the generally accepted panel of tastes to which humans are sensitive, making five altogether, along with bitter, sweet, salty and sour.
(The umami taste can come from inosinate or guanylate—in meats and plants—as well as from glutamate. MSG, or monosodium glutamate, occurs naturally in vegetables like tomatoes, peas, mushrooms and garlic; and in green tea, soy, seaweed and kimchi.
As the sodium component of L-glutamic acid, MSG is a product of fermenting corn, tapioca and various forms of sugar including sugar cane, sugar beets and molasses. As a flavor-enhancer added during food preparation, MSG also occurs naturally in ingredients, such as yeast and soy extracts, that are used in processed foods like deli meats and canned vegetables.)
Now the previously maligned MSG may be changing its image—based on new evidence that substituting it for table salt creates a salty flavor while reducing overall sodium consumption. In addition, in the decades since fears arose about “MSG attacks”—symptoms that included flushing, headaches and nausea—blinded studies have failed to reproduce the effects.
Detecting each of the five tastes can be important for health and a warning, too: sweet and salty can indicate foods rich in nutrients, while bitter or sour signals poisonous plants or protein-rich food that is rotting. The umami flavor, as it occurs in meats, aged cheeses and seafood, can signal a good source of protein. For tomatoes, the sweet and salty flavor combination comes from high glutamic content —and drying both tomatoes and mushrooms can increase the glutamate.
Among other proposals for a fifth taste sensation are savory (similar to umami), calcium (bitter and chalky), kokumi (heartiness), piquance (spicy), coolness (minty, fresh), metallicity (gold and silver), fat and carbon dioxide (in carbonated soda). “There is no accepted definition of a basic taste,” said Michael Tordoff, a behavioral geneticist at the Monell Chemical Senses Center in Philadelphia. “The rules are changing as we speak.”
Smell, texture and temperature can also affect the taste sensations experienced with different foods. And spicy, while often described as a taste, is technically a pain signal sent by nerves sensitive to touch and temperature — caused by capsaicin in foods seasoned with chili peppers.
Umami-rich, high-protein foods may help curb the appetite because they are more filling. And despite suggested links of umami to higher rates of obesity, no effect of MSG has been found in cells or body parts related to weight gain. Notes Cleveland Clinic dietician Beth Czerwony, “When your food tastes better, you’re inclined to eat more of it.”
The neurotransmitter glutamate plays a role in learning and memory. Variations in availability in the brain, too little or too much, can affect mood, depression and OCD; while excess has been linked to Parkinson’s and Alzheimer’s diseases. But investigators are still working to determine the relative role of receptor sensitivity compared with that of glutamate levels.
MSG contains about 12 percent sodium —2/3 less than that in table salt, which means that substituting MSG for salt in some foods can reduce sodium intake by 25 to 40 percent, according to George Mason University nutritionist Taylor Wallace. Americans are beginning to understand that “MSG is completely safe,” says Wallace, who predicts “a shift toward using the ingredient as a replacement for some salt to improve health outcomes.”
MSG earned a bad reputation beginning in the late 1960s based on a cluster of reported reactions that became known as MSG symptom complex, most often associated with Chinese food (Asian recipes often include umami, and it is an ingredient in soy sauce.) Czerwony explains that while a small percentage of people may be sensitive to MSG, the effects should disappear in less than an hour.
The FDA now classifies MSG as “generally recognized as safe” (GRAS), its category for food additives determined by experts to be safe—along with the statement that side effects can occur in someone with MSG sensitivity but only after consuming consumed three grams or more of MSG without food. Bacon contains less than 200 mg of glutamate per 100 grams (3.5 ounces), while aged parmesan has about 2,500 mg.
Both taste recognition and sensitivity can diminish with age, with confusion occurring most often among sour, bitter and umami tastes. In a Finnish study at the Functional Foods Forum, those over age 50 and male gender exhibited less sensitivity generally to taste.
Umami-based recipes are popping up everywhere—including from local DC-area umamimami Dyala Madani, whose website urges: “Think Parmesan, braised Beef, Chicken Soup and Shiitake Mushrooms. The deliciousness that is Umami is the flavor that we strive for when we cook and when we eat.”
What I remember from early MSG-attack days is an itchy scalp—maybe what’s called “tingling” in the symptom list —after eating Chinese food. But since learning that MSG is present in almost all processed foods, I realize that the post-Chinese restaurant itchy scalp could have been due more to power of suggestion—or to a coincidental manifestation of my perennially dry skin.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter fills us in on health news we can use.
THE “EXPLODING” popularity during the pandemic of ASMR (autonomic sensory meridian response)—listening or watching other people whisper, brush their hair, crinkle paper and even clean their ears—has led our well-being editor, Mary Carpenter, to revisit her fall 2018 post. On YouTube, ASMR hovers between the second and third most popular search term both in the U.S. and worldwide.
“It’s no surprise that ASMR exploded in popularity during the pandemic,” said Cleveland Clinic psychologist Susan Albers—because of reduced access to mental health, and because ASMR “helps with sleep, reducing anxiety, and inducing calm.”
Tingling is how ASMR adherents describe the sensation, relaxing but at the same time euphoric—while others feel nothing. And only among those in the adherent group, according to Essex University psychologist Giulia Poerio, have researchers found “simultaneously lowered heart rates and increased skin conductance—a slight sweating that indicates sensory arousal.”
The “heightened sensory sensitivity” of ASMR enthusiasts also makes some enthusiasts prone to misophonia—a negative reaction to sounds, such as sniffling or typing, but also to the whispering that others find so pleasing. Extreme misophonia may resemble obsessive-compulsive disorder, according to recent research, with sufferers’ efforts to avoid possible triggers interfering with their daily functioning.
ASMR may be a kind of auditory-tactile synesthesia—and the skin response, a paresthesia, which involves sensations of tingling and chills. Dividing ASMR triggers into six groups, Sam Parker in The Guardian puts sound at number one, “by far the most popular,” followed by visuals—such as paint being mixed. Eating is its own category: watching and listening to people chew. The next two are crushing (objects like sponges being compressed) and role-playing. Last comes “old-fashioned touch, such as someone “’drawing’ on your back.”
The doyenne and maybe most-watched Internet ASMRtist, Maria, started her own YouTube channel GentleWhispering ASMR in 2011. “I try to be nurturing, almost a motherly figure,” Maria told “Follow This.” Tracing ASMR’s popularity to increased stress and insomnia in today’s culture, she says: “Our main concern is a viewer’s sleep.”
“People who have insomnia are in a hyper state of arousal,” Columbia University sleep disorders expert Carl Bazil told the New York Times. Grouping ASMR with other behavioral treatments for insomnia such as progressive relaxation, Bazil suggests ASMR videos might be another way “to shut your brain down.” ASMR has been compared to a sensation called musical frisson, a ripple of chills or goosebumps in response to music—studied by Montreal neuroscientist Robert Zatorre, who found a corresponding increase in the brain’s dopamine activity.
On functional MRIs of 22 relaxed subjects, those who reported experiencing ASMR showed differences in their brain networks compared to typical controls, in studies by University of Winnipeg psychologist Stephen Smith and colleagues.
In the first group, unusual areas of the brain, specifically those related to vision, were activated as part of what’s called the brain’s “default mode network”—structures along the brain’s midline that fluctuate together when people are daydreaming; and during altered states of consciousness, such as psychedelic experiences. In the first group, too, there was more blending of different brain networks compared to the controls.
Personality studies of the two groups found the ASMR group “more open to new experience, also more neurotic with a greater level of emotional instability and less agreeable,” said Smith, noting that “at this point it’s a lot of speculation.”
Of 475 self-reported “tingleheads,” 75% said whispering was an effective trigger; and a “sizeable majority” of these said they watched ASMR videos to help them sleep and cope with stress, according to University of Wales psychologists. Despite the reputation of ASMR videos being used for “braingasms” and “whisper porn,” only about 5% of subjects said they chose ASMRotica with sex as their goal.
An Idiot’s Guide to ASMR published in 2015 and Brain Tingles in 2018 are the work of ASMR guru Craig Richard, professor of biopharmaceutical sciences at Shenandoah University in Virginia. Richard, founder of ASMR University, a clearinghouse website with interviews and blogs related to ASMR, believes the intimate experiences of ASMR may trigger feelings of being loved.
Richard addresses the possible connection of the tinglehead to what is often called the Highly Sensitive Person—individuals in the 15 or 20% of the population who struggle with a range oft atypical sensory sensitivities, called “sensory processing sensitivity” or “sensory integration disorder.”
Many ASMR enthusiasts like the anonymity of viewing or listening to stimuli—characterized as “intimacy without vulnerability” by the creators of the Brooklyn N.Y. Whisperlodge, which offers a “sensory journey of live ASMR.” But to critics, the close-up face shots of these videos create artificial intimacy. Maria (of GentleWhispering) believes that artificial intimacy is not better but “if it helps someone, it helps someone, that’s the bottom line.”
If I have a heightened sensory sensitivity, it is mostly misophonia—unpleasant reactions to knuckle cracking and throat clearing. I maneuver desperately to get a “quiet” car seat on Amtrak. After viewing a few ASMR videos, I can’t imagine getting any benefit from these experiences nor can I imagine finding time for them when I rarely get to my clearly beneficial P.T. exercises.
—Mary Carpenter
Every Tuesday in this space, well-being editor Mary Carpenter fills us in on health news we can use.
MARIJUANA is back in the news: in DC, with proposals to restrict and fine “pot-gifting” —adding marijuana as a “gift” to purchases, such as a $50 bottle of apple juice, as a lower-price and easier-to-access alternative to medical dispensaries. And in New Jersey, medical marijuana companies have just received the go-ahead to sell to all adults—without needing a doctor’s okay — although the approval at first covers only sales of “medical marijuana.”
(Compared to recreational marijuana, cannabis destined for medical use differs mostly in the oversight of production methods, such as controlled indoor environments and strictly monitored pesticides. But in states like California, clients interested in medical as well as psychoactive effects often purchase the same products, such as low-dose lozenges made by Kiva that come with health claims including “mood enhancing” and “tranquil night.” )
Also in recent news, University of Chicago researchers have observed Covid protection using CBD—although in doses so high as to be exorbitantly expensive for humans, and in studies of human lung cells rather than actual humans. (CBD, one of the cannabinoids in marijuana, does not produce psychoactive effects.) CBD appeared to activate a cellular stress response—typically triggered in the presence of viruses and other pathogens, involving interferons — that prevented entry of the coronavirus into cells.
In addition, a review of 1,212 patients from the National COVID Cohort Collaborative found a 6% infection rate among people taking pharmaceutical grade CBD—compared to 8.9% for those not taking CBD. But other researchers said the acids that bind to Covid-19’s spike protein exist in the raw cannabis plant but are destroyed in processing and not generally present in commercially available products.
Meanwhile, cannabis enthusiasts claim benefits for everything from weight loss to focus, sleep, anxiety and depression—although respected clinical studies have not confirmed these effects. One exception is CBD’s successful treatment of some forms of epilepsy, which led to FDA approval, adding to enthusiasts’ belief in marijuana’s other health effects.
Medical cannabis proved successful, according to a recent Johns Hopkins survey, in reducing emergency room visits for more than 800 users— making them 39% less likely to have visited an ER in the month before being surveyed, compared to a control group of more than 460 people not using marijuana medically. In the survey taken before and after medical cannabis use and in comparison with non-users, the marijuana group reported about a 9% reduction in pain and a 12% reduction in anxiety, as well as a 14% lower use of prescription medicines.
Pain control is the most common reason for medical marijuana use in the U.S., according to Harvard professor and Medical Letter blogger Peter Grinspoon. While not strong enough for severe pain, such as post-surgery, marijuana is “quite effective,” Grinspoon writes, for chronic pain…and nerve pain in general; for nerve pain as a good alternative to highly sedating opiates; and instead of NSAIDs, for people who suffer side effects, such as stomach pain or GERD, from these medications.
But sleep problems drive many to seek respite from marijuana—including San Francisco-based tech manager P.D., whose doctor prescribed low-dose THC to take in combination with melatonin for help with restless nights. Marijuana, writes Valeriya Safronova, “can start the day, end it or prolong it.”
Non-medical products from California-based Dosist have names like “sleep,” and “bliss.” And Fit gummies created by Wana Brands in Colorado claim to “disrupt unhelpful eating habits,” i.e., help with weight loss. Supporting research offered by Wana Brands, however, lists investigators and trials for which there is no record at N.I.H, as required; and efforts by the New York Times to track these down were unsuccessful.
“The science is very far behind the marketing and the public consumption,” said Margaret Haney, co-director of the Substance Use Research Center at Columbia University. Cannabis research is fraught with difficulty because of different individuals’ reactions to marijuana, as well as problems with product consistency— in quality and dosing— and very limited sourcing for federally approved experimentation.
Meanwhile, warnings from the American Heart Association (AHA) link cannabis use to heart attack, atrial fibrillation and stroke— although these may in fact be due to effects of inhaling or vaping that also occur with tobacco products. Acknowledged AHA spokesperson, Colorado pharmacy and rehabilitative medicine professor Thomas Page, “Unfortunately, most of the available data are short-term, observational and retrospective studies, which identify trends but do not prove cause and effect.”
An additional 2022 AHA statement reported that marijuana’s effects on the brain—in animal studies—have included thinning of brain areas involved in orchestrating thoughts and actions as well as disruption of memory and learning.
But short-term effects on memory are what might make marijuana helpful for veterans suffering PTSD, which involves “unpleasant, intrusive memories that people can’t help but remember,” writes Grinspoon, who also points out that “memory returns to normal with abstinence.” Grinspoon considers marijuana a “fantastic muscle relaxant” and describes marijuana’s ability to lessen tremors in Parkinson’s disease patients.
The body’s endocannabinoid system (ECS) is “critical for almost every aspect of our moment-to-moment functioning,” Grinspoon explains. Cannabinoid receptors in the brain (CB1 receptors) help control levels and activity of most other neurotransmitters, while a second type, CB2, “exists in our immune tissues” —which could be the link to Covid protection.
“The medical community has been, as a whole, overly dismissive of [medical marijuana],” according to Grinspoon, who encourages patients to talk with their doctors about potential uses of marijuana for various health issues. “I often hear complaints from other doctors that there isn’t adequate evidence to recommend medical marijuana,” he writes, “but there is even less scientific evidence for sticking our heads in the sand.”
And while questions about inadequate evidence for marijuana’s effects help fuel controversies surrounding marijuana dispensaries—including issues like “pot-gifting”—what most people are fighting about is profits. Companies like Wana appear to take advantage of the confusion—but customers who find relief from the products may be the ultimate victims.
On trips to Colorado and California, I have purchased low-dose marijuana lozenges that help me with sleep. With Kiva mints in California, I appreciated being able to rely on dosage—a low 2.5 mg.; as well as on effects —slightly drowsy, whereas a local friend’s concoctions make wild images speed through my brain. But because federal law prohibits both sending these by mail and traveling with them across state lines, I must travel to obtain this relief.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
“I’D WAGER every woman in America is reaching for that battered old jar of Vaseline that’s been lurking in medicine cabinets for decades,” said NYC editor N.M. “Slugging” —smearing the face with a layer of heavy occlusive such as petroleum jelly at night before going to bed—has recently “taken Tiktok by storm,” according to National News. The practice earned its nickname from “the slimy mess it makes… reminiscent of a slug trail.”
“Initially a K-Beauty trend [originating in South Korea], slugging appears to have first surfaced in the U.S. in 2014,” writes Janna Mandell in the Washington Post.Said dermatologist Joshua Zeichner, at New York City’s Mount Sinai Hospital, petroleum jelly “creates the ideal environment to allow your skin to repair itself.”
For those who dip rarely into the skin-care world, another trend—more important health-wise yet missed by many—is the increasing differences between medical and cosmetic dermatologists. At DC writer W.C.’s recent full-body cancer-screening appointment, the dermatologist either missed or was too uninterested to mention the weeping red poison ivy sores that covered her legs — but also brushed aside her worries about dark spots on her very sore lips. The physician was a cosmetic dermatologist, she later learned, who “must have decided if I’d had no plastic surgery by this point, I was unlikely to become a high-paying or otherwise-rewarding customer.”
Cosmetic dermatologists put “the spotlight on ‘desire’ [while] medical dermatologists target the ‘disease’ aspect of dermatology,” according to the Millburn Laser Practice site. Cosmetic dermatology “is purely aesthetic,” including treatments with Botox, fillers, peels and lasers; and surgical procedures such as skin tightening.
The medical practitioner, on the other hand, “solely treats skin ailments to reduce health risks” —which may mean they pay closer attention and have more frequently honed skills for medical conditions. These can include full-body cancer scans as well as Rosacea—persistent blushing, flushing, and blood vessels visible beneath the skin; alopecia; acne; eczema; psoriasis; and warts.
For the DC writer, the medical dermatologist she saw several weeks later examined the lip spots closely and offered both reassurance that they were not cause for concern and practical suggestions, such as to avoid potentially irritating lip sunscreen except as needed for immediate sun exposure.
Her other suggestion was to regularly apply Aquaphor, an ointment containing humectant moisturizers such as lanolin, but petroleum jelly, too, the most common ingredient for “slugging.” Also called petrolatum and first sold as Vaseline, the jelly creates an occlusive, water-resistant barrier that prevents release of moisture from the skin—and can help maximize the effects of hydrating products.
“At least 10 times a day” is how often Atlanta dermatologist Tiffany Clay recommends petroleum jelly in her practice, “especially for my eczema patients who have a compromised skin barrier and tend to be on the dry side.” The jelly works best on moist skin, especially right after bathing—to create a “moisture sandwich,” explains New York City aesthetician Charlotte Palermino, the original social media popularizer of slugging, who says it makes her dry skin “juicy.”
“You hydrate your skin, you moisturize your skin, and then you trap it all in with an occlusive,” Palermino explains. For slugging, she advises using a pea-sized portion of the jelly, also covering one’s pillow with a towel for protection. (Slugging may cause problems for skin that is oily or prone to acne.)
Moisturizers for use with petroleum jelly should be fairly mild and not include “active ingredients” such as retinoids or exfoliants, which could damage the skin. The best moisturizing emollients are ointments that employ Vaseline as the base, with added mineral oil — but can also include lotions, which contain water but often have added fragrances; and creams, which contain slightly more Vaseline. Humectants, by contrast, work by attracting moisture from the air—but in dry conditions can draw too much moisture from lower layers of the skin.
The slimy trail made by slugs and snails is mucus, with qualities of both a glue and a lubricant that helps the creature glide forward when pressure is lifted or stick to surfaces when pressure is applied, according to BBC Science. Investigations are now underway to see whether the “adhesive and elastic properties of this slime…might lead to a synthetic glue that’s capable of repairing tissue damage.”
Slugging turns out to be something I’ve done for decades, though I’m rarely so up on trends, to battle very dry skin. My concoction is about one-half lanolin—with a little almond oil to counter the sheep smell and a few squirts of some commercial liquidy cream like Lubriderm to make mixing easier. The other half is Vaseline, requiring the towel for pillow protection but making it too greasy for most friends —although with slugging so hot, some may come around.
—Mary Carpenter regularly reports on need-to-know topics in health and medicine.
TO GET or not to get a fourth Covid vaccine as an additional booster is the question, first sparked by the pharmaceutical companies’ headlines-grabbing announcements of their applications for approval to add another shot. Soon afterwards came many “recommendations” and “authorizations,” most recently from the FDA, saying that people over 50 and those who are immunocompromised are eligible for a fourth shot, although FDA advisors will not weigh in officially until a meeting scheduled for April 6.
What this tangle of official communiqués has done is shift the burden onto individuals to make their own decisions —based on health status, worries and personal goals, according to Washington Post contributing columnist Leana Wen. Many are getting a fourth shot because of upcoming plans to socialize or travel, or specific fears about long-lasting Covid symptoms.
Among reasons to wait on getting the fourth shot are hopes that newly formulated mRNA vaccines in the works will better protect against recent omicron variants. Also, some worry that the body’s immune system responds less well to every additional booster or when shots are too close together to allow for build-up of immunity between each one. In addition, many fear future Covid surges that are likely to occur in late summer or early fall—making it smarter to schedule additional boosters closer to that time.
“If you’re more than five or six months out from your last booster, and you’re at high to very high risk, the obvious choice is to get the shot,” said Dr. Robert Wachter, chair of the Department of Medicine at the University of California, San Francisco. “As a healthy 64-year-old man whose third shot was seven months ago, I will get one this week if I can.”
Before the latest flurry of advisories, the recommendation for deciding when to take extra-protective measures was to keep track of local infection levels. The new government website Covid.gov —which evaluates risks by county from “low” to “medium” to “high” based on whether levels put a strain on local health services—lists the greater DC area numbers as “low.” But the New York Times data site at the end of last week concluded for DC alone that “cases have increased recently and are very high”—albeit also noting low rates on measures, such as test positivity.
Newly formulated bespoke vaccines against recent variants, although at first expected to be ready by this month, have in animal research provided “little advantage over standard jabs” and are now on the schedule for late summer. While studies to date have been small, researchers say they “offer early hints that a single dose of a customized vaccine won’t change the game against Omicron.”
As for risks that too many boosters, or giving boosters too close together, could diminish the vaccines’ effectiveness, reports from Israel show that a fourth shot boosts immunity back up to levels seen in months following the third shot. The worry about giving boosters too close together seems mostly theoretical in the absence of clinical studies documenting such an effect.
“If the goal of vaccination is to prevent hospitalization and death, the vaccine plus one booster should be sufficient,” writes Wen; but if the goal is “to reduce any infection from Covid-19, it’s more complicated.”
Many of the worries about any infection concern the risk of lingering Covid symptoms. Even among those with asymptomatic Covid, as many as one-third have reported problems linked to “Long Covid” (officially diagnosed at least three months after the original infection) that range from intense fatigue to brain fog. And a new issue comes from recent research, which included patients with “less severe infection,” showing that Covid may shrink the brain’s gray matter in areas linked to memory processing and smell.
Tissue loss and damage seen in the study participants was “above and beyond” the structural brain changes that normally occur with age, according to Texas A&M neuroscientist Jessica Bernard, who was not involved in the study. The research involved the U.K biobank—which has collected brain-scan images from more than 45,000 U.K. residents, providing before- and after-infection imaging for study participants; it included 401 people who showed signs of prior Covid infection and 384 who had not had Covid but were appropriately matched in terms of age, sex and Covid risk factors.
Among the study’s limitations was the absence of documentation of specific Covid symptoms. For patients who lost their sense of smell, for example, infection in cells close to olfactory neurons could have directly caused shrinkage in brain regions related to smell. Alternatively, the infection could have diminished the signals to brain regions involved in smell, which resulted in atrophy.
For anyone opting out of a fourth shot, the risk of serious infection is becoming lower with increased availability of antiviral treatment—medications including Paxlovid developed by Pfizer and Molnupiravir by Merck; as well as the intravenous antiviral medication Remdesivir. And with the recent government “test-to-treat” initiative, more pharmacies and clinics are offering immediate treatment to anyone getting positive Covid test results. Eligibility criteria, on the other hand, limit antiviral prescriptions to people who have symptoms of Covid— and to within a few days of the onset of those symptoms.
Before deciding, I considered the advantages of waiting for a bespoke vaccine—and maybe also until late summer—for better chances of having a targeted and better-timed immune effect— or at least for FDA advisors to recommend the additional jab. In the end, though, I signed up for the extra booster, spurred by personal decisions from experts like Wachter at UCSF and because I worry about Covid’s effects on the brain, both the newly reported shrinkage and long-Covid symptoms. In addition, by the end of last week, the New York Times was reporting “a rapid increase in levels of the BA.2 subvariant in the Northeast.”
In our MyLittleBirdWell-Being series “Answers to Readers’ Questions,” Mary responds to a reader comment on the post, “Stay Parasympathetic:”
“This is a great reminder to meditate and exercise… it’s fun and even good for us. The trouble is setting aside the time to do these enjoyable things and not just fuss over the ‘to do’ list.”
MLB: You are right, both that regular meditation practice is the best route to lasting changes in various stress-related physiologic functions, and that it requires a lot of motivation and even then can be a struggle to find the time—with the result of upping stress levels rather than lowering them. While a recent slew of app-based devices as well the Apple watch can help, interacting with electronics can bring its own stress—and still requires motivation.
What can boost motivation is biofeedback — along with the improvements achieved by “learning to voluntarily control certain body functions such as heartbeat, blood pressure, and muscle tension with the help of a special machine,” according to the National Cancer Institute. Regular sessions of biofeedback training —not treatment, experts emphasize — lasting from five minutes to an hour, can lead to improvement in bodily dysfunctions that occur in joints such as the jaw and the liver’s production of bile, as well as chronic and acute pain.
Choosing personal goals can also help. While hypertension was originally both an aim and measurement of stress reduction, another possibility is breathing— to improve both volume, increasing the amount of oxygen taken in; and pace, to slow and deepen the breath in order to engage the calming parasympathetic nervous system. While many devices “simply pace a distinctive breathing pattern, biofeedback improved breathing behavior,” according to researchers in Kaiserslautern, Germany.
Many devices offering breath biofeedback require strapping cumbersome “respiratory sensory belts” around the abdomen. But for newer apps like Belly-Bio Interactive Breathing and Alphabeats, a mobile phone on the abdomen enables the phone’s “built-in accelerometers to capture the abdominal breathing movements,” explain the German researchers — though they note that placing and maintaining the correct position of the phone is tricky, and “immediate effects on the user’s relaxation state should, however, not be expected.”
Now a soft, grapefruit-sized ball called the Orb (from the Israeli company Reflect) sits in the hands and requires no interaction with apps or additional electronic devices. Instead, the Orb’s soft light changes color to give biofeedback on two variables related to stress—skin conductance response (also called electrodermal response) as a measure of physiologic arousal; and, the latest gold standard in health assessment, heart rate variability (HRV), which is linked to breath.
Heart rate variability is the variation in time intervals between heart beats, explains Brigham Young University psychologist Patrick Steffen. Greater fluctuations in heart rhythm mean longer intervals between heart beats—which allow for more flexibility responding to changing physiological needs that range, for example, from sleep to strenuous exercise.
Lower HRV, by contrast, indicates less flexibility and responsiveness —and “predicts mortality and morbidity and also occurs in depression, anxiety and chronic stress,” writes Steffen. A key part of HRV—also hypothesized to be a pathway through which biofeedback improves HRV— is breathing at resonance frequency (RF), approximately six breaths per minute, with slight differences for each individual.
Research subjects who breathed at their own RF (measured beforehand for each individual) for 15 minutes reported higher positive mood, along with showing a higher HRV ratio, Steffen said – also noting that about six breaths per minute was the pace at which “heart rate and breathing synchronize or become resonant.” And better scores on RF breathing linked to the HRV ratio were a good “measure of parasympathetic activity.”
For more than 30 years, HRV biofeedback has helped patients with disorders including asthma and depression—and others with performance enhancement. Earlier gadgets involving “wearables” used with apps included the EmWave2, with a sensor worn on the ear lobe that records heart rate to encourage smooth HRV; and the Muse 2 that relies on an electroencephalography (EEG) headset to measure brainwaves, which helps users “meditate less but better.”
Most devices come with a high price tag. Of the early wearables, the EmWave2 costs $229, and the Muse 2, $249.99. The Orb costs $229—with a discount for early adaptors.
“Taking control of your breathing, you can gain indirect control over your heart rate,” writes Kyle Pearce on diygenius. But while Pearce points out that devices “can offer us a more accurate recording and a more comprehensive analysis,” the body can be its own feedback machine.
Among those who prefer taking cues from the body, Richard Davidson, founder of the Center for Healthy Minds at the University of Wisconsin-Madison and a “dedicated meditator,” criticizes the Muse’s EEG feedback, noting that “meditation” in Sanskrit means “familiarization,” and believing that only increasing familiarity with the nature of one’s own mind can lead to more effective meditation.
Because my focus is breath, I found a body-alone biofeedback exercise that involves putting one hand on the chest and the other on the abdomen, then breathing in slowly and deeply through the nose until I feel the abdomen expand, followed by expansion of the chest and then holding the breath for three seconds, and exhaling through pursed lips to make a relaxing, whooshing sound. But as commitment and time remain challenging for me, getting help from the Orb’s soft lights becomes very appealing.
—Mary Carpenter regularly reports on topical issues in health and medicine.
“WE CAN either change the complexities of life—an unlikely event, for they are likely to increase —or develop ways that enable us to cope more effectively.” From The Relaxation Response by Herbert Benson — quoted in Jeffrey Rediger’s Cured.
“Stay parasympathetic” as an email sign-off is particularly ironic because those words encourage cutting down on technology use —which can stimulate the opposite, fight-or-flight (sympathetic) mode of the nervous system. Accessing the parasympathetic, rest-and-digest mode, however, can require even more drastic measures: closing the eyes entirely, slowing the breath, taking a walk outdoors.
When Harvard cardiologist Herbert Benson, who died last month, published The Relaxation Response in 1975 about the effects of stress on the body, he risked professional disgrace— because his first human subjects were meditators, at the time considered very fringe. But Benson offered trustworthy evidence that diminishing stress by way of mental activity (meditation) could reduce high blood pressure—thought to be caused by disease in the kidneys —and, even more, that the regular meditators’ “extremely low” resting blood pressure resulted in long-term positive physiological changes throughout the body.
“There’s More to Burnout Than Being Tired” screamed the headline on a New York Times article last week—listing pandemic-related insomnia as the number one symptom: “chronic stress interferes with the neurological and hormonal system that regulates sleep…and your sleeplessness could exacerbate the problem.” By then, there was a new stressor: the Ukraine War.
Now “even mainstream medicine accepts that our stress levels and thought patterns…can impact our physical health,” writes Harvard psychiatrist and McLean Hospital medical director Jeffrey Rediger in his book Cured. Rediger explains that Benson’s meditators engaged the part of the nervous system that enables rest, the ideal conditions that are “becoming essential for surviving and thriving in the modern era: turning off the flow of stress hormones…and allowing the body to recalibrate and heal.”
The stress response is one of Rediger’s four pillars—along with the immune system, nutrition and identity—in each person’s “biological environment” that support healing. But in writing Cured, Rediger risked professional scorn, not unlike Benson, by investigating spontaneous remissions in patients dying from end-stage diseases—lupus, debilitating Type 2 diabetes and many kinds of cancer— that had spread into the organs, from which “you don’t come back,” Rediger writes.
Physicians generally dismiss cases of spontaneous healing, because most occur in isolation–far removed from one another in time, geography and disease category—and have insufficient documentation of both the diagnosis and the remission, Rediger explains. Also, medical training persuades doctors to focus on the pathology and ignore the story, especially if the story appears to be one of miraculous recovery.
“This compelling book is the result of 17 years spent tracking these people down and verifying their stories,” writes Washington Post editor Mary Hadar, who notes that Western medicine “waits for people to get sick rather than strengthening their immune systems so they won’t become sick.” But, Hadar points out, “every doctor knows the placebo effect is real: The mind can change what’s happening in the body.”
Jeffrey Rediger discovered a database compiled in the early 1990s by the California-based Institute of Noetic Sciences—that researches consciousness and the mind—which listed 3,500 references to “spontaneous healing” culled from about 800 medical journals. As he began to study individual cases, Rediger found that, for each person, after receiving a fatal diagnosis “something changed”—that the cause of healing came not from an external pill or a procedure but from within.
Diet, for example, varied among individuals—with some vegetarian but others ketogenic and meat-based and with each patient designing their own based on what made them feel good and on what they believed, from their reading and research, could help them heal. After Rediger eliminated sugar and processed foods from his own diet, he wrote, “It’s nearly impossible for me to get ill any longer.”
What the recovering patients had in common was adopting an “anti-inflammatory lifestyle”—changing diet but also adding activities like exercise and meditation—to shift the body into the parasympathetic mode, which can support all four pillars to help with healing. Using the analogy of gears on a standard transmission car, Rediger explains, high gears that are best suited for highway driving will damage the car if used on a steep hill: persistent stress over time keeps people’s bodies in the damaging higher gears.
Based on both mental activity and personal identity, perception plays an important role in reducing the toxic kind of “threat stress,” according to findings from the British Whitehall study that followed 18,000 men between the ages of 20 and 64 for ten years. If the men perceived instead the “challenge stress” that can lead to high performance and responded more positively — for example, thinking “I’ve got this”— their bodies remained healthier.
Critics of Cured point out that “from a scientific standpoint, there is a severe issue of selection bias…[no] stories about people who became ill and then changed their diet, avoided stress, embraced love…and still died anyway,” according to the Guardian review.
Another criticism is the implication that “if you get sick, and stay sick, you have no one to blame but yourself.” Rediger is “aware that his ideas may be perceived as victim-blaming,” explains Mary Hadar. But he “responds that his goal is empowerment…Don’t be discouraged by the [poor prognosis] statistics… don’t give in to despair.” According to Rediger, “we have more power than we know when it comes to healing.”
In the late 1970s, despite various counterculture brushes with yoga and meditation, I attended one of Herbert Benson’s early stress seminars thinking the topic too flaky—I had been sent as a medical reporter and had no other interest. What swayed me was observing many in the audience of medical practitioners willingly engage in exercises that included short meditations. By 2006, the Benson-Henry Institute was an established part of Mass General Hospital researching the effects, mechanisms and clinical applications of “mind/body approaches to medicine.”
Today my best method for in-the-moment engagement of the parasympathetic mode involves focusing on the exhale: slowing it down, extending it past what feels natural and then holding the breath before inhaling.
—Mary Carpenter regularly reports on topical issues in health and medicine.
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The TV series “Dopesick” portrayed how Purdue Pharma shamelessly marketed its opioid drug OxyContin beginning in the mid-1990s—sales agents convinced physicians the formulation was non-addictive. The next 20 years brought an explosion in opioid prescribing and a crisis of opioid overdose-related deaths.
But 2016 CDC Guidelines created to respond to overprescribing opioids are now under revision–charged with causing an acceleration of opioid overdose-related deaths. In 2020, the American Medical Association stated: “It is clear that the CDC Guidelines [to limit, discontinue or taper patients’ opioids] has harmed many patients.”
Debate rages, however, about where to direct blame for opioid overdose-related deaths — more than 100,000 occurring in the 12 months that ended in April, 2021, an increase of 28.5% over the previous year —and specifically about how to explain the connection between the two events—the proliferation of opioid prescriptions spurred by Purdue Pharma and the restrictions on prescribing imposed by the 2016 guidelines.
With about 30% of opioid overdose-related deaths each year labeled as suicides, questions arise about how many occurred for reasons unconnected to prescription opioids, as in “deaths of despair,” or the numbers who overdosed in pursuit of the euphoria provided by opioids— in contrast to people for whom addiction or intolerable pain, created by restrictions on their prescribed opioids, drove them to seek cheap but deadly street drugs like fentanyl and heroin.
At the heart of the debate, however, are questions about the risk of addiction—officially, opioid use disorder—for the five to eight million Americans taking medically prescribed opioids for severe chronic pain. According to the National Institute on Drug Abuse (NIDA), “roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them,” while 8 to 12% develop an opioid use disorder—although the latter number could be as low as 1%.
From 255 million opioid prescriptions written in 2012, the number decreased to 142 million in 2020 — in response to the restrictive CDC Guidelines but varying in different parts of the country. Even cancer patients, explicitly exempted from the guidelines, “seem to have been hurt,” writes Maia Szalavitz in the New York Times. In a study of 100,000 medical records of patient prescribed opioids for chronic pain, drastic reductions or cuts in dosage under the guidelines increased the risk of overdose by 28% and of mental health crises by 78%.
Tolerance and physical dependence occur naturally with prescription oxycodone—in Percoset and OxyContin— but “resolve rapidly after discontinuation of the opioid…in a few days to a few weeks,” according to a New England Journal of Medicine review by psychiatrist Nora Volkow, now director of NIDA, and psychologist Thomas McLellan, founder and director of Philadelphia’s Treatment Research Institute.
Addiction—characterized by compulsive drug-seeking and use despite negative consequences —on the other hand, “develops slowly, usually only after months of exposure” and works via different molecular processes than tolerance, which makes it is a “separate, often chronic medical illness,” according Volkow and McLellan.
Of patients prescribed opioids, “only a small percentage” will develop an addiction, they write —with genetic vulnerability accounting for up to 40% of risk, along with history of trauma —reported by 90% of women with opioid use disorder. Mental illness may also play a role along with geographical or social context. The risk of addiction is higher in Appalachia, for example, than in Southern California.
But the Mayo Clinic site states that “taking opioid medications for more than a few days increases your risk of long-term use. The odds you’ll still be on opioids a year after starting a short course increase after only five days on opioids.” And even without “opioid use disorder,” withdrawal symptoms—the “dopesickness” of the TV series—linked to dependence can drive patients to seek more opioids with a desperation that can lead to psychosis and death.
Among many of the 18 million Americans reporting severe to moderate pain, more than 16% of men and 20% of women experience pain most days or every day over a three-month period. Of 245 opioid prescriptions written in 2104, 3 to 4% (9.6. to 11.5 million people) received opioid therapy for longer than three weeks. And in one Medicaid study, over 50% of opioid prescriptions covered more than six months.
Accompanying the analgesic effects of opioids are those of euphoria—because opioids bind to mu-opioid receptors in brain regions that are involved in both. Opioids also depress respiration, an effect that increases over time and can cause overdose and death. In addition to oxycodone, opioids include hydrocodone (in Vicodin) and codeine, as well as fentanyl, methadone, tramadol along with others.
Questions also arise about which kinds of pain are best treated by opioid medications. Acute, so-called nociceptive, pain—caused by injury or following surgery—that originates in peripheral pain receptors may be the most responsive to opioids. But the severe chronic pain that affects 40% of Americans often originates with signals from the brain and involves over-sensitization of the nervous system. University of Michigan oral surgeon Elizabeth Hatfield makes the comparison to getting sunburned—after which pain can arise with “things that normally feel okay” like a warm shower or a sheet touching your skin.
Chronic pain involving inflammation may respond well to NSAIDs—with better results from combining ibuprofen (Advil) with acetaminophen (Tylenol) —or to non-drug treatments that can affect the brain component, such as CBT (cognitive behavior therapy). But many chronic pain sufferers find relief only with opioid drugs. And especially away from large urban areas, the family physicians most often responsible for treating pain have received very little specialized training—one reason Purdue Pharma agents most successfully convinced doctors in regions like Appalachia to prescribe and then continue upping doses of OxyContin.
Finding better ways to assess pain levels— as well as the best dosage for different individuals— are primary goals of the government’s HEAL (Helping to End Addiction Long-term) initiative. Sensory testing to accurately measure nerve pain is one possibility. Volkow and McLellan write about the advantages of “access to biomarkers of pain and analgesia” via neuroimaging or genetic analyses that could help tailor dosages for individuals.
In addition, investigations into alternative pain medications have led to cell-based therapies as well as to the semisynthetic opioid Naltrexone. Used as a nasal spray to reverse opioid drug overdoses, naltrexone in low doses has for years been an “off-label option,” according to Hatfield, “because of its reduction in pain intensity [as well as] in opioid use for patients with chronic pain.”
The advice I received about taking Percoset 10 years ago following surgery that left a temporary pin in my forearm was to “stay ahead of the pain.” At my two-week checkup, however, I learned that I had received a double prescription by mistake and needed to stop taking the drug. When I woke up the next morning, intense aching pain spread through my entire body and lasted until late in the night. Because I did not desperately seek more pills, I believe I must have been withdrawing from dependence—not addiction —but the experience gave me new respect and deep empathy for anyone trying to quit taking opioid drugs.
—Mary Carpenter regularly reports on topical issues in health and medicine.
COVID in March, 2022, brings lifted mask mandates and altered priorities—which altogether shift responsibility away from the collective onto the individual, leaving each person to decide how much risk they are willing to take, writes Katherine Wu in the Atlantic. For many people, what she calls the “Great American Unmasking Part Deux” is too much too soon.
For the “vulnerable vaccinated”—those over 65, because immunity following vaccination appears to wane more quickly with age, as well as people with underlying or immune-compromising conditions —the most pressing question is if and when to get a fourth vaccination. While Israeli researchers found that the fourth dose offers “very little extra protection,” says infectious disease specialist Gili Regev-Yochay in Tel HaShomer, “for those vulnerable populations …I would recommend they receive any protection they can.”
Remaining uncertainties, however, create good reasons to hold off on a fourth shot, notably questions about how long vaccine-induced immunity remains protective; and how well suited current vaccines are for fighting Omicron variants. In addition, new variants could arise at any point, and vaccines coming down the research pipeline might offer better protection against them. Finally, many who believe autumn will be the next period of widespread concern about Covid suggest waiting on an additional booster at least until summer’s end.
Meanwhile, a different immune system weapon— “memory T-cells” — have shown better endurance over time than antibodies and may even offer “abortive immune protection,” stopping the virus before it enters and infects the body. The T-cells created by an earlier SARS virus have lasted 17 years to date; and with the Omicron variant, T-cells have proved so protective that they are expected, researchers told the New York Times, “to mount a similarly robust attack on any future variant as well.”
While the first two shots of mRNA vaccines increased the levels of T-cells against the coronavirus, the third dose appeared to have no effect. But new vaccines in the works that specifically target T-cell production could provide a complementary shot “particularly in [populations] with impaired ability to mount sufficient immune responses,” according to German researchers.
“Test to treat” is an appealing component of the U.S. government’s newly proposed Covid plans, according to Washington Post contributing columnist Leana Wen. That proposal calls for increasing numbers of easily accessible sites, such as pharmacies, that would offer both free testing and, for those who receive positive results, immediate availability of the antiviral pills that must be taken early in the course of a Covid infection.
Supplies of the currently most effective antiviral pill, Pfizer’s paxlovid, are increasing, but the medication requires a prescription, involving consultation with a physician followed by an additional visit to a pharmacy or health care center. Drawbacks to the government’s plan include its high price tag, plus the possibility of resistance to paxlovid in future variants of the virus.
For now, the “Swiss cheese model” is the recommended method of protection from Covid infection: using several different strategies, such as boosters and good masks, so that holes or failings in each strategy disappear when they are layered together, explains David Leonhardt.
“Let’s dispense with the notion that masks are only protective if everyone is wearing them,” writes Harvard public health expert Joseph Allen. One person wearing a good N95 or KN95 “medical” mask (filtration rate of 95%) and talking to an unvaccinated person is better protected than when both people wear standard surgical masks (filtration rates closer to 70%). According to Allen, “One-way masking is fine.”
Endemic is what many hope this virus will become—meaning “within the people” vs. epidemic, “upon the people,” writes Donald S. Burke on STAT. The four currently endemic coronaviruses —a gang of four known as CCC (common cold coronaviruses) —cause mild upper respiratory infections and have infected “almost everyone on earth” during childhood. On the other hand, endemic viruses like Ebola remain virulent and deadly.
The SARS-CoV-2 virus could “still shock the human species with a devastating evolutionary leap…depending on the organs damaged and the extent of [the damage],” explains Burke. Most animal coronaviruses infect cells lining the gastrointestinal as well as the respiratory tract—but researchers have found the SARS-CoV-2 virus in the intestine, kidneys and nervous system.
This virus is “pantropic…far more mutable than we initially assumed,” explains Joel Achenbach in the Washington Post. “It can infect an incredible array of animals…the latest variant, Omicron, came out of nowhere on the family tree of the virus.” Achenbach quotes coronavirologist Benjamin Neuman of Texas A&M University: “Viruses are basically unaccountable – a swirling ever-evolving cloud…as the virus pinballs through a complex immunological landscape.”
During this “pandemic limbo,” I watch the numbers—of hospitalizations and deaths, cases and variants. Covid infections in the U.S. appear to be on the decline, or at least leveling off—although cases of the so-called “stealth omicron” BA.2 variant, which is more transmissible and better at evading immunity than the original omicron, are now doubling every week. But Yale epidemiologist Nathan Grubaugh told NPR last week that the BA.2 variant should only “extend our tail, meaning it might slow down the decrease in cases.”
While many suggest that Covid will become no worse than the seasonal flu, for now severe illness such as lung injury is more frequent with Covid, and the mortality rate is higher. New Japanese research found the omicron variant “40% deadlier than seasonal flu,” although some have criticized the study design.
My greatest reasons for caution stem from the risk of Long Covid—a risk still unknown for the Omicron variant, because not enough time has passed. That diagnosis usually comes about three months following the original infection, according to the LA Times. Early research suggests, however, that “being vaccinated before getting Covid-19 could help prevent the lingering illness or at least reduce its severity.”
For now, I plan to wear a mask indoors in crowded places. Although proof-of-vaccine cards and recent negative test results may provide good layers for the Swiss-cheese model of protection, even an individual possessing both of these could be contagious with a new infection. And I recently discovered a KF94 mask that fits better and is more comfortable than the N95s, as well as offering a high level of protection (94% filtration) and receiving high scores on reliability—as long as the package confirms “made in Korea.”
In MyLittleBird’s Well-Being series, Answers to Readers’ Questions.
QUESTION: What is it with shoulders? Why do there seem to be so many injured shoulders; and when and how should these injuries be treated?
MY LITTLE BIRD: Most shoulder discomfort can ratchet up slowly (except for serious injuries), beginning with the barely noticeable and moving almost imperceptibly to the unpleasant and worrisome—therein lies the challenge in figuring out when and how to seek help. In general, though, inflammation is at the root of most shoulder issues—and most respond to the same treatments regardless of the specific diagnosis.
(Shoulder symptoms indicating serious damage that requires immediate medical attention include: the shoulder joint looks deformed; the shoulder doesn’t work at all; the pain is intense; the shoulder swells suddenly; or the arm or hand is weak or numb. Also, some injuries, such as dislocation—when the top of the arm pops out of the socket— need a doctor to get the shoulder back in place; separation—when a torn ligament causes movement of the collarbone; and fracture—usually of the collarbone or humerus, upper arm bone. )
Common shoulder impairments arise either from an incident, like falling; or over time from arthritis—and motion-related issues—anything from immobility to excess or repetitive movements, especially when done incorrectly. Diagnosis can depend on details of the discomfort —such as what time of day or night it most often occurs and which activities make it worse, such as raising the affected arm—and is often confirmed using a scan— an X-ray or MRI. Noises the shoulder makes can provide important clues: crackling sounds when lifting the arm overhead can signal a rotator cuff tear, as can pain at night; while catching, locking or grinding sounds and sensations more likely indicate injury to the cartilage.
So many muscles, tendons and bones converge at the shoulder joint—with each susceptible to its own damage leading to pain or impeding normal movement. The rotator cuff alone has four tendons, each attaching a different muscle to the scapula (shoulder blade) and the humerus. According to Harvard Health Publications, “The most common cause of shoulder pain is rotator cuff tendonitis—inflammation of key tendons in the shoulder.”
When accompanied by normal muscle strength, shoulder pain suggests rotator cuff tendinitis, while pain with weakness can indicate a tear. Rotator cuff impingement, by contrast, occurs when a rotator cuff muscle swells and cramps the space between the shoulder and arm bones to cause pinching. Muscle strain and bone spurs can also cause swelling around the joint. The risk of rotator cuff tears increases with age and long-term wear and tear on the body.
Pain slightly lower on the upper arm may signal biceps tendinitis, often found in concert with rotator cuff damage—which occurs, for example, in swimmer’s shoulder, linked to the high number of swim stroke repetitions. Also for swimmers, impingement syndrome arises when a “tendon in the shoulder rubs and catches on surrounding tissues,” creating a dull ache that hurts during use or when sleeping on the affected side of the body.
Frozen shoulder is another specific shoulder issue, which often seems to arise out of the blue, more commonly in women, and after age 40. Also called adhesive capsulitis, the capsule of connective tissue surrounding the shoulder thickens and tightens, and raising the affected arm can create a sudden, sharp pain.
Treatments include steroid injections; physical therapy; and strong “medical doses” of NSAIDs, such as for naproxen (Alleve), two pills twice a day. Frozen shoulder has a reputation of resolving in six months no matter what steps are taken – but according to the Mayo Clinic, the average is more like one to three years.
When shoulder pain arises suddenly—most often after a fall —the initial treatment is several days of rest, along with ice applied every four to six hours. Afterwards, and for most slowly worsening shoulder ailments, recovery includes a combination of physical therapy and NSAIDs like Advil—taking as little as two weeks though more “stubborn cases” take months or longer to heal. Corticosteroid injections can offer quick relief but appear to offer no long-term advantage over the PT/NSAID combination, according to Harvard Health.
Professional physical therapy sessions can help kickstart treatment, although most shoulder exercises are easy to master. The challenge is maintaining a regular practice. Most shoulder exercises require holding positions for 5 to 20 seconds, with many repeats. The doorway stretch involves standing in a doorway, holding the side of the frame with the affected arm slightly below shoulder height, and turning away from the arm to feel a slight stretch. For the cross-body or crossover arm stretch, lift the affected arm in front of the body, using the opposite arm for support if needed and to pull the affected arm across the body.
The pendulum exercises may be the most versatile: standing pendulum uses the weight and momentum of the arm to “encourage movement at the shoulder joint while maintaining inactivity of the injured muscle,” according to Healthline. Lying Pendulum is best for those who have trouble standing due to balance or back pain; and the more advanced “weighted pendulum” —done while leaning on a table with the unaffected arm—adds a dumbbell or wrist weight.
When I had a “frozen shoulder,” I did everything —the doctor’s visit with scan, the steroid shot and the physical therapy. When I recovered in about six months, I had no idea what did or did not help. Now I have something like “swimmer’s shoulder,” even after months of no swimming due to Covid, and suspect the time has come to begin exercises.
—Mary Carpenter regularly reports on topical issues in health and medicine.
The following is a new post in MyLittleBird’s Well-Being series “Answers to Readers’ Questions”:
Q: If I have a family history of cancer and heart disease, should I get genetic testing to figure out my personal risks (despite knowing I don’t have the BRCA variants signaling susceptibility to breast cancer)?
A:What most experts say: If there is anything you would be willing and able to do, such as more frequent screenings or changes in diet, to better protect yourself in the event that the results you get are “actionable”—then predictive genetic testing could be helpful.
Among commercially available and relatively inexpensive screening tests, the Color Extended test ($258.95) can analyze genes related to cardiac disease and medication response, as well as to eight types of cancer: breast, ovarian, uterine, colorectal, melanoma, pancreatic, stomach and prostate, according to the American Society of Clinical Oncology. Such genetic screenings —also offered by 23 AND ME, Veritas and others — require an order from a physician, either one’s own or one provided by the company.
The risk of breast cancer rises from 13% of women in the general population to between 45 and 72% of women with a BRCA variant—who are expected to develop breast cancer by 70 to 80 years old. Also, in screenings of unselected populations, 50% of those discovered to have BRCA variants reported no personal or family history to indicate increased cancer risk.
Between 5% and 10% of all cancers might be related to inherited genetic mutations, with about 15% of colorectal cancers linked to a genetic profile called Lynch syndrome. For heart disease, the picture is more complicated, with interactions among various genes as well as lifestyle factors playing a greater role.
Critics have warned that “our ability to sequence DNA…has far outpaced our ability to understand how those genes cause cancer,” according to Wired. Said former UCSF researcher, “If you talk to docs, they say, ‘BRCA, that’s the only thing I’m interested in because I don’t know what to do with the other information.’” (Although that opinion dates from 2016, it remains widespread today.)
But according to the CDC, screening those populations with no family history is worthwhile for three conditions—Hereditary Breast and Ovarian Cancer Syndrome (cancers linked to the BRCA variants), Lynch Syndrome and Familial Hypercholesterolemia (very high cholesterol starting at an early age). For these three, there is sufficient evidence that interventions can reduce morbidity and mortality.
In results from an unselected population genetic-screening study for Mass General Brigham Biobank, “worrisome gene variants” found in 425 of 36,000 participants had “effects [that] could be ameliorated by…enhanced cancer surveillance or aggressive medical treatments to lower cholesterol, for example,” writes Gina Kolata in The New York Times.
One-third of the Biobank study participants contacted about their variants said they did not want to hear “what the gene was or what its effects might be.” But among those who did, at least one was grateful to learn he had Lynch syndrome —leading him to discover several relatives who had died from cancer, and to have screenings for liver and skin cancer as well as to begin annual colonoscopies.
While hereditary colon cancer has two forms—Lynch syndrome and another called polyposis— familial CRC (colorectal cancer) also occurs in “many other families” in which several members who have no apparent association with an identifiable genetic variant are diagnosed with colon cancer.
For breast and ovarian cancer, guidelines from the National Comprehensive Cancer Network (NCCN) updated in 2019 “still have a strong focus on BRCA1 and 2 mutations but also now include other high and moderate penetrance genes associated with breast, ovarian and pancreatic cancer,” according to NCCN Guidelines Panel Chair Mary B. Daly. Penetrance refers to the likelihood that certain genes or gene variants will result in disease.
For heart conditions other than Familial Hypercholesteremia, genetic screening can also detect variants linked to cardiomyopathy (abnormality of the heart muscle), arrhythmia (abnormality of the heart rhythm) and arteriopathy (problems with the structures of arteries in the heart and other parts of the body). Finding the relevant genetic variants can motivate patients and healthcare providers to do more intensive or frequent monitoring for these conditions.
As genetic screening tests become more accessible, though, the issues involved remain complicated. One question relates to everyone who might be affected by one person’s genetic testing, such as other family members. Notes the American Cancer Society (ACS): “Not everyone might want to know if they are at increased risk.”
Also, genetic testing can lead to additional medical tests, screenings and procedures — each potentially involving more stress and anxiety, as well as greater time and expense. The availability of insurance coverage raises questions about whether insurers or employers might use the resulting information to the detriment of the person being tested. According to the ACS, “Some people choose to pay for genetic testing themselves in order to keep the results as private as possible.”
For me, one parent had colon cancer but suffered so many other health problems that my risk is uncertain. As recommended, I’ve had regular colonoscopies since age 50, but I might schedule these more frequently if I knew I had a greater genetic risk. On the other hand, I remain unsure about whether I want to know and what I would do with that information.
—Mary Carpenter regularly reports on topical issues in health and medicine.
Mary is updating her 2016 post on hypermobilitybecause she found out about a recently opened (2019) D.C.-area clinic, which specializes in connective tissue disorders that underlie hypermobility – it currently has an 18-month waiting list because there are so few physicians and clinicians treating these conditions.
POTS (postural orthostatic tachycardia syndrome)—lightheadedness, fainting and rapid heartbeat that happen when standing up—is one of many medical issues that can be linked to the connective tissue weaknesses underlying hypermobility. Connective tissues, which form fat, bone and cartilage, do not just hold ligaments and joints but also support nerves, immune and circulatory systems and other organs.
As a result, connective tissue weakness can lead to an overactive immune system—causing unexplained allergic reactions, such as swelling and difficulty breathing —as well as osteoarthritis, unexplained bruises and abnormal scarring, and constant thirst. More serious problems include diverticulitis, uterine prolapse and mitral valve disease that can lead to congestive heart failure.
Connective tissue knits the body together, explains Alissa Zingman, founder of the P.R.I.S.M. clinic in Silver Spring, Maryland, who spent years seeking help for her own pain and frequently dislocated joints before she found doctors who took her complaints seriously and diagnosed ED (Ehlers-Danlos Syndrome). P.R.I.S.M. assesses and treats patients whose symptoms suggest underlying connective tissue weakness.
Some rheumatologists screen earlier for osteoporosis in hypermobile patients—although the arthritis pain common in this group can make it difficult to detect hypermobile joints. But most physicians rarely consider that hypermobility might be a complicating factor when treating related conditions— from chronic allergic reactions to severe diverticulitis.
It’s a long wait to get an appointment with P.R.I.S.M. but identifying your hypermobility is important so you can do exercises that are good for you and avoid high-risk activities like hot yoga and too much stretching.
Back to our 2016 post:
EVER FEEL like Gumby? Do double-jointed tricks with your thumbs, remember dropping into splits easily in your youth? But have such difficulty standing for long periods that an hour at a museum is more tiring than one spent climbing Maryland’s Billy Goat Trail – and standing on one leg is nearly impossible? Also, tired and achy? Have cold hands and feet?
“Emerging awareness” is how local Certified Advanced Rolfer™ and movement therapist Rebecca Carli-Mills describes the current thinking about hypermobility—as descriptions and classifications change with new research. People with lax joints fall along a broad spectrum, from those with hypermobility but only mild or no related symptoms —to those more severely affected, some of whom are diagnosed with Ehlers-Danlos Syndrome.
Loose joints create strain on the soft connective tissues designed to stabilize joints, which makes the connective tissue both too lax for stabilizing and more vulnerable to tearing and pain – resulting in joint hypermobility syndrome (JHS). While JHS most commonly causes excessive flexibility, hypermobile people can also feel stiffness, tension and pain in the joints.
“Remarkably, this process [of tissue damage related to hypermobility] occurs so gradually that many people with JHS do not even notice…when in fact their necks are a mass of knotted soft tissue,” writes Alan Pocinki, hypermobility expert at George Washington Hospital. JHS affects three times as many women as men, occurs in as much as 10% of the population, and tends to diminish with age.
With reduced awareness of the location of their bodies in space, called proprioception, “hypermobile people frequently bang into things and may have been told they were clumsy or awkward—a klutz,” notes Carli-Mills.
Identifying joints as loose or hypermobile is crucial when choosing good exercises and activities—and avoiding those that can make problems worse. Isometric, or resistance, exercises keep the joints stable while working the muscles. Before any movement, engage the body’s stability. According to Pocinki, the worst exercises for hypermobile joints are free-flow stretching like ballet or gymnastics—anything that involves grabbing a joint and pulling or pushing to “loosen it up.”
Pilates exercises can help strengthen the core to decrease the load on susceptible joints: an example is the “bird-dog” pose — on all fours, stretch one arm out in front and the opposite leg in back, like a dog pointing toward its prey. The best exercises involve weight lifting and tension bands, increasing repetitions while maintaining low weight or resistance. According to Pocinki, if you can’t do eight repetitions without straining, the weight is too heavy.
Fatigue and pain are the most common symptoms that accompany hypermobility—caused by poor posture, ineffective movements and “improper muscle recruitment” when performing simple tasks, according to a hypermobility blog. And Pocinki explains that almost every JHS patient has chronic neck strain because the neck ligaments are too loose to support the neck, which forces the neck muscles to work harder.
To assess a person’s degree of hypermobility, the Beighton score uses movements, such as bending your little finger backwards; bending your thumb forward to touch your forearm; hyperextending your elbows and/or knees; and putting your palms flat on the floor without bending your knees. For a diagnosis of JHS, that score is combined with other criteria, many related to pain—such as the number of joints affected, the duration of pain, back pain and soft-tissue problems such as tendonitis.
Increasing muscle tone and stability can be a slow process, says Carli-Mills, but “people improve more quickly if they give up things that are bad for them, like running and stretchy hot yoga. And she advises, “Bring more mindfulness to movement and action to activate the nervous system in a different way.”
I appreciate the growing recognition of hypermobility, having done double-jointed tricks since childhood. And I’m grateful for the specific advice —such as that from the British Hypermobility Syndromes Association: Stay in any one position for a maximum of half an hour. On the other hand, because hypermobility affects so many body parts and joints and calls for doing so many things to counter related problems, it can feel like fighting against the inevitable—and sometimes I yearn to just slouch in a chair and read.
—Mary Carpenter regularly reports on topical issues in health and medicine.
“Life is like riding a bicycle. To keep your balance, you must keep moving.” Albert Einstein
I am an inveterate fidgeter, doodling uncreative flowers and “removing” split ends (from my then-longish hair) through school and college years, and still “fixing” cuticles, all deemed “bad” habits that I have worked tirelessly and unsuccessfully to conquer.
In recent years, though, fidgeting has gained new respect as a means of sharpening focus and increasing attention, along with scientific respectability—and sales of so-called “fidget widgets” have soared. (“Widgets” can mean most any gadget, and recently also refers to a software application.) According to Harvard psychiatry professor John Ratey, fidgeting increases levels of the neurotransmitters and norepinephrine similarly to the effects of ADHD medication.
Medical interest in fidgeting began in the ADD community, starting in the late 1990s when gadgets, actually called “fidgets”—squishy stress balls, “magic cubes” that are variations on Rubik’s cube—became common and even on offer in special education classrooms. Attention “deficit” increases with the length, familiarity and repetitiveness of a task, according to Purdue University education studies professor Sydney Zentall. What can help the brain to focus is any activity that uses a sense other than the one required for the primary task, such as listening to music while reading.
Having ADHD may make fidgets more effective. In a 2015 study of school-age boys and girls, the 26 with ADHD gave more accurate answers on cognitive tests when they fidgeted and less accurate when they did not—compared to the 18 children without ADHD for whom fidgeting had no impact either way.
“Most major religions have some form of prayer beads — the word “bead” is derived from the Middle English word for a prayer— which are used for focusing and counting,” writes Will Dunn in The New Statesman. But in Victorian times, teachers punished fidgeting students with a stiff caning or made them wear “finger stocks” to keep their hands still. And in recent years, hundreds of schools in the U.S. have banned the spinners—which one called “helicopters of distraction.”
When sales of fidget spinners hit the big time in the late 2010s, I chose a black three-pronged gadget that twirls smoothly on ball bearings—although I haven’t mastered the suggested one-finger balance. But for occasions when I tend to fidget most, my little helicopter is either not at hand, such as for unanticipated phone conversations; inappropriate, such as when dining with others; or excessively distracting—for talking, reading and doing almost anything else.
It turns out there’s an inverted U-curve for fidgeting: The right amount can get you to a “zone” of perfect attention, but too much can impair performance. Says University of Illinois psychologist Alejandro Lleras, “When you are…stimulated in the right way, you can do things for hours.”
Since the early days of spinners, balls and cubes, new fidget-gadgets have flooded the market which includes, according to Dunn: “popping key rings, pea pod poppers (which involve squeezing little rubber peas from a rubber pod), silicone snappers, infinity cubes and an articulated plastic chain called Wacky Track—something crackles and pops in the background.”
During a six-month period in 2021, more than 12 million pop-its were sold in the U.K. —amounting to two for every primary school child—for something most prefer to call a “tool,” not a toy. Pop-its may have evolved from bubble wrap—after a 1992 study at Western New England College when 30 undergraduates, asked to pop two six-inch sheets of bubble wrap for five minutes, “reported feeling significantly more energized, less tired, and more calm,” writes Dunn. After popping little bubbles on flat plastic surfaces in an array of colors and designs, you can flip the gadget over and pop them all back again.
Sensations like the pops and squeezes produced by fidgets—called “affordances” —can have specific emotional effects, according to UC Santa Cruz computational media professor Katherine Isbister. “When people are angry, they like to squeeze something hard” — while soft furry textures can be calming.
When the spinning fidgets didn’t help me, I tried something completely different for calming the hands called Jin Shin Jyutsu, a Japanese physio-philosophy used throughout the U.S. for general relaxation and in medical settings. As described on a British Cancer center website, Jin Shin Jyutsu involves “holding the fingers [to] move through uncomfortable emotions and experiences rather than being trapped by them.”
“Gently wrapping” the fingers of one hand around each finger on the other, you hold “softly until you feel a gentle rhythmic pulse.” Each finger affects different issues: the thumb for worry, the index finger for fear, the middle finger for anger and the ring finger for sadness. The little finger has been my focus, to cover a host of issues—anxiety, insecurity, bloating, breathing—but the method proved too distracting for my fidgeting needs.
On some positive notes, I have learned that any movement, including fidgeting, at least once during each half-hour period can help counter the hypermobility, beginning with loose joints, that creates myriad problems. I am also working on general self-acceptance. But a new fidget with only two prongs that could be an improvement just arrived at my door —and to my surprise, on its surface, I found two adult-sized pop-its that so far are quite satisfying.
—Mary Carpenter regularly reports on topical issues in health and medicine.
PREDICTING WHO might be likely to develop “long-haul” symptoms of Covid—disabling fatigue, cognitive problems, pain and shortness of breath—might relieve the biggest worry many people have about the coronavirus. Last week, Seattle researchers described four biological factors linked to higher risk for Long Covid—which could help determine early on which patients should receive Covid treatment, although existing antiviral drugs are currently difficult to procure.
In addition, in tandem with one of the biological factors —high levels of autoantibodies that mistakenly attack the bodies’ own tissues—the researchers found another indicator, low levels of protective antibodies against Covid. Having fewer protective antibodies, even in the fully vaccinated, can mean a poor immune response to Covid in those patients who suffer the virus’s long-term as well as its most virulent effects.
Besides the autoantibodies, another of the four factors linked to Long Covid was high levels of coronavirus RNA, or “viral load,” in the blood early on, which can lead to more severe infection. Reactivation of Epstein-Barr virus (EBV) was a third factor: Like chickenpox and other herpesviruses, EBV can remain dormant in the body following infection and is present in some 90% of the world’s population. In rare cases, EBV can lead to Guillain Barré— an autoimmune syndrome with symptoms, such as severe fatigue, similar to those of Long Covid.
Type 2 diabetes was the fourth factor, although the researchers cautioned that could turn out to be only one of several medical conditions associated with Long Covid. In addition, sufferers with long-haul respiratory problems had low levels of the stress hormone cortisol either caused by the steroids given to treat infection-related lung damage or because adrenal glands are among the organs targeted by the coronavirus. According to ZRT Laboratory, diminished cortisol can lead to chronic health problems like fatigue.
Looking at 20 possible symptoms of Long Covid in more than 200 patients two to three months after infection, the Seattle researchers found one to two Long Covid symptoms in 24%—and three or more symptoms in 37%, among whom almost all had one or more of the four biological factors. The most influential of these factors, the autoantibodies, occurred in two-thirds of the Long Covid cases.
Outside commentators noted possible weaknesses in the Seattle research, which was conducted at several universities and centers, including the Institute for Systems Biology, Swedish Medical Center and the University of Washington—such as the relatively short two-to-three-month follow-up. Another was the high number of patients who had been hospitalized, which made untangling the effects of different variables more complicated. In the Seattle patient group—ranging in age from 18 to 89—more than 70% had been hospitalized with the initial infection.
But a different study at the University of Washington found similar biological factors in a group of 100 patients that included many with mild infections—and used data from 457 healthy people as comparison. “The [four-factors Seattle] study is large and comprehensive and is a great resource for the community studying Long Covid,” said Yale immunologist Akiko Iwasaki.
Autoantibodies or “rogue” antibodies—responsible for autoimmune diseases like lupus—can disable immune system proteins and attack other organs affected by Covid, explained David Lee at New York University Langone Health. Although women with Covid infections have less severe symptoms and fewer deaths, they experience long-haul difficulties at more than four times the rate of men. (Women are also more likely to have autoimmune diseases, such as lupus, MS and rheumatoid arthritis.)
Along with the high autoantibody levels, the high viral load and low levels of protective Covid antibody levels together contribute to long-haul symptoms. Iwasaki told the New York Times: “The quicker one can eliminate the virus, the less likelihood of developing persistent virus or autoimmunity, which may drive Long Covid.”
A similar, so-called “immunoglobulin, signature,” proposed by Zurich researchers, includes having asthma along with low pre-infection blood levels of protective antibodies — which together indicate greater risk of Long Covid as well as of reinfection with the virus. University Hospital Zurich immunologist Carlo Cervia told The Guardian: “People with asthma and low [protective antibody] levels can assume they are at an increased risk for Long Covid.”
To what degree vaccination might protect against Long Covid is unclear —with mixed results from the few studies that investigated the question, especially for the omicron variant, Iwasaki told Nature. In an Israeli study of more than 3,000 participants, those fully vaccinated with the Pfizer-BioNTech vaccine were 54% less likely to report headaches, 64% less likely to report fatigue and 68% less likely to report muscle pain than their unvaccinated counterparts.
But if recovering quickly from Covid infection means less risk of long-haul symptoms, the two antiviral medications “supposed to be an important weapon against the pandemic in the U.S.” are in short supply, according to TIME magazine. And of the two, the “pill considered to be far superior, Pfizer’s, takes six to eight months to manufacture…[now] being carefully rationed, reserved for the highest-risk patients.”
But a positive benefit of the new Long Covid findings may affect investigators of long-haul Lyme disease. Symptoms common to both include disabling fatigue; cognitive problems that include difficulty focusing; and pain. Respiratory problems that occur with Long Covid, on the other hand, are not typical of those with long-haul Lyme. Posted last May on the Johns Hopkins Lyme Disease Research Center site: “We are hopeful that the tremendous resources for long-haul Covid research could help accelerate Lyme disease knowledge and treatments as well.”
HAIR LOSS is what drove Pittsburgh anesthetist C.T. to look ever farther afield— after years of debilitating malaise with no clear diagnosis or successful treatment. Eventually choosing functional medicine practitioners, C.T. received test results that indicated toxicity from a range of causes, including heavy metals, especially mercury, as well as mold—all to blame for excessive inflammation underlying her difficulties; and she received a detailed plan for healing.
Soon after that came the Covid pandemic with an explosion of hair-loss complaints—also linked to inflammation and traced primarily to stress or in some cases to post-viral inflammation after infection. Worry-related stress is the most common cause of telogen effluvium, temporary hair loss (more common in women than men), which can also follow illness and childbirth.
Appreciation of functional, also called integrative or complementary medicine, appears to be growing—with its success at treating chronic complaints not resolved, and often not taken seriously, by traditional physicians. At the Cleveland Clinic’s Center for Functional Medicine, a study found better outcomes for new patients —who see a registered dietician and a health coach and have the option of meeting with a behavioral health therapist—compared to those not enrolled in the program.
For hair loss, environmental toxins as well as medications— antibiotics and antidepressants, weight-loss and cholesterol-lowering drugs—can play an important role. One-sided hair thinning often follows trauma, such as a head injury; hair treatments or styling, including relaxers and tight braids; regularly sleeping on the same side; and repetitive behaviors, including trichotillomania.
Among pandemic hair-loss sufferers, treatments have focused on supplements such as biotin—becoming known as a “hair growth supplement,” although its efficacy is not agreed on by dermatologists or well established by scientific studies. Sales have soared for biotin-containing products such as Nutrafol—which also contains vitamin A, Vitamin D and zinc—and RevitaLash Thickening shampoo and conditioner.
The supplements promise to stimulate hair growth, which take three months or so to kick in but with less risk of side effects than older remedies like topical Rogaine, or minoxidil; or expensive injections of PRP (platelet-rich plasma therapy using the patient’s own blood), although that may work better for genetically linked female or male-pattern baldness.
But combating inflammation as an underlying cause of hair loss along with chronic ailments, notably fatigue and pain, usually begins with diet: A wide variety of options range from eliminating different combinations of sugar, gluten, dairy and alcohol to more extreme paleo- plus-keto combinations that can exclude all carbs, including some fruits and most grains. Other regimens add healthy foods—notably fermented preparations such as kimchi and kefir, which contain probiotics that support the body’s immune system—as well as supplements.
For years, C.T. had visited physicians who appeared stumped by her condition and “blindly prescribed pharmaceutics that produced uncomfortable side effects and led to little improvement,” she said. For her new specialists, she noted, the challenge was to reduce inflammation without causing more harm.
Toxic-element testing found elevated levels of mercury—leading C.T. first to replace her old amalgam, mercury-containing fillings and to avoid eating seafood high in mercury. But for detoxing, she explained, plants are the best candidates: they “clean pollution in water, air and soil, and can pull toxins from the body as well.”
(“Plant detox” has different meanings depending on the toxins targeted and the parts of the body involved: “juice cleanse” detox usually refers to clearing general toxins from the colon in the absence of specific medical issues, which has little scientific support. But whole-body detox regimens generally begin with both chronic health complaints and extensive medical testing. For both C.T. and M.L., a former subject of a MyLittleBird post, specific health complaints along with their own formal medical training helped guide choices of practitioners and detox plans.)
After tests detected six heavy metals above reference levels, every day C.T. drank fresh teas made with cilantro, parsley, ginger and turmeric, as well as juice extracted from a head of celery, although it tasted “awful.” Compared to IV chelation, a serious medical procedure used by some for heavy-metal detoxing that mechanically removes and cleans the blood, C.T. considers plant detox a “gentle chelation.”
Mercury is the most destructive of toxic heavy metals—the “silent killers of the 21st century,” according to neurobiologist Dietrich Klinghardt, who practices in Germany and Washington State. Heavy-metal toxins stored in the body cause immune system deficiency, according to Klinghardt, who found a direct correlation between stored toxins and infectious pathogens.
Because skin is the organ with the largest permeable surface area, C.T. explained, weekly infrared saunas as well as daily baths with bentonite clay helped with heavy-metal removal. And she added twice-daily capsules of Advanced Cellular Zeolite, made from volcanic ash, as well as activated charcoal capsules to remove circulating toxins extracted by the detox agents.
Also, to replace antioxidants depleted by the toxicity, she took glutathione, which the body relies on to regulate antioxidants and helps protect cells from damage. And to counter the demineralization of bones, she added daily supplements of Trace Mineral Drops, a preparation of concentrated minerals.
Homeopathic preparations formed a cornerstone of C.T.’s detox, including incrementally increasing amounts of Renelix, apoHepat and Itires, each of which contains ingredients, such as apis mellifera, colchicum, mandragora root and echinacea. And finally, she added CBD products that contain a “tiny” amount of THC—specifically the fabled “Rick Simpson Oil.”
C.T. worked on the regimen over “quite a year of treatment,” she said. Afterwards, retesting showed her heavy metals at an acceptable level; her energy had returned; and her hair grew back. Because of ongoing exposure to the air and water, as she explained it, she continues to drink the teas and keeps to a diet that’s “always anti-inflammatory—sugar to a minimum, etc.”
For C.T., both her medical training and her debilitating health issues contributed to her belief in treatments like homeopathy —a belief that C.T. acknowledges may be necessary for whatever role the placebo effect plays in their success, in the absence of rigorous scientific evidence. She pointed to the precedent of acupuncture, for which anecdotal evidence slowly accumulated to mobilize the scientific research that ultimately documented its efficacy.
Without the motivation of disabling chronic health complaints, the lack of scientific support affects my ability to believe and thus my interest in experimenting with alternative treatments like homeopathy. But I am impressed by how these options help others when traditional medicine has failed. For hair issues, on the other hand, I strongly believe in the benefits of silk pillows, which at least give me a good reason to splurge on this luxury.
—Mary Carpenter regularly reports on topical issues in health and medicine.
