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11:07 AM
June 1st, 2017

Narcotics Addiction and Overdose

Narcotics Addiction and Overdose

The Erie County Medical Society shares the deep concern and sadness of the community locally and broadly over the recent surge in narcotics related deaths. This surge is superimposed on the steadily climbing number of such deaths over recent years.

 

One factor contributing to the recent increase may be the emergence into availability of heroin forms that can be snorted or smoked instead of injected intravenously. First, this presents a less repulsive method of administration than intravenous injection. Second, it caters to the mistaken illusion that the drug is less dangerous when snorted or smoked than when injected.

 

While no “magic bullet” currently exists, progress toward the solution of the problem begins with understanding. Accordingly, we present this information to enhance understanding of the disease.

 

Scope of Problem

The year 2014 witnessed 47,055 drug overdose deaths in the US compared with 32,675 traffic accident deaths. These data are from the US Centers for Disease Control and the US Department of Transportation, respectively. Meanwhile,

here in Erie County, Pennsylvania, drug-related deaths rose 61% from 59 in 2015 to 95 in 2016.

 

Fentanyl has become a major factor in drug overdose deaths. Fentanyl is either legally manufactured but illegally obtained, or illegally manufactured and obtained. Fentanyl-related deaths increased 80% in 2014.

 

Internationally, the US is hit especially hard by opioid abuse. Americans constitute less than 5% of the world’s population, but consume 80% of the world’s opioids. Americans consume 99% of the world’s supply of hydrocodone, the active ingredient of VicodinTM. Finally, Americans consume two-thirds of the world’s illegal drugs.

 

Causes of Opioid Dependence

Opioid dependence is a disorder with pharmacologic, genetic, social, and psychodynamic causes. It is a true medical problem, not a moral failing or personality shortcoming.

 

Pharmacologic factors weigh heavily in opioid addiction. Certainly, drugs other than opioids have significant addiction potential; but, opioids, with their rapid development of physical dependence and their severe protracted abstinence syndrome, make abstinence especially difficult.

 

Genetic factors also contribute. There is a high degree of heritable vulnerability for opioid dependence. Gene polymorphisms for receptors for dopamine, serotonin, and other neurotransmitters also seem associated with opioid dependence vulnerability. Perhaps future medications can be designed to take advantage of these genetic factors.

 

Psychopathologic diagnoses seem to factor in. Preexisting mental health diagnoses seem to increase risk for long-term opioid use among adolescents with chronic pain.

 

Social factors have notable influence as indicated by the high rate of drug use in areas with poor parental functioning, high crime, and high unemployment.

 

Signs of Opioid Abuse

Opioid abuse is evidenced by any two of the following signs occurring within a 12-month period.

  1. Taking larger amounts than intended.
  2. Unsuccessful efforts to reduce use.
  3. Spending substantial time and activity related to opioids.
  4. Craving opioids.
  5. Failure to fulfill obligations of home, work, or school.
  6. Continuing opioid use despite opioid-related problems.
  7. Relinquishing social and other interests because of opioid use.
  8. Continuing opioid-related activities when those activities present a physical hazard.
  9. Tolerance and withdrawal, except when the opioids are used exclusively for medical reasons and under close medical supervision.

Tolerance, Withdrawal, and Addiction

Tolerance, withdrawal, and addiction are three separate entities. They are not just different ways of saying “addiction.”

 

Tolerance is the requirement for increased doses of the drug to achieve the same effect. Thus, increasing doses of the drug are needed to induce the same euphoria.

 

Withdrawal is the occurrence of symptoms on abrupt cessation of the drug. The onset and duration vary with the drug. Heroin withdrawal symptoms tend to peak in 36-72 hours and last 7-14 days.

 

The symptoms of withdrawal are typically diarrhea, runny nose, nausea, “gooseflesh,” restlessness, tremors, abdominal cramping, muscle aches, and craving for the drug.

 

Addiction consists of drug craving, compulsive use, and strong tendency to relapse after withdrawal.

 

Toxicity

At some unspecified point, the side effects of opioid use turn into toxicity. The typical side effects are small pupils, loss of appetite, sleep disturbances, and constipation. As side effects become toxicity, blood pressure may fall, stupor develops (sometimes to the point of unresponsiveness), and respirations slow (sometimes to the point of stopping).

 

Toxicity Treatment

Clearly, respiratory insufficiency is an emergency, as inadequate respirations lead to death or irreversible brain damage in only a few minutes. The treatment is to begin artificial respiration and reverse the opioid.

 

The principal opioid reversal agent is naloxone. At one time, this medication was supplied only in glass ampoules for professional use. The ampoules had to be broken open and the medication drawn into a syringe and subsequently injected into a flowing IV line. Administration systems for this medication have been redesigned to be more user-friendly so that the lay public can utilize them in an emergency situation.

 

In 2014, the FDA approved a naloxone autoinjector for home use by family members and caregivers. The device is designed for use on the outer thigh, through clothing. It has no visible needle, contains two doses of naloxone, and comes with voice prompts that begin playing as soon as it is removed from the box. A trainer mock-up allows the potential user to acquire the “feel” of the device without actually administering any medication.

 

In 2015, the FDA approved naloxone for intranasal spray. This permits bystander rescue by simply spraying half the naloxone charge into each nostril of an unresponsive patient.

 

A shortcoming of these two rescue technologies is the short duration of the reversal medication, naloxone. The reversal dissipates quickly and the respiratory depressant effect of the opioid reestablishes itself. The temporary reversal of the opioid requires subsequent transportation to the emergency department (ED) to preclude subsequent respiratory re-arrest. The newly revived patient sometimes refuses such transportation for fear of being put into a situation where the craved opioids are unavailable.

 

Addiction Treatment

 

Addiction treatment is a different matter from toxicity treatment. Toxicity treatment involves the emergency treatment of respiratory arrest. Addiction treatment is less emergent but more complicated.

 

The goals of addiction treatment are

  1. Ameliorating withdrawal symptoms
  2. Reducing cravings
  3. Reducing needle sharing and promiscuous behavior leading to the spread of other diseases as HIV and hepatitis
  4. Reducing relapse rates 
  5. Reducing drug diversionMaintaining longer abstinence

 

  • The general outline of addiction treatment is
    1. Switch the patient from short-acting opioids to longer-acting opioids. This reduces the “rush” of the rapid opioid onset and the “withdrawal” of the rapid opioid offset. It also reduces target drug craving and replaces the more dangerous target drugs with drugs having a broader margin of safety.
    2. Switch the patient to opioids of a different form, such as subcutaneous implants, that cannot easily be diverted to street sale.
    3. Switch the patient to oral opioids combined with opioid reversal agents that are effective intravenously but not orally. This reduces the risk of these drugs being diverted to intravenous use for the attainment of a “rush.”  
    4. Slowly taper the substituted opioid to reduce withdrawal and craving.
    5. Add adjuvants as clonidine and COMT inhibitors to prolong abstinence and reduce cravings.
    6. Reduce stress with propranolol to reduce the risk of relapse.
    7. Begin cognitive behavioral therapy to help identify and avoid situations conducive to relapse.
    8. Recognize that detoxification alone is not sufficient to effect long-term abstinence.
    9. Institute group therapy to help minimize the social stigma of having lost the ability to control one’s behavior with respect to a substance.
  • Things You Need to Know

    1. Even after prolonged recovery, it is never possible to use the target substance in a controlled manner.
    2. Treatment alone is hardly ever successful without rehabilitation.
    3. Will power is not enough.
    4. Relapse during recovery is not unusual and could be a valuable experience.
    5. Dysphoria, or unpleasant mood effect after abstinence, is the main reason for relapse.
    6. Even after long abstinence, it is necessary to avoid high-risk situations.
    7. A major aid to abstinence is Narcotics Anonymous.
    8. Friends and family must be compassionate but assertive and resist the urge to engage in enabling behavior with the patient.
    9. Finally, remember that addiction is a disease, not a character flaw or moral shortcoming. Addicted patients deserve the attention and respect of the healthcare delivery system.
  • Sources

  • The primary reference here is Dixon and Xiong, which provides much useful information, but is written at a technical level. I have reformulated some of the information to make it more available to the general public.

     

    Dixon, D., DO, & Xiong, G., MD. (2017, May 03). Opioid Abuse. Retrieved May 31, 2017, from http://emedicine.medscape.com/article/287790-overview

     

    Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014. MMWR. Morbidity and Mortality Weekly Report,64(50-51), 1378-1382. doi:10.15585/mmwr.mm6450a3

 

 Thomas Falasca, DO

This video is a narcotics overdose case from Saint Paul's Emergency Room in British Columbia

Narcotics Addiction and Overdose

The Erie County Medical Society shares the deep concern and sadness of the community locally and broadly over the rec ...See More


Narcotics Addiction and Overdose

Narcotics Addiction and Overdose

The Erie County Medical Society shares the deep concern and sadness of the community locally and broadly over the recent surge in narcotics related deaths. This surge is superimposed on the steadily climbing number of such deaths over recent years.

 

One factor contributing to the recent increase may be the emergence into availability of heroin forms that can be snorted or smoked instead of injected intravenously. First, this presents a less repulsive method of administration than intravenous injection. Second, it caters to the mistaken illusion that the drug is less dangerous when snorted or smoked than when injected.

 

While no “magic bullet” currently exists, progress toward the solution of the problem begins with understanding. Accordingly, we present this information to enhance understanding of the disease.

 

Scope of Problem

The year 2014 witnessed 47,055 drug overdose deaths in the US compared with 32,675 traffic accident deaths. These data are from the US Centers for Disease Control and the US Department of Transportation, respectively. Meanwhile,

here in Erie County, Pennsylvania, drug-related deaths rose 61% from 59 in 2015 to 95 in 2016.

 

Fentanyl has become a major factor in drug overdose deaths. Fentanyl is either legally manufactured but illegally obtained, or illegally manufactured and obtained. Fentanyl-related deaths increased 80% in 2014.

 

Internationally, the US is hit especially hard by opioid abuse. Americans constitute less than 5% of the world’s population, but consume 80% of the world’s opioids. Americans consume 99% of the world’s supply of hydrocodone, the active ingredient of VicodinTM. Finally, Americans consume two-thirds of the world’s illegal drugs.

 

Causes of Opioid Dependence

Opioid dependence is a disorder with pharmacologic, genetic, social, and psychodynamic causes. It is a true medical problem, not a moral failing or personality shortcoming.

 

Pharmacologic factors weigh heavily in opioid addiction. Certainly, drugs other than opioids have significant addiction potential; but, opioids, with their rapid development of physical dependence and their severe protracted abstinence syndrome, make abstinence especially difficult.

 

Genetic factors also contribute. There is a high degree of heritable vulnerability for opioid dependence. Gene polymorphisms for receptors for dopamine, serotonin, and other neurotransmitters also seem associated with opioid dependence vulnerability. Perhaps future medications can be designed to take advantage of these genetic factors.

 

Psychopathologic diagnoses seem to factor in. Preexisting mental health diagnoses seem to increase risk for long-term opioid use among adolescents with chronic pain.

 

Social factors have notable influence as indicated by the high rate of drug use in areas with poor parental functioning, high crime, and high unemployment.

 

Signs of Opioid Abuse

Opioid abuse is evidenced by any two of the following signs occurring within a 12-month period.

  1. Taking larger amounts than intended.
  2. Unsuccessful efforts to reduce use.
  3. Spending substantial time and activity related to opioids.
  4. Craving opioids.
  5. Failure to fulfill obligations of home, work, or school.
  6. Continuing opioid use despite opioid-related problems.
  7. Relinquishing social and other interests because of opioid use.
  8. Continuing opioid-related activities when those activities present a physical hazard.
  9. Tolerance and withdrawal, except when the opioids are used exclusively for medical reasons and under close medical supervision.

Tolerance, Withdrawal, and Addiction

Tolerance, withdrawal, and addiction are three separate entities. They are not just different ways of saying “addiction.”

 

Tolerance is the requirement for increased doses of the drug to achieve the same effect. Thus, increasing doses of the drug are needed to induce the same euphoria.

 

Withdrawal is the occurrence of symptoms on abrupt cessation of the drug. The onset and duration vary with the drug. Heroin withdrawal symptoms tend to peak in 36-72 hours and last 7-14 days.

 

The symptoms of withdrawal are typically diarrhea, runny nose, nausea, “gooseflesh,” restlessness, tremors, abdominal cramping, muscle aches, and craving for the drug.

 

Addiction consists of drug craving, compulsive use, and strong tendency to relapse after withdrawal.

 

Toxicity

At some unspecified point, the side effects of opioid use turn into toxicity. The typical side effects are small pupils, loss of appetite, sleep disturbances, and constipation. As side effects become toxicity, blood pressure may fall, stupor develops (sometimes to the point of unresponsiveness), and respirations slow (sometimes to the point of stopping).

 

Toxicity Treatment

Clearly, respiratory insufficiency is an emergency, as inadequate respirations lead to death or irreversible brain damage in only a few minutes. The treatment is to begin artificial respiration and reverse the opioid.

 

The principal opioid reversal agent is naloxone. At one time, this medication was supplied only in glass ampoules for professional use. The ampoules had to be broken open and the medication drawn into a syringe and subsequently injected into a flowing IV line. Administration systems for this medication have been redesigned to be more user-friendly so that the lay public can utilize them in an emergency situation.

 

In 2014, the FDA approved a naloxone autoinjector for home use by family members and caregivers. The device is designed for use on the outer thigh, through clothing. It has no visible needle, contains two doses of naloxone, and comes with voice prompts that begin playing as soon as it is removed from the box. A trainer mock-up allows the potential user to acquire the “feel” of the device without actually administering any medication.

 

In 2015, the FDA approved naloxone for intranasal spray. This permits bystander rescue by simply spraying half the naloxone charge into each nostril of an unresponsive patient.

 

A shortcoming of these two rescue technologies is the short duration of the reversal medication, naloxone. The reversal dissipates quickly and the respiratory depressant effect of the opioid reestablishes itself. The temporary reversal of the opioid requires subsequent transportation to the emergency department (ED) to preclude subsequent respiratory re-arrest. The newly revived patient sometimes refuses such transportation for fear of being put into a situation where the craved opioids are unavailable.

 

Addiction Treatment

 

Addiction treatment is a different matter from toxicity treatment. Toxicity treatment involves the emergency treatment of respiratory arrest. Addiction treatment is less emergent but more complicated.

 

The goals of addiction treatment are

  1. Ameliorating withdrawal symptoms
  2. Reducing cravings
  3. Reducing needle sharing and promiscuous behavior leading to the spread of other diseases as HIV and hepatitis
  4. Reducing relapse rates 
  5. Reducing drug diversionMaintaining longer abstinence

 

 

 Thomas Falasca, DO

This video is a narcotics overdose case from Saint Paul's Emergency Room in British Columbia

Secondhand Smoke

9-12 million US children younger than 5 years of age may be exposed to secondhand smoke in the home.

...See More

Secondhand Smoke

Dangers of Secondhand Smoke

 

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Scope of Problem

Smokers in the US consume over 500 billion cigarettes annually. Secondhand smoke, known technically as environmental tobacco smoke (ETS) is increasingly recognized as a health hazard to children and adults.

 

Danger to Children

9-12 million US children younger than 5 years of age may be exposed to secondhand smoke in the home. Secondhand smoke is estimated to cause an annual increase of 150,000-300,000 cases of lower respiratory tract infections in children younger than 18 months of age. It also increases the incidence of fluid in the middle ear, known as serous otitis media. Two-week old children of mothers who smoke have been observed to have diminished lung elasticity.

 

The Centers for Disease Control (CDC) estimates that maternal smoking is responsible for 700 annual cases of sudden infant death syndrome (SDS).  Further, secondhand smoke is a risk factor for the development asthma in children and increases the severity of asthma in children already afflicted with the problem.

 

Danger to Adults

Chronic obstructive pulmonary disease (COPD) in middle-aged adults seems to be correlated with their mothers’ smoking during the years of raising them. Further, an additional 3,000 cases annually of lung cancer in adults are associated with exposure to secondhand smoke. This association is strongest with small-cell lung cancer.

 

Smoke Avoidance

Smoke avoidance in public places is easier now that laws prohibit or restrict smoking in many public places. Consequently, the greatest danger of exposure to secondhand smoke occurs in the home and in personal vehicles.

 

There is little ambiguity about what constitutes exposure to smoke in a personal vehicle. However, what constitutes exposure to smoke in the home is sometimes misunderstood.

 

It is imperative that no smoking should take place in the home, whether or not the child is present at the time. Smoking cannot simply be restricted to a portion of the home. Neither can an air filtration system in the home be relied upon to eliminate exposure to secondhand smoke.

 

Addiction

Since smoke, once present, is difficult to contain, the best solution is liberation from smoking.

 

This is easier said than done, and there are good reasons. Nicotine acts on at least two areas of the brain. First, it stimulates the cerebral cortex causing a sense of increased alertness. Second, it stimulates the limbic system activating the reward center. Finally, it differs from other substances with these effects in that it does not excessively stimulate the peripheral nervous system. While other such substances cause tremors and anxiety, nicotine seems not to present these problems.

 

Nevertheless, there is help in dealing with this addiction.

 

Non-medical Aids

While most former smokers have quit independently, this does not work for everyone. Fortunately, there are many programs available. These include group support, hypnosis and self-hypnosis, behavioral aversive therapy, and gradual withdrawal.

 

One of the most underrated aids to tobacco liberation is repeated effort.

Few endeavors in life meet with unqualified success on the first attempt. Consequently, an attempt at smoking liberation that is followed by a return to smoking should not be viewed as a failure, but as a temporary success laying the groundwork for future endeavors.

 

Medical Aids

The addition of medical aids doubles the success rate in liberation from smoking. Of course, discussion with your doctor is always recommended as medical aids can have side effects as well as desired effects. The most important medical aids for liberation from smoking are nicotine patch, nicotine gum or lozenge, bupropion, and varenicline.

 

Nicotine patches slowly liberate nicotine to ameliorate withdrawal symptoms. Some of these are worn during daytime hours only in order to reduce the potential for sleep disturbance. Other patch systems are worn 24 hours a day and work for people who awaken craving a cigarette. Nicotine patches are slow onset and slow offset, requiring about 4 hours for blood levels of nicotine to rise or fall following application or removal.

 

Nicotine gums and lozenges, along with sprays and inhalers, are used intermittently and increase blood levels of nicotine within about 15 minutes of administration.

 

Bupropion is an antidepressant that is of some help in liberation from smoking. It may take 6-7 days to reach steady-state blood levels; consequently, it may be started before discontinuing smoking.

 

Varenicline attaches to the same sites of action as nicotine. Consequently, it both provides some stimulation to those sites and reduces the action of nicotine at those sites. It is considered by some to be the most effective of the medical aids.

 

Summary

Many aids, both non-medical and medical, are available to achieve liberation from smoking. These aids, in addition to effective smoke avoidance can sharply reduce the harmful effects of smoke upon the smoker as well as upon the adults and children in proximity.

 

Sources

Pharmacological interventions for smoking cessation/ an overview and network meta-analysis - Cahill 

Nicotine receptor partial agonists for smoking cessation - Cahill - 2016 - The Cochrane Library - Wi

Passive Smoking and Lung Disease.  WebMD.  Author: Timothy D Murphy, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP 

 

Thomas Falasca, DO

Watch this fun and informative video on secondhand smoke from the Canadian Government!  

Shingles ~ What You Need to Know

Shingles is a disease that eventuates in a great deal of pain, suffering, and disability. Further, treatments are onl ...See More


Shingles ~ What You Need to Know

What Is Shingles?

Shingles is the return of an infection long forgotten from childhood. Current medical thinking is that when a childhood case of chickenpox resolves, the virus causing it does not vanish. Instead, it migrates from the skin, along the path of nerves, to a collection of nerve cells called a ganglion, which resides close to the spinal cord or brain. Then, when the immunity containing the virus in the ganglia diminishes, the virus reemerges along the distribution of the nerve causing an outbreak.

 

What Are the Symptoms?

Symptoms usually begin with an unusual feeling in a broad localized area called a dermatome. The feeling can be a sensation of tingling, itching, or, more usually, pain. Thereafter the area may become reddened and very slightly swollen. Small blisters then form in the area and the sensation may change to burning, throbbing, or stabbing. The blisters may enlarge and coalesce and the contained fluid changes from clear to cloudy. The blisters then rupture, scab over, and gradually resolve.

 

Often, this ends the episode entirely; but, sometimes there are sequelae. The most frequent of these are scars in the area and pain long after the resolution of the blisters.

 

Who Gets Shingles?

Shingles can afflict anyone who has previously been infected with chickenpox. However, certain risk factors substantially increase the possibility of being afflicted. Common risk factors include immunosuppressive therapy either for autoimmune diseases or for transplant rejection prevention, and TNF (Tumor Necrosis Factor) inhibitors such as are used in the treatment of rheumatoid disease.

 

Diseases that pose risk factors for shingles are inflammatory bowel disease, rheumatoid arthritis, chronic obstructive pulmonary disease, asthma, chronic kidney disease, lymphoma, multiple myeloma, HIV, acute lymphocytic leukemia, and depression.

 

However, the most common risk factor is age. The probability of shingles increases with age and reaches 50% in those over 85 years old. Only 10% of shingles patients are younger than 20 years old.

 

Incidence of shingles is also reported to be higher in whites by 75% and in females. 

 

Since the introduction of widespread chickenpox vaccination in 1995, the incidence of shingles may decrease as the vaccinated population ages.

 

Can You Get Shingles Without Ever Having Been Infected with Chickenpox?

Technically, no. But, practically, one may forget ever having had chickenpox, especially if the case was mild. The US Centers for Disease Control (CDC) estimates that 99.5% of those born in the US and over 40 years of age have been infected with chicken pox.

 

Additionally, shingles is possible in persons who have been exposed to the attenuated virus by chicken pox vaccination. However, the likelihood of shingles here is much less than in those exposed to the wild virus in community- acquired chickenpox.

 

Finally, children have gotten shingles because their mother contracted chickenpox when she was pregnant with them.

 

Can Shingles Recur?

Yes, shingles recurs in about 4% of shingles sufferers.

 

What Are the Consequences of Shingles?

The most common complication of shingles is post-herpetic neuralgia (PHN). It is a continuation, or sometimes reappearance after a brief respite, of the pain that accompanies the shingles episode. Occasionally the quality of the pain or discomfort changes somewhat. PHN may last for months or years. Like shingles itself, PHN also increases in likelihood with age. 50% of shingles victims over the age of 60 develop PHN.

 

A less serious complication from a shingles episode is localized bacterial infection from scratching the skin lesions. More serious but rare complications are meningo-encephalitis, ischemic stroke, spread of shingles far beyond the original restricted distribution, paralysis, and blindness, deafness, or facial weakness from shingles of the face.

 

Is There a Test for Shingles?

Although laboratory tests for shingles virus exist, they are generally used only in unusual circumstances as in cases in which the typical symptoms do not appear or cases in which an early recognition of the attack is needed because of a patient’s low immunity.

 

The physician typically diagnoses shingles from the appearance of the involved skin and the history provided by the patient.

 

What Is the Treatment for Shingles?

 

The most specific treatment for shingles is one of the antiviral drugs. These are most effective when begun within 72 hours of appearance of the rash, but they have some effect even when given later. These drugs can both shorten and soften the attack and reduce the risk of subsequent PHN.

 

Nonspecifically, there are numerous options for the treatment of the pain associated with shingles and PHN. These involve analgesics such as ibuprofen or sometimes stronger, anti-seizure medications, antidepressants, and sometimes corticosteroids. Nerve injection is also used. Sometimes a capsaicin cream or lidocaine path is helpful.

 

Of course, the best way to approach a problem is not to have it, so let us go on to discuss prevention.

 

Shingles Prevention - Chicken Pox Vaccination

 

Since shingles is reactivation of a childhood chickenpox infection, an effective approach is the two-dose vaccination against chickenpox. It will prevent chickenpox in about 90% of those vaccinated and will shorten and reduce the severity of the chickenpox infection in the rest. By herd immunity, it also reduces the community frequency of chickenpox, thus protecting those who cannot be vaccinated.

 

Shingles Prevention - Shingles Vaccination

 

Those who have already had chickenpox can also be vaccinated but with the single-dose shingles vaccine. Because the incidence of shingles, and, in those afflicted by shingles, the incidence of PHN increases substantially with age, the CDC recommends shingles vaccination for all those 60 years of age and older. The Infectious Disease Society of America is more aggressive and recommends shingles vaccination for those 50 years of age and older.

 

The shingles vaccine is not perfect, but it reduces the incidence of shingles by 70% in those aged 50-59, by 64% in those aged 60-69, and by a somewhat lesser amount in those 70 years of age and older.

 

Testing for a previous chicken pox infection is not required for shingles vaccination. Even those with a past attack of shingles can be vaccinated, since a subsequent attack of shingles is still possible. Of course, the shingles vaccination is not a treatment for a current attack of shingles or PHN.

 

Since the virus in the shingles vaccine is severely weakened, but still live, it is contraindicated in pregnancy and in those with immunodeficiency states, leukemia, lymphoma, HIV, tuberculosis, or those on immunosuppressive therapy, chemotherapy, or radiation therapy.

 

Conclusion

 

Shingles is a disease that eventuates in a great deal of pain, suffering, and disability. Further, treatments are only partially effective in many and ineffective in some. We are fortunate to live at a time when there are vaccines to substantially reduce the frequency and severity of chickenpox, shingles, and post-herpetic neuralgia. All who are candidates for these vaccinations are well advised to take advantage of them to keep our lives and senior years free of disability and pain.

 

Thomas Falasca, DO

 

More on shingles in this informative video!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Osteoporosis

Your best defense against osteoporosis is awareness.  This includes preventive measures, risk factors, consequen ...See More


Osteoporosis

What Is Osteoporosis?

 

Osteoporosis is what it sounds like, porous bone.  

 

Microscopically, bone appears as a network of structural supports running in all directions enclosing a vast number of spaces.  The multidirectional structures provide strength in all directions.  The spaces provide lightness as well as compartments for blood-producing bone marrow.  

 

This structural network is the subject of continuous activity, in which bone is being resorbed and new bone is being laid down.  But when bone resorption outpaces bone construction, the spaces enlarge and coalesce while the network structures thin or disappear.  The density gradually decreases and the bone becomes fragile and subject to fracture.  Moderate decreased density and increased fragility is known as osteopenia.  Severe decreased density and increased fragility is known as osteoporosis.  The bones most frequently fractured are the spinal vertebrae, the hip, and the wrist.

 

Who Gets Osteoporosis?

 

An estimated 10 million Americans have osteoporosis and an additional 43 million have osteopenia.  

 

Women are four times more likely than men to develop osteoporosis.  A great deal of this increased propensity occurs after menopause.

 

Frequency and site of osteoporotic fracture is related to age.

  • The frequency of osteoporotic fracture begins substantially increasing after the age of 50. 
  • Wrist fractures predominate in the age range 50-59 years.
  • Spinal vertebral fractures predominate in the age range 60-69 years.
  • Hip fractures predominate in the age range 70-79 years.

 

Asians and white people, especially those of northern European descent, are more likely to develop osteopenia and osteoporosis.

 

Other risk factors increasing the probability of osteoporosis are

  • Family history of osteoporosis.
  • Thin build or small stature.
  • Amenorrhea.
  • Late menarche.
  • Early menopause.
  • Inactivity or immobilization.
  • Some medications, including anticonvulsants, systemic steroids, thyroid supplements, heparin, chemotherapeutic agents, anti-psychotic drugs, and insulin.
  • Tobacco or alcohol use.
  • Androgen or estrogen deficiency.
  • Calcium deficiency.
  • Dowager hump.
  • Diseases such as hyperthyroidism, hyperparathyroidism, celiac disease, malabsorption, inflammatory bowel disease, rheumatoid disease, leukemia, heart failure, multiple sclerosis, and sarcoidosis.

 

What Are the Consequences of Osteoporosis?

 

The major consequence of osteoporosis is osteoporotic fracture.  These fractures can be painful, unsightly, debilitating, and lead to difficulties of digestion, breathing, and mobility as well as more fractures. Further, they impact life expectancy.

 

While some spinal vertebral compression fractures may be painless, other fractures of the spinal vertebrae and other bones can be quite painful, both acutely and long-term.

 

Spinal vertebral compression fractures lead to the infamous and unsightly dowager’s hump.  

 

The forward bending produced by the spinal vertebral compression fractures impedes lung expansion and compresses the abdominal contents, thus restricting gastric capacity and impacting nutrition.

 

The forward-bending posture effected by the spinal compressions impedes balance and gait. This leads to falls and additional fractures.

 

Following hip fracture, only one-third of patients return to their previous level of functioning and one-fifth require long-term nursing home care.

 

Persons having experienced a hip fracture have twice the likelihood of another fracture as persons without fracture.

 

Vertebral fracture increases the five-year mortality risk by 15%.

 

Hip fracture is associated with a one-year mortality increase of 20%.

 

What Are the Signs of Osteoporosis?

 

Some signs of osteoporosis are shortening and curvature of the spine frequently manifested as a forward bending posture.  But osteoporosis is often a silent disease that doesn’t manifest itself until an osteoporotic fracture occurs.

 

What Are the Available Tests?

 

Because osteoporosis is largely a silent disease, testing is important to determine if osteoporosis is present or if bones are losing density to a serious degree.  Several testing modalities are available.

 

DEXA scanning is the current standard for evaluating bone mineral density and consequent fracture risk. It is used to calculate bone mineral density at the lumbar spine, hip, and upper thigh.  

 

Peripheral DEXA scanning is used to evaluate bone mineral density at the wrist.  It is used to evaluate patients at very low fracture risk. Its ability to predict spinal vertebral fracture is lower than DEXA done at the lumbar spine.

 

QCT scanning is used to measure bone mineral density in the lumbar spine.  It is somewhat more sensitive than DEXA but requires a higher radiation dose. Currently, only about 5% of all bone mineral density evaluations are done by QCT.

 

QUS differs from DEXA, peripheral DEXA, and QCT in that the DEXAs and QCT are x-ray modalities, while QUS is an ultrasound modality, done at the heel, and achieving measurements by means of sound waves.  Although low-cost and portable, QUS does not have the accuracy of the two DEXA scans or QCT. Additionally, QUS is not used for tracking skeletal changes over time or monitoring response to treatment.

 

Who Should Be Tested, and When?

 

The National Osteoporosis Foundation (NOF) recommends bone mineral density testing for all women 65 years of age or older and all men 70 years of age or older.  It further recommends testing for all post-menopausal women with risk factors and all men over 50 years of age with risk factors, such as those indicated above.

 

For patients diagnosed with osteoporosis, the NOF recommends re-testing 1-2 years after beginning treatment and at 2-year intervals thereafter.

 

For those without major risk factors and who test in the normal range, the NOF states only that longer re-test intervals are acceptable.

 

The best advice is to consult your physician about the need for bone mineral testing, the type of testing appropriate for you, and the appropriate testing interval. Your physician is in the best position to tailor the guidelines to your specific health situation.

 

Treatment Choices

 

Your physician now has more treatment choices than ever to offer those affected by osteoporosis. Bisphosphonates can inhibit bone resorption.  Additionally, there are estrogens, calcitonin, parathyroid hormone type drugs, selective estrogen receptor modulators, monoclonal antibodies, calcium salts, and vitamin D. Finally, there are braces to redistribute spinal forces and even interventional techniques such as kyphoplasty.

 

Prevention

 

The best way to deal with a problem is not to have it!  Accordingly, prevention is paramount in any approach to osteoporosis.  Of course, preventive measures cannot guarantee that osteoporosis will not occur, but these measures greatly reduce the chances. Imperfect prevention is certainly better than no prevention!  

 

In osteoporosis prevention, here are some key elements:

  • Stop smoking.
  • Moderate alcohol consumption.
  • Engage in weight-bearing exercise. 
  • Ensure adequate calcium and vitamin D intake.
  • Consult with your doctor about periodically evaluating bone mineral density.                                                                                                                          

 

Conclusion

 

Your best defense against osteoporosis is awareness.  This includes preventive measures, risk factors, consequences, and the availability of bone mineral density testing and treatment options.  Such awareness can enable you to avoid disfigurement, disability, and even life-shortening consequences.

 

Thomas Falasca, DO                                                       

     

SOURCES:

 

National Osteoporosis Foundation         nof.org
NIH Senior Health                                   nihseniorhealth.gov      
American College of Rheumatology       rheumatology.org

Endocrine Society                                   hormone.org

                                                                                                                             

 

 

 

 

Watch this fun and informative video from the Endocrine Society!

 

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