tag:theconversation.com,2011:/africa/topics/medication-1014/articlesMedication – The Conversation2024-03-20T22:21:47Ztag:theconversation.com,2011:article/2262232024-03-20T22:21:47Z2024-03-20T22:21:47ZElon Musk says ketamine can get you out of a ‘negative frame of mind’. What does the research say?<p>X owner Elon Musk <a href="https://thenightly.com.au/business/cnbc-elon-musk-suggests-his-prescription-ketamine-use-is-good-for-investors-c-14000709?utm_source=sendgrid&utm_medium=email">recently described</a> using small amounts of ketamine “once every other week” to manage the “chemical tides” that cause his depression. He says it’s helpful to get out of a “negative frame of mind”.</p>
<p>This has caused a range of reactions in the media, including on X (formerly Twitter), from strong support for Musk’s choice of treatment, to allegations he has a drug problem.</p>
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<p>But what exactly is ketamine? And what is its role in the treatment of depression?</p>
<h2>It was first used as an anaesthetic</h2>
<p>Ketamine is a <a href="https://doi.org/10.3389/fnhum.2016.00612">dissociative anaesthetic</a> used in surgery and to relieve pain. </p>
<p>At certain doses, people are awake but are disconnected from their bodies. This makes it useful for paramedics, for example, who can continue to talk to injured patients while the drug blocks pain but without affecting the person’s breathing or blood flow. </p>
<p>Ketamine is also used to sedate animals in veterinary practice. </p>
<p>Ketamine is a mixture of two molecules, usually referred to a S-Ketamine and R-Ketamine.</p>
<p>S-Ketamine, or esketamine, is stronger than R-Ketamine and was approved in 2019 in the United States under the drug name Spravato for serious and long-term <a href="https://doi.org/10.1080/14740338.2022.2066651">depression</a> that has not responded to at least two other types of treatments.</p>
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Read more:
<a href="https://theconversation.com/fda-approves-promising-new-drug-called-esketamine-for-treatment-resistant-depression-111966">FDA approves promising new drug, called esketamine, for treatment-resistant depression</a>
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<p>Ketamine is thought to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717708/">change chemicals in the brain</a> that affect mood.
While the exact way ketamine works on the brain is not known, scientists think it changes the amount of the neurotransmitter glutamate and therefore changes symptoms of <a href="https://doi.org/10.3389/fnhum.2016.00612">depression</a>. </p>
<h2>How was it developed?</h2>
<p>Ketamine was first synthesised by chemists at the Parke Davis pharmaceutical company in Michigan in the United States as an anaesthetic. It was tested on a group of prisoners at Jackson Prison in Michigan in 1964 and found to be fast acting with <a href="https://pubs.asahq.org/anesthesiology/article/113/3/678/10426/Taming-the-Ketamine-Tiger">few side effects</a>.</p>
<p>The US Food and Drug Administration <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126726/">approved</a> ketamine as a general anaesthetic in 1970. It is now on the World Health Organization’s core list of essential medicines for health systems worldwide as an <a href="https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02">anaesthetic drug</a>. </p>
<p>In 1994, following patient reports of improved depression symptoms after surgery where ketamine was used as the anaesthetic, researchers began studying the effects of low doses of ketamine on <a href="https://pubmed.ncbi.nlm.nih.gov/8122957/">depression</a>. </p>
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<img alt="Depressed woman looks down" src="https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Researchers have been investigating ketamine for depression for 30 years.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-attractive-latin-woman-lying-home-1147331690">SB Arts Media/Shutterstock</a></span>
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<p>The first clinical trial results were <a href="https://www.biologicalpsychiatryjournal.com/article/S0006-3223(99)00230-9/abstract">published in 2000</a>. In the trial, seven people were given either intravenous ketamine or a salt solution over two days. Like the earlier case studies, ketamine was found to reduce symptoms of depression quickly, often within hours and the effects lasted up to seven days. </p>
<p>Over the past 20 years, researchers have studied the effects of ketamine on <a href="https://doi.org/10.1016/j.neuropharm.2022.109305">treatment resistant depression, bipolar disorder</a>, <a href="https://theconversation.com/ketamine-can-rapidly-reduce-symptoms-of-ptsd-and-depression-new-study-finds-216077">post-traumatic sress disorder</a> <a href="https://pubmed.ncbi.nlm.nih.gov/34199023/">obsessive-compulsive disorder, eating disorders and for reducing substance use</a>, with generally positive results. </p>
<p>One study in a <a href="https://www.sciencedirect.com/science/article/pii/S0165032723006110">community clinic</a> providing ketamine intravenous therapy for depression and anxiety found the majority of patients reported improved depression symptoms eight weeks after starting regular treatment.</p>
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Read more:
<a href="https://theconversation.com/ketamine-injections-for-depression-a-new-study-shows-promise-but-its-one-of-many-options-209591">Ketamine injections for depression? A new study shows promise, but it's one of many options</a>
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<p>While this might sound like a lot of research, it’s not. A <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00304-8/fulltext">recent review</a> of randomised controlled trials conducted up to April 2023 looking at the effects of ketamine for treating depression found only 49 studies involving a total of 3,299 patients worldwide. In comparison, in 2021 alone, there were 1,489 studies being conducted on <a href="https://www.centerwatch.com/articles/25599-oncology-trials-outpacing-rest-of-the-field-in-complexity-and-duration-study-shows#:%7E:text=The%20number%20of%20investigational%20drugs,genetic%20sequencing%20technologies%2C%20CSDD%20says.">cancer drugs</a>. </p>
<h2>Is ketamine prescribed in Australia?</h2>
<p>Even though the research results on ketamine’s effectiveness are encouraging, scientists still don’t really know how it works. That’s why it’s not readily available from GPs in Australia as a standard depression treatment. Instead, ketamine is mostly used in specialised clinics and research centres. </p>
<p>However, the clinical use of ketamine is increasing. <a href="https://www.tga.gov.au/sites/default/files/auspar-esketamine-hydrochloride-210507-pi.pdf">Spravato nasal spray</a> was <a href="https://www.tga.gov.au/resources/auspmd/spravato">approved</a> by the Australian Therapuetic Goods Administration (TGA) in 2021. It must be administered under the <a href="https://adf.org.au/insights/ketamine-treat-depression/">direct supervision</a> of a health-care professional, usually a psychiatrist. </p>
<p>Spravato <a href="https://www.tga.gov.au/resources/auspmd/spravato">dosage</a> and frequency varies for each person. People usually start with three to six doses over several weeks to see how it works, moving to fortnightly treatment as a maintenance dose. The nasal spray <a href="https://www.unsw.edu.au/newsroom/news/2023/10/why-low-cost-ketamine-is-still-inaccessible-to-many-with-severe-">costs</a> <a href="https://www.medicalrepublic.com.au/esketamine-snubbed-by-pbac-again/17835">between A$600 and $900</a> per dose, which will significantly limit many people’s access to the drug. </p>
<p>Ketamine can be prescribed “off-label” by GPs in Australia who can prescribe schedule 8 drugs. This means it is up to the GP to assess the person and their medication needs. But <a href="https://www.medicalrepublic.com.au/caution-as-esketamine-approved-for-depression/4975#:%7E:text=GPs%20and%20other%20clinicians%20can,8%20drug%20poses%20serious%20risks.">experts in the drug</a> recommend caution because of the lack of research into negative side-effects and longer-term effects. </p>
<h2>What about its illicit use?</h2>
<p>Concern about use and misuse of ketamine is heightened by highly publicised deaths connected to the <a href="https://www.pbs.org/newshour/arts/autopsy-report-shows-actor-matthew-perry-died-from-effects-of-ketamine">drug</a>. </p>
<p>Ketamine has been used as a recreational drug since the 1970s. People report it makes them feel euphoric, trance-like, floating and dreamy. However, the amounts used recreationally are typically higher than those used <a href="https://pubmed.ncbi.nlm.nih.gov/16529526/">to treat depression</a>. </p>
<p>Information about deaths due to ketamine is limited. Those that are reported are <a href="https://journals.sagepub.com/doi/10.1177/02698811211021588">due to accidents or ketamine combined with other drugs</a>. No deaths have been reported in <a href="https://pubmed.ncbi.nlm.nih.gov/36410032/">treatment settings</a>.</p>
<h2>Reducing stigma</h2>
<p>Depression is the third leading cause of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717708/">disability worldwide</a> and effective treatments are needed. </p>
<p>Seeking medical advice about treatment for depression is wiser than taking Musk’s advice on <a href="https://www.washingtonpost.com/wellness/2022/05/04/wellbutrin-elon-musk-antidepressant/">which drugs to use</a>. </p>
<p>However, Musk’s public discussion of his mental health challenges and experiences of treatment has the potential to reduce stigma around depression and help-seeking for mental health conditions. </p>
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Read more:
<a href="https://theconversation.com/ketamine-can-rapidly-reduce-symptoms-of-ptsd-and-depression-new-study-finds-216077">Ketamine can rapidly reduce symptoms of PTSD and depression, new study finds</a>
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<p><em>Clarification: this article previously referred to a systematic review looking at oral ketamine to treat depression. The article has been updated to instead cite a review that encompasses other routes of administration as well, such as intravenous and intranasal ketamine.</em></p><img src="https://counter.theconversation.com/content/226223/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julaine Allan receives funding from the Australian Government to conduct research on mental health and substance use interventions, treatments and outcomes. </span></em></p>What exactly is ketamine and what is its role in the treatment of depression?Julaine Allan, Associate Professor, Mental Health and Addiction, Rural Health Research Institute, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2256802024-03-14T19:25:21Z2024-03-14T19:25:21ZCould ADHD drugs reduce the risk of early death? Unpacking the findings from a new Swedish study<figure><img src="https://images.theconversation.com/files/581833/original/file-20240314-23-yi6tr0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8192%2C5457&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-beautiful-woman-taking-tablet-glass-2177446101">Dragana Gordic/Shutterstock</a></span></figcaption></figure><p>Attention-deficit hyperactivity disorder (ADHD) can have a considerable impact on the day-to-day functioning and overall wellbeing of people affected. It causes a variety of symptoms including difficulty focusing, impulsivity and hyperactivity. </p>
<p>For many, a diagnosis of ADHD, whether in childhood or adulthood, is life changing. It means finally having an explanation for these challenges, and opens up the opportunity for treatment, including medication.</p>
<p>Although <a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">ADHD medications</a> can cause side effects, they generally improve symptoms for people with the disorder, and thereby can significantly boost quality of life.</p>
<p>Now a <a href="https://jamanetwork.com/journals/jama/fullarticle/2816084">new study</a> has found being treated for ADHD with medication reduces the risk of early death for people with the disorder. But what can we make of these findings?</p>
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<h2>A large study from Sweden</h2>
<p>The study, published this week in JAMA (the prestigious journal of the American Medical Association), was a large cohort study of 148,578 people diagnosed with ADHD in Sweden. It included both adults and children.</p>
<p>In a cohort study, a group of people who share a common characteristic (in this case a diagnosis of ADHD) are followed over time to see how many develop a particular health outcome of interest (in this case the outcome was death). </p>
<p>For this study the researchers calculated the mortality rate over a two-year follow up period for those whose ADHD was treated with medication (a group of around 84,000 people) alongside those whose ADHD was not treated with medication (around 64,000 people). The team then determined if there were any differences between the two groups.</p>
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Read more:
<a href="https://theconversation.com/adhd-medications-have-doubled-in-the-last-decade-but-other-treatments-can-help-too-191574">ADHD medications have doubled in the last decade – but other treatments can help too</a>
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<h2>What did the results show?</h2>
<p>The study found people who were diagnosed and treated for ADHD had a 19% reduced risk of death from any cause over the two years they were tracked, compared with those who were diagnosed but not treated. </p>
<p>In understanding this result, it’s important – and interesting – to look at the causes of death. The authors separately analysed deaths due to natural causes (physical medical conditions) and deaths due to unnatural causes (for example, unintentional injuries, suicide, or accidental poisonings).</p>
<p>The key result is that while no significant difference was seen between the two groups when examining natural causes of death, the authors found a significant difference for deaths due to unnatural causes.</p>
<h2>So what’s going on?</h2>
<p>Previous studies have suggested ADHD is associated with an increased risk of <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789090?">premature death</a> from unnatural causes, such as injury and poisoning.</p>
<p>On a related note, <a href="https://pubmed.ncbi.nlm.nih.gov/32662370/">earlier studies</a> have also suggested taking ADHD medicines may reduce premature deaths. So while this is not the first study to suggest this association, the authors note previous studies addressing this link have generated mixed results and have had significant limitations.</p>
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Read more:
<a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">How do stimulants actually work to reduce ADHD symptoms?</a>
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<p>In this new study, the authors suggest the reduction in deaths from unnatural causes could be because taking medication alleviates some of the ADHD symptoms responsible for poor outcomes – for example, improving impulse control and decision-making. They note this could reduce fatal accidents.</p>
<p>The authors cite a number of studies that support this hypothesis, including research showing <a href="https://publications.aap.org/pediatrics/article-abstract/124/1/71/71653/Do-Stimulants-Protect-Against-Psychiatric?redirectedFrom=fulltext">ADHD medications</a> may prevent the onset of mood, anxiety and <a href="https://publications.aap.org/pediatrics/article-abstract/104/2/e20/62430/Pharmacotherapy-of-Attention-deficit-Hyperactivity?redirectedFrom=fulltext">substance use disorders</a>, and <a href="https://www.biologicalpsychiatryjournal.com/article/S0006-3223(19)31274-0/abstract">lower the risk</a> of accidents and criminality. All this could reasonably be expected to lower the rate of unnatural deaths.</p>
<h2>Strengths and limitations</h2>
<p>Scandinavian countries have well-maintained national registries that collect information on various aspects of citizens’ lives, including their health. This allows researchers to conduct excellent population-based studies. </p>
<p>Along with its robust study design and high-quality data, another strength of this study is its size. The large number of participants – almost 150,000 – gives us confidence the findings were not due to chance.</p>
<p>The fact this study examined both children and adults is another strength. Previous research relating to ADHD has often focused primarily on children.</p>
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Read more:
<a href="https://theconversation.com/how-hormones-and-the-menstrual-cycle-can-affect-women-with-adhd-5-common-questions-210627">How hormones and the menstrual cycle can affect women with ADHD: 5 common questions</a>
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<p>One of the important limitations of this study acknowledged by the authors is that it was observational. Observational studies are where the researchers observe and analyse naturally occurring phenomena without intervening in the lives of the study participants (unlike randomised controlled trials). </p>
<p>The limitation in all observational research is the issue of confounding. This means we cannot be completely sure the differences between the two groups observed were not either partially or entirely due to some other factor apart from taking medication.</p>
<p>Specifically, it’s possible lifestyle factors or other ADHD treatments such as psychological counselling or social support may have influenced the mortality rates in the groups studied.</p>
<p>Another possible limitation is the relatively short follow-up period. What the results would show if participants were followed up for longer is an interesting question, and could be addressed in future research.</p>
<h2>What are the implications?</h2>
<p>Despite some limitations, this study adds to the evidence that diagnosis and treatment for ADHD can make a profound difference to people’s lives. As well as alleviating symptoms of the disorder, this study supports the idea ADHD medication reduces the risk of premature death. </p>
<p>Ultimately, this highlights the importance of diagnosing ADHD early so the appropriate treatment can be given. It also contributes to the body of evidence indicating the need to <a href="https://theconversation.com/with-rising-mental-health-problems-but-a-shortage-of-services-group-therapy-is-offering-new-hope-214711">improve access</a> to mental health care and support more broadly.</p><img src="https://counter.theconversation.com/content/225680/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hassan Vally does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The study found people with ADHD who took medication had a lower risk of dying from unnatural causes than those with ADHD who were not taking medication.Hassan Vally, Associate Professor, Epidemiology, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2228582024-03-08T13:38:33Z2024-03-08T13:38:33ZAsthma meds have become shockingly unaffordable − but relief may be on the way<figure><img src="https://images.theconversation.com/files/579691/original/file-20240304-18-r33cu5.jpg?ixlib=rb-1.1.0&rect=25%2C51%2C8538%2C5469&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Its price will take your breath away.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-using-blue-asthma-inhaler-medication-royalty-free-image/1179346207?">Brian Jackson/Getty Images</a></span></figcaption></figure><p>The <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">price of asthma medication has soared</a> in the U.S. over the past decade and a half. </p>
<p>The jump – in some cases from around <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a little over US$10</a> <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">to almost $100</a> for an inhaler – has meant that patients in need of asthma-related products <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">often struggle</a> to buy them. Others simply <a href="https://asthma.net/living/cannot-afford-inhalers">can’t afford</a> them. </p>
<p>To make matters worse, asthma <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">disproportionately affects</a> lower-income patients. Black, Hispanic and Indigenous communities have the <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">highest asthma rates</a>. They also shoulder <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">the heaviest burden</a> of asthma-related deaths and hospitalizations. Climate change will likely <a href="https://www.hsph.harvard.edu/c-change/subtopics/climate-change-and-asthma/">worsen asthma rates</a> and, consequently, these disparities.</p>
<p>I’m a health law professor at <a href="https://www1.villanova.edu/university/law/faculty-scholarship/faculty-directory/profiles/AnaSantosRutschman.html">Villanova University</a>, <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=2667484">where I study</a> whether patients can get the medicines they need. And I’ve been watching this affordability crisis closely.</p>
<p>In many ways, it shows what happens when law and policy decisions aren’t aligned with public health needs. The good news, however, is that there finally seems to be some political will to rein in the price of asthma meds.</p>
<h2>Why inhaler prices are skyrocketing</h2>
<p>In 2008, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/frequently-asked-questions-popular-topics/transition-cfc-propelled-albuterol-inhalers-hfa-propelled-albuterol-inhalers-questions-and-answers">banned inhalers</a> that use chlorofluorocarbons, or CFCs – which were once widely used as propellants – because they can damage the ozone layer. The FDA was following a timeline set by an environmental treaty, the <a href="https://www.unep.org/ozonaction/who-we-are/about-montreal-protocol">Montreal Protocol</a>, which the U.S. ratified in the late 1980s. </p>
<p>From 2009 onward, CFC inhalers were phased out and replaced with hydrofluoroalkane, or HFA, ones, which are more environmentally friendly. They’re also a lot pricier. For patients with insurance, the average out-of-pocket cost of an inhaler rose from $13.60 per prescription in 2004 to $25 immediately after the 2008 ban, <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a 2015 study found</a>.</p>
<p>Today, the <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">average retail price</a> of an albuterol inhaler is $98. Unlike CFC inhalers, which have <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">generic versions</a>, HFA inhalers are <a href="https://www.scientificamerican.com/article/unlikely-victims-of-banning-cfcs/">covered by patents</a>. While <a href="http://doi.org/10.1089/jamp.2016.1297">the drug itself</a> hasn’t changed, the switch to a different device allowed companies to increase their prices.</p>
<p>In 2020, the FDA finally approved the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-generic-commonly-used-albuterol-inhaler-treat-and-prevent-bronchospasm">first generic version</a> of an albuterol inhaler. But generic competition still isn’t robust enough to lower prices meaningfully.</p>
<p>Patients with good insurance <a href="https://allergyasthmanetwork.org/advocacy-updates/united-healthcare-albuterol-epinephrine-cost/">may pay very little</a> or even nothing. But uninsured patients face steep market prices, and as of 2023, there were <a href="https://aspe.hhs.gov/sites/default/files/documents/e06a66dfc6f62afc8bb809038dfaebe4/Uninsured-Record-Low-Q12023.pdf">over 25 million</a> uninsured Americans. <a href="https://www.cdc.gov/asthma/asthma_stats/insurance_coverage.htm">Even insured patients may have trouble</a> affording their asthma meds, the CDC has found. </p>
<p>The same asthma medication for which U.S. patients pay top dollar is available elsewhere at much cheaper prices. Consider the following case for inhalers. The pharmaceutical company Teva sells <a href="https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ccd3aaec-4892-40d0-ad60-3e570178fbe1">QVAR RediHaler</a>, a corticosteroid inhaler, <a href="https://doi.org/10.1016/S2213-2600(24)00012-2">for $286</a> in the U.S.</p>
<p>In Germany, Teva sells that same inhaler for $9.</p>
<h2>Seeking meds from Mexico and Canada</h2>
<p>Some U.S. patients have traveled abroad to obtain cheaper asthma medication. After the 2008 ban on CFCs, it became common for patients to <a href="https://doi.org/10.1177/8755122515595052">visit border towns in Mexico</a> to purchase albuterol inhalers. They were sold for <a href="https://doi.org/10.1177/8755122515595052">as little as $3 to $5</a>. </p>
<p>A study of inhalers available to U.S. patients in Nogales, Mexico – about an hour south of Tucson, Arizona – found that Mexican products were <a href="http://doi.org/10.1177/8755122515595052">generally comparable to U.S. inhalers</a>. But researchers found some differences in performance, suggesting that American patients who use them could be getting a slightly different dose than their usual.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Asthma medication is seen on the shelves of a Mexican pharmacy." src="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asthma meds are considerably more affordable south of the border.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-interior-of-farmacia-san-pablo-news-photo/1041982048">Jeffrey Greenberg/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>There have also been reports of Americans turning to Canadian pharmacies to purchase asthma inhalers at much cheaper prices. In one case, a U.S. pharmacy would have charged $857 for a three-month supply. A patient obtained it for <a href="https://www.seattletimes.com/life/wellness/canadian-pharmacy-provided-inhaler-at-a-fraction-of-us-cost/">$134 from a pharmacy in Canada</a>.</p>
<h2>One potential fix: Importing cheaper meds</h2>
<p>U.S. law has long <a href="https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/frequently-asked-questions-about-drugs">prohibited</a> personal importation of pharmaceutical drugs. However, a recent development could <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05">pave the way for states</a> to import cheaper asthma drugs.</p>
<p>In January 2024, the <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05/">FDA authorized</a> the importation of certain prescription drugs from Canada for the first time. <a href="https://www.kff.org/policy-watch/what-to-know-about-the-fdas-recent-decision-to-allow-florida-to-import-prescription-drugs-from-canada/">For now</a>, this authorization is limited to Florida, and it covers only drugs for HIV/AIDS, prostate cancer and certain mental health conditions.</p>
<p>Should it prove successful, the program could serve as a blueprint for other states.</p>
<h2>Another possible solution: Price-capping</h2>
<p>Policymakers could also try borrowing a page from the insulin playbook. Insulin prices <a href="https://doi.org/10.1001/jamanetworkopen.2023.18074">climbed for almost two decades</a> before Congress acted, capping the cost of insulin for Medicare patients. The 2022 <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376/text">Inflation Reduction Act</a> established an out-of-pocket ceiling of $35 per month for prescription-covered insulin products. </p>
<p>If this cap had been in effect two years earlier, it would have saved 1.5 million Medicare patients about $500 annually, <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">a recent study estimated</a>. It also would have saved Medicare <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">$761 million</a>.</p>
<p>A similar approach could be taken for asthma meds.</p>
<p>Congress could create an asthma-specific rule similar to the insulin case. Or it could place provisions for asthma-med prices into a larger piece of legislation.</p>
<p>While this approach depends on the political environment, there are signs the government is becoming more willing to act. In January 2024, the U.S. Department of Health and Human Services <a href="https://www.hhs.gov/about/news/2024/01/29/readout-hhs-officials-meeting-private-sector-patient-advocacy-leaders-improve-national-access-important-asthma-medications.html">hosted a meeting</a> to discuss the problem with manufacturers and other stakeholders.</p>
<p>It’s a start. And – together with other measures – it brings some hope that asthma meds might soon become more affordable to those in need.</p><img src="https://counter.theconversation.com/content/222858/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ana Santos Rutschman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An inhaler that costs nearly $300 in the US goes for just $9 in Germany. What gives?Ana Santos Rutschman, Professor of Law, Villanova School of LawLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2216842024-01-28T13:55:15Z2024-01-28T13:55:15ZThe contraceptive pill also affects the brain and the regulation of emotions<figure><img src="https://images.theconversation.com/files/570657/original/file-20231221-19-oxth15.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C988%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Like natural hormones, known as endogenous hormones, the artificial hormones contained in the pill, known as exogenous hormones, can have effects on the brain.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Oral contraceptives, also known as birth control pills, are <a href="https://doi.org/10.18356/1bd58a10-en">used by more than 150 million women worldwide</a>. Approximately one-third of teenagers in <a href="https://www150.statcan.gc.ca/n1/en/pub/82-003-x/2015010/article/14222-eng.pdf">North America</a> and <a href="https://doi.org/10.1001/jamapsychiatry.2016.2387">Europe</a> use them, making them the most prescribed drug for teenagers.</p>
<p>It is well known that oral contraceptives have the power to alter a woman’s menstrual cycle. What’s less well known is that they can also have an effect on the brain, particularly in the regions that are important for regulating emotions.</p>
<p>As a doctoral student and professor of psychology at UQAM, we were interested in the impact of oral contraceptives on the brain regions involved in emotional processes. We published our <a href="https://doi.org/10.3389/fendo.2023.1228504">results in the scientific journal Frontiers in Endocrinology</a>.</p>
<h2>How does the pill work?</h2>
<p>There are several methods of hormonal contraception, but the most common type in North America is the contraceptive pill, more specifically, <a href="https://doi.org/10.1016/j.yfrne.2022.101040">combined oral contraceptives</a> (COCs). These are made up of two artificial hormones that simulate one of the types of estrogen (generally ethinyl estradiol) and progesterone.</p>
<p>Like natural hormones, known as endogenous hormones, the artificial hormones contained in the pill, known as exogenous hormones, <a href="https://doi.org/10.1016/j.yfrne.2022.101040">have an effect on the brain</a>. They bind to receptors in different areas and signal the brain to reduce the production of endogenous sex hormones. It is this phenomenon that leads to the cessation of menstrual cycles, preventing ovulation.</p>
<p>In other words, while using COCs, users’ bodies and brains are not exposed to the fluctuations in sex hormones typically seen in women with a natural cycle.</p>
<h2>The pill’s effects on the brain: neuroscience to the rescue!</h2>
<p>When they start taking COCs, teenage girls and women are informed of their different side effects, mainly physical (nausea, headaches, weight changes, breast tenderness). However, the fact that sex hormones affect the brain, particularly in areas important for regulating emotions, is not generally discussed.</p>
<p>Studies have associated the use of COCs with <a href="https://doi.org/10.1016/j.psyneuen.2018.02.019">poorer ability to regulate emotions</a> and a <a href="https://doi.org/10.1001/jamapsychiatry.2016.2387">higher risk of developing psychopathologies</a>.</p>
<p>In addition, women are more likely than men to suffer from <a href="https://doi.org/10.1016/j.jpsychires.2011.03.006">anxiety and chronic stress disorders</a>. Given the widespread use of COCs, it is important to gain a better understanding of their effects on the anatomy of the brain regions that are responsible for emotional regulation.</p>
<p>We therefore conducted a study to examine the effects of COCs on the anatomy of brain regions involved in emotional processes. We were interested in the effects associated with their current use, but also in the possibility of lasting effects, i.e. whether COCs could affect brain anatomy even after women stopped taking them.</p>
<p>To do this, we recruited four profiles of healthy individuals: women currently using COCs, women who had used COCs in the past, women who had never used any method of hormonal contraception, and men.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="magnetic resonance imaging" src="https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/567191/original/file-20231221-24-r2t5pd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Magnetic resonance imaging (MRI) is used to analyze the morphology of certain regions of the brain.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Using brain imaging, we found that only women currently using COCs had a slightly thinner ventromedial prefrontal cortex than men. This part of the brain is known to be essential for regulating emotions such as fear. The scientific literature shows that <a href="https://doi.org/10.1073/pnas.0502441102">the thicker this region is, the better the emotional regulation will be</a>.</p>
<p>COCs could therefore alter emotional regulation in women. Although we have not directly tested the link between brain morphology and mental health, our team is currently investigating other aspects of the brain and mental health, which will allow us to better understand our anatomical findings.</p>
<h2>An effect associated with the dose, but that doesn’t last</h2>
<p>We tried to better understand what could explain the effect using COCs on this region of the brain. We discovered that it was associated with the dose of ethinyl estradiol. In fact, among COC users, only those using a low-dose COC (10-25 micrograms) – not a higher dose (30-35 micrograms) – were associated with a thinner ventromedial prefrontal cortex.</p>
<p>It may seem surprising that a lower dose was associated with a cerebral effect…</p>
<p>Given that all COCs reduce concentrations of endogenous sex hormones, we propose that estrogen receptors in this brain region may be insufficiently activated when low levels of endogenous estrogen are combined with a low intake of exogenous estrogen (ethinyl estradiol).</p>
<p>Conversely, higher doses of ethinyl estradiol could help to achieve adequate binding to estrogen receptors in the prefrontal cortex, simulating moderate to high activity similar to that of women with a natural menstrual cycle.</p>
<p>It is important to note that this lower grey matter thickness was specific to current COC use: women who had used COCs in the past showed no thinning compared to men. Our study therefore supports the reversibility of the impact of COCs on cerebral anatomy, in particular on the thickness of the ventromedial prefrontal cortex.</p>
<p>In other words, the use of COCs could affect brain anatomy, but in a reversible way.</p>
<h2>And now?</h2>
<p>Although our research has no direct clinical orientation, it is helping to advance our understanding of the anatomical effects associated with the use of COCs.</p>
<p>We are not calling for women to stop using their COCs: adopting such discourse would be both too hasty and alarming.</p>
<p>It’s also important to remember that the effects reported in our study appear to be reversible.</p>
<p>Our aim is to promote basic and clinical research, but also to increase scientific interest in women’s health, an area that is still understudied.</p><img src="https://counter.theconversation.com/content/221684/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexandra Brouillard is a student member of the Research Centre of the Institut universitaire en santé mentale de Montréal. She holds a doctoral scholarship from the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Marie-France Marin is a regular researcher at the Centre de recherche de l'Institut universitaire en santé mentale de Montréal, a professor in the Department of Psychology at the Université du Québec à Montréal and an associate professor in the Department of Psychiatry and Addictology at the Université de Montréal. She was supported by a salary grant from the Fonds de recherche du Québec - Santé (2018-2022) and currently holds a Canada Research Chair in Hormonal Modulation of Cognitive and Emotional Functions (2022-2027). The project discussed in the article is funded by the Canadian Institutes of Health Research and has received support from pilot project funds from the Research Centre of the Institut universitaire en santé mentale de Montréal and the Quebec Bioimaging Network.</span></em></p>Oral contraceptives modify the menstrual cycle. What’s less well known is that they also reach the brain, particularly the regions important for regulating emotions.Alexandra Brouillard, Doctorante en psychologie, Université du Québec à Montréal (UQAM)Marie-France Marin, Professor, Department of Psychology, Université du Québec à Montréal (UQAM)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/WlWJxfHVY9I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
</figure>
<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130412023-09-11T23:27:09Z2023-09-11T23:27:09ZWith a pharmacare bill on the horizon, Big Pharma’s attack on single-payer drug coverage for Canadians needs a fact check<figure><img src="https://images.theconversation.com/files/547294/original/file-20230908-23-s1i9fc.jpg?ixlib=rb-1.1.0&rect=201%2C23%2C4974%2C3243&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Under a pharmacare plan, a single bargaining agent negotiates for lower prices from drug companies.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/with-a-pharmacare-bill-on-the-horizon-big-pharmas-attack-on-single-payer-drug-coverage-for-canadians-needs-a-fact-check" width="100%" height="400"></iframe>
<p>Health Minister Mark Holland <a href="https://www.cbc.ca/news/politics/mark-holland-health-minister-pharmacare-1.6938470">announced in August</a> that the federal government intends to introduce pharmacare legislation in the fall. Now the battle lines are being drawn.</p>
<p>One of the many virtues of pharmacare — a universal drug coverage plan — is that there will be a single bargaining agent looking for lower prices from the drug companies. Australia has a single buyer and has brand-name prices that are on average <a href="https://www.canada.ca/en/patented-medicine-prices-review/services/annual-reports/annual-report-2021.html">29 per cent lower than Canada’s</a>. That difference on Canadian annual sales of $17.4 billion translates into savings of about $5 billion.</p>
<p>Pharmaceutical and insurance industries that stand to lose profit through lower drug prices are not happy about pharmacare. They are speaking out and mobilizing their allies. </p>
<h2>‘Fill in the gaps’</h2>
<p>Innovative Medicines Canada, the lobby group for Big Pharma, is pushing for a “<a href="https://innovativemedicines.ca/newsroom/all-news/imc-calls-on-canadas-premiers-to-improve-patient-access-to-medicines/">fill in the gaps</a>” model. That means providing coverage for people who don’t have drug insurance, but leaving the current system otherwise untouched.</p>
<p>Québec already has “filled in the gaps.” However, it <a href="https://doi.org/10.1503/cmaj.170726">hasn’t achieved the solutions shown in countries with pharmacare</a>. Québec spends more per capita on drugs than other provinces. A greater percentage of people in Québec (8.7 per cent) report spending more than $1,000 on prescription drugs in one year, compared to comparable countries with pharmacare (three per cent) or even the rest of Canada (4.8 per cent).</p>
<p>In Québec, nine per cent of its residents report that they go without their medications because they cannot afford them. While this is an improvement on the rest of the country, with 11 per cent of Canadians in other provinces skipping medications due to costs, it is still significantly higher than the numbers in most comparable countries with pharmacare (six per cent or less).</p>
<h2>The 97 per cent myth</h2>
<p>GreenShield, a not-for-profit health benefits provider and a member of the Canadian Life and Health Insurance Association (CLHIA), appears to share the insurance industry’s stand against pharmacare. In July it <a href="https://www.theglobeandmail.com/business/article-greenshield-cares-essential-medicines-low-income/">announced a pilot program</a> that will offer up to $1,000 in drug coverage to low-income Canadians who do not have public or private prescription drug insurance.</p>
<p>In making the announcement, GreenShield’s chief executive Zahid Salman repeated the myth that 97 per cent of Canadians already have drug coverage. That 97 per cent number is theoretical. Having some form of coverage does not necessarily make drugs affordable. For example, if you live in <a href="https://www.gov.mb.ca/health/pharmacare/estimator.html">Manitoba</a> and your family income is $47,500, you’ll first have to pay $2,760 out of pocket. Anything less and there’s no public coverage. </p>
<p>According to a recent report from <a href="https://www150.statcan.gc.ca/n1/pub/75-006-x/2022001/article/00011-eng.htm">Statistics Canada</a>, 33 per cent of seniors in Manitoba don’t have drug coverage. (That figure might be lower if some seniors who are eligible for provincial insurance didn’t register or were unaware that they were covered.)</p>
<h2>Not everyone has workplace benefits</h2>
<p>CLHIA came out swinging after the federal NDP tabled a <a href="https://www.ctvnews.ca/politics/ndp-attempts-to-prod-liberals-into-action-on-pharmacare-by-tabling-its-own-bill-1.6439036">pharmacare bill</a> in June. The NDP’s bill called for a federal, universal, public and single-payer drug plan. In other words, a plan similar to what Canadians already enjoy for doctor and hospital services. </p>
<p>Denis Ricard, chair of the CLHIA’s board of directors, has claimed that “<a href="https://breachmedia.ca/greenshield-insurance-industry-fights-liberal-ndp-pharmacare/">a fully one-payer national pharmacare is going to be a disaster for this country</a>.”</p>
<p>The <a href="https://betterhealthbenefits.ca/">Better Health Benefits, Together</a> campaign being run by the CLHIA warns that Canadians “can’t afford to lose their workplace benefits because of politics…Done the wrong way, Canadians will lose access to medicines they use today.” </p>
<p>The campaign fails to mention that workplace benefits do not cover everyone, and exclude those experiencing unemployment, which affects some populations more than others. For example, <a href="https://www150.statcan.gc.ca/n1/pub/75-006-x/2022001/article/00011-eng.htm">racialized Canadians have a higher unemployment rate</a> than the rest of the population and therefore are less likely to have work-based drug coverage. </p>
<p>Nor does the campaign mention that, according to <a href="https://www150.statcan.gc.ca/n1/pub/75-006-x/2022001/article/00011-eng.htm">Statistics Canada</a>, “the majority of insurance coverage changes due to the pandemic were negative,” with immigrants faring worse than non-immigrants.</p>
<h2>High deductibles</h2>
<p>Joining the battle against pharmacare is <a href="https://www.thestar.com/opinion/contributors/canada-has-in-fact-achieved-universal-drug-insurancecoverage/%2520article_65bc7a1e-8fb2-56d5-abb8-1b5890909597.html">Brett Skinner</a>, the CEO of the free market Canadian Health Policy Institute. Skinner’s message is that a national government-run drug insurance program is not necessary and will be bad for patients and costly for taxpayers. </p>
<p>He argues that private plans cover more drugs, and cover new drugs more quickly than public plans, and that if Canadians are faced with high deductibles there are provincial programs to deal with them.</p>
<p>He neglects to mention that <a href="https://doi.org/10.1177%2F20542704231166620">only about 10 to 15 per cent of new drugs provide any substantial new benefits</a> compared to existing drugs. He fails to note that a third of the difference in the time between public and private coverage is because <a href="https://doi.org/10.9778/cmajo.20220063">drug companies don’t take advantage of the opportunity to apply for coverage as quickly as they could</a>. </p>
<p>Skinner also ignores the fact that <a href="https://doi.org/10.1503%2Fjpn.180051">people living in Manitoba</a> with an annual income of just over $55,000 who are taking three drugs a day are faced with deductibles of up to $350 every three months. British Columbia residents aren’t far behind at $300 every three months.</p>
<p>Big Pharma, the insurance industry and free market zealots are all motivated by money and ideology. In a battle over people’s health, greed shouldn’t be the winner.</p><img src="https://counter.theconversation.com/content/213041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Between 2019-2023, Joel Lexchin received payments for writing briefs on the role of promotion in generating prescriptions for two legal firms. He is a member of the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. Between 2017 and 2023 he was a coinvestigator on four different projects funded by the Canadian Institutes of Health Research.</span></em></p>Pharmaceutical and insurance industries that could lose profit through lower drug prices are not happy that a pharmacare bill is planned for fall. They are speaking out and mobilizing their allies.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2098102023-08-04T12:30:37Z2023-08-04T12:30:37ZCollege students with loans more likely to report bad health and skip medicine and care, study finds<figure><img src="https://images.theconversation.com/files/539773/original/file-20230727-29-hz1qlc.jpg?ixlib=rb-1.1.0&rect=70%2C151%2C7629%2C4428&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study found that those with student loans are more likely to delay medical, dental and mental health care. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/burnout-anxiety-and-fatigue-creative-student-royalty-free-image/1445373401?phrase=college+students+mental+health">PeopleImages/iStock via Getty Images </a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Students who took out loans to pay for college rated their overall health and mental health as being worse than those who didn’t take out student loans. They also reported more major medical problems and were more likely to report delaying medical, dental and mental health care and using less medication than the amount prescribed to save money. </p>
<p>We <a href="https://doi.org/10.1080/07448481.2022.2151840">reported these findings</a> in an article published in the Journal of American College Health. The findings are based on surveys collected in 2017 from over 3,200 college students at two public universities in the United States.</p>
<p>We asked students to rate their physical and mental health on a 4-point scale – excellent, good, fair and poor. We also asked if they had experienced any major medical problems in the past year or whether they had ever postponed medical, dental or mental health care to make ends meet since starting college. Those who indicated they were taking regular medication for physical health problems, such as for asthma or high blood pressure, were asked if they ever took less medication than prescribed to save money. </p>
<p>Students with loans reported worse outcomes than those without loans, even after accounting for differences between them in terms of race, age and gender, as well as their parents’ education level and marital status.</p>
<p>Despite their worse self-reported mental health, students with loans were equally likely as students without loans to have received a new mental health diagnosis or treatment for a mental disorder in college. They also were equally likely to have visited a mental health practitioner in the past year or to use mental health medication. But they were almost twice as likely as those without debt to report delaying mental health care. </p>
<h2>Why it matters</h2>
<p>Our findings suggest that student loans may have hidden costs in the form of worse physical and mental health, more medical problems and diminished use of medical and mental health care. Stress from student loans <a href="https://eric.ed.gov/?id=EJ1141137">can affect students</a> while they are still in college, <a href="https://doi.org/10.1037/cdp0000207">harming both mental and physical health</a>.</p>
<p>College students are often at a <a href="https://doi.org/10.1037/11381-002">crucial juncture</a> when they are first leaving their parents’ home and <a href="https://doi.org/10.1038/oby.2008.365">establishing habits</a> – such as those related to medical and dental care – that may persist beyond college. Declining to seek medical care <a href="https://doi.org/10.1016/j.jchf.2021.05.010">can result</a> in <a href="https://doi.org/10.7326/0003-4819-114-4-325">worse medical problems</a>, potentially leading to diminished health and shorter lives for college graduates with loans.</p>
<p>One of the advantages of getting a college degree is <a href="https://doi.org/10.2105/AJPH.2011.300216">improved</a> <a href="https://www.forbes.com/sites/michaeltnietzel/2019/06/17/new-evidence-for-the-broad-benefits-of-higher-education/?sh=a4e88834c5c1">health</a>. But students who take out loans to attend college may not see those benefits, especially if they defer medical care or use less medicine to save money.</p>
<p>Previous generations had greater access to free or low-cost <a href="https://press.jhu.edu/books/title/12165/history-american-higher-education">public higher education</a> – access that has eroded as state budgets <a href="https://doi.org/10.1525/ctx.2009.8.1.76">failed to keep up</a> with the <a href="https://www.acenet.edu/Documents/Anatomy-of-College-Tuition.pdf">rising demand for and costs</a> of higher education. The current system of higher education funding <a href="https://educationdata.org/student-loan-debt-statistics">requires most people to take on debt</a> to get a college degree; the <a href="https://ticas.org/affordability-2/student-aid/student-debt-student-aid/student-debt-and-the-class-of-2019/">most recent national data</a> indicates that among 2019 graduates of public or private nonprofit, four-year universities, 62% had student debt.</p>
<h2>What’s next</h2>
<p>We are writing a book that explores how debt affects life after college, including the consequences for health, housing, romantic relationships and career trajectories. So far, we have found that inequalities in health and delays in doctor visits persist after graduation. We have also found that college graduates who put off doctor visits to save money in college were a little over twice as likely to experience a recent major medical problem 15 months and 3.5 years after graduation. We also found they were over four times as likely to be be putting off medical care to save money after graduation, showing these habits persist well after they leave college.</p><img src="https://counter.theconversation.com/content/209810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arielle Kuperberg receives funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Joan Maya Mazelis receives funding from the National Science Foundation.</span></em></p>College students who postpone medical care to save money end up paying for it down the line in the form of worse health, a researcher contends.Arielle Kuperberg, Professor of Sociology, University of North Carolina – GreensboroJoan Maya Mazelis, Associate Professor of Sociology, Rutgers UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2050592023-07-28T12:52:44Z2023-07-28T12:52:44ZBreastfeeding: mothers taking prescription medicines faced with a lack of information – new review<figure><img src="https://images.theconversation.com/files/534299/original/file-20230627-15-svfyno.jpg?ixlib=rb-1.1.0&rect=85%2C0%2C9504%2C6260&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most medicines are safe for most breastfed babies, while serious harm to infants is rare.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-son-sitting-on-sofa-breastfeeding-2251534251">Krakenimages.com/Shutterstock</a></span></figcaption></figure><p>Breastfeeding is a cornerstone of early childhood nutrition and development. However, taking prescription medicines can reduce breastfeeding rates because parents who take such medications often face a lack of information about their potential impact on babies or how medicines affect lactation. </p>
<p>To better understand the effects of medicines on breastfeeding, we conducted a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0284128">systematic review</a> of the available information. We scoured electronic databases for research on the impact of prescription medicines on breastfeeding. These studies examined how medicines affected milk composition, milk production and the health of breastfed infants. </p>
<p>We found a limited number of high-quality studies, with only ten established databases reporting on breastfeeding, medicines and infant outcomes together. And, unfortunately, none of these studies covered educational outcomes, making it difficult to assess potential long-term risks, harms and benefits.</p>
<p>Our research shows that more data collection is needed. And our work and <a href="https://doi.org/10.1371/journal.pone.0225133">other research</a> highlights there is a need for additional support to help breastfeeding mothers overcome physical barriers, including delayed milk production and <a href="https://pubmed.ncbi.nlm.nih.gov/28027444/">anxiety</a> about the use of prescription medicine.</p>
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
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<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
<p><em><a href="https://theconversation.com/science-experiments-traditionally-only-used-male-mice-heres-why-thats-a-problem-for-womens-health-205963">Science experiments traditionally only used male mice – here’s why that’s a problem for women’s health</a></em></p>
<hr>
<h2>Safety</h2>
<p>Most medicines are safe for most breastfed babies, while serious harm to infants is rare. In most cases, the benefits of breastfeeding outweigh the risks of harms associated with medicine use. Still, this can be a complex issue and it’s essential to weigh the benefits and risks carefully.</p>
<p>There are some medicines that require extra checks on infants and their ability to breastfeed. For example, infants whose mothers use antibiotics such as amoxicillin and erythromycin (which are known to be safe to use during breastfeeding), should be checked for oral thrush and diarrhoea, as prompt treatment is important. </p>
<p>The <a href="https://bnf.nice.org.uk">British National Formulary</a> (BNF) offers advice on the prescribing and administration of medicines. Infants of mothers taking certain medicines, such as those for epilepsy, mental health conditions, sedatives, or opioids, should be monitored for signs of sedation, sleepiness, poor feeding, weight loss and irritability. </p>
<p>Health professionals should also assess how effectively the baby is feeding by observing suckling and attachment to the breast. This is important because these types of medicines can interfere with an infant’s ability to feed and receive adequate nutrition.</p>
<p>The BNF expresses reservations regarding prescribing some sedative medicines that pass into breastmilk, where there is a risk of infant sedation, as with benzodiazepines (such as diazepam), and some anti-seizure medicines such as phenobarbital or primidone. </p>
<p>It recommends avoiding certain medicines during breastfeeding altogether, including some antipsychotics, such as olanzapine and clozapine, and the antidepressants escitalopram and fluoxetine. But other antidepressants, such as citalopram, may be used with caution. Most antipsychotic injections should be avoided during breastfeeding too, as should fingolimod which is used to treat multiple sclerosis. </p>
<p>Breastfeeding while using many medicines for serious illness, such as cancer, should be discussed with medical professionals. There may be little or no information from human studies, and there may be too little information to guarantee safety. Examples include many monoclonal antibodies used to treat cancer, and the immunosuppressant, mycophenolate mofetil, which is used to prevent the rejection of kidney, heart or liver transplants.</p>
<h2>Advice</h2>
<p>Mothers taking medicines should not blame themselves for being hesitant towards breastfeeding. Medical advice should be sought before birth. And families should not feel compelled to choose between breastfeeding and continuing with prescription medicines.</p>
<p>It’s essential for doctors, pharmacists and other health professionals to consult reliable information sources, including <a href="https://wicworks.fns.usda.gov/resources/lactmed">LactMed</a> and <a href="https://www.e-lactancia.org/">E-lactancia</a>, or contact the <a href="https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/">Drugs in Breastmilk helpline</a>.</p>
<p>To help families who need prescription medicines, it is crucial for public health teams controlling the collection of routine healthcare data to treat data collection on medicine use during and after pregnancy and during labour as a priority. This would allow research into the benefits and harms of medicine use before and during breastfeeding. </p>
<p>Such information would help parents make informed decisions regarding their medical treatment, breastfeeding and monitoring infants. It would also help minimise parental anxiety and potentially harmful false dilemmas.</p><img src="https://counter.theconversation.com/content/205059/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sue Jordan receives funding from the ConcePTION project. The ConcePTION project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 821520. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA. Funding was awarded to SJ, SLL. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. </span></em></p><p class="fine-print"><em><span>Sophia Komninou does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Not enough data is being collected about the impact taking prescription medication has on breastfeeding.Sophia Komninou, Lecturer in Public Health Nutrition, Swansea UniversitySue Jordan, Professor of Medicines Management and Health Services Research, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076822023-07-13T12:37:25Z2023-07-13T12:37:25ZMyths about will power and moral weakness keep people with opioid use disorder from receiving effective medications like methadone, buprenorphine and naltrexone<figure><img src="https://images.theconversation.com/files/534714/original/file-20230628-17-b8qav.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse dispenses liquid Methadose, an FDA-approved medication that helps people addicted to opioids.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vanessa-leavitt-dispenses-a-dosage-of-the-liquid-form-of-news-photo/462014722">Whitney Hayward/Portland Press Herald via Getty Images</a></span></figcaption></figure><p>The <a href="https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf">most effective science-based treatment</a> for opioid use disorder is medication. Methadone and buprenorphine prevent intense cravings and other symptoms of withdrawal, while naltrexone works by blocking <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">the effects of opioids</a>. </p>
<p>Despite <a href="https://doi.org/10.1001/jamanetworkopen.2020.29676">abundant research</a> <a href="https://doi.org/10.1016/j.jsat.2021.108447">showing these medications reduce the risk</a> <a href="https://doi.org/10.1001/jamanetworkopen.2023.14925">of relapse and overdose</a>, many people, no matter their relationship with opioids or with people who use them, are still <a href="https://doi.org/10.1177/19367244231159096">hesitant to support the use of these medications</a>. And the majority of people who would benefit from such treatments <a href="https://doi.org/10.1016/j.drugpo.2022.103786">do not have access to them</a>.</p>
<p><a href="https://scholar.google.com/citations?user=NKKkSF8AAAAJ&hl=en">We</a> <a href="https://scholar.google.com/citations?user=fZr3zoUAAAAJ&hl=en">study</a> opioid use disorder and the attitudes that surround it. To better understand hesitancy around the use of medication to treat opioid use disorder, we <a href="https://scholar.google.com/citations?hl=en&user=D4mtQ3IAAAAJ">and</a> <a href="https://scholar.google.com/citations?hl=en&user=_VuWPDAAAAAJ">our</a> <a href="https://www.lifespringhealthsystems.org/">colleagues</a> <a href="https://www.ecommunity.com/locations/community-fairbanks-recovery-center">conducted</a> focus groups with three populations intimately involved in the opioid crisis – those in recovery, their friends and family and their health care providers – as well as with community members with no direct connection to opioid use disorder. We spoke with 101 people in all across rural and urban locations in Indiana. </p>
<p>We asked what they thought about using medication to treat opioid use disorder. We found all four groups had negative opinions about using medication. No matter who they were, <a href="https://doi.org/10.1177/19367244231159096">participants voiced</a> an underlying belief that opioid use disorder results from moral weakness that can be overcome with willpower and commitment to behavior change, despite research-based evidence that overwhelmingly shows that opioid use disorder is a <a href="https://www.ncbi.nlm.nih.gov/books/NBK541390/">chronic brain disease best managed with medication</a>. </p>
<p>Across all four groups, we heard three myths about using medication for opioid use disorder. Research reveals these stigmatizing beliefs are counter to reality.</p>
<h2>Medication isn’t trading one drug for another</h2>
<p>Many of our participants expressed the belief that using medication is the same as using opioids to get high. This misperception is likely rooted in the outdated idea that recovery is defined by <a href="https://nida.nih.gov/research-topics/recovery">total abstinence from all substances</a>, except perhaps caffeine and nicotine. As one service provider working with people in recovery declared, “If you’re on Suboxone or you’re on methadone and you’re not being tapered down, you’re using.” </p>
<p>The truth is, taking medication is not the same as using prescription or street opioids to get high. These medications <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">do not produce the same experience of euphoria or high</a> as heroin, morphine or other opioids. <a href="https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes">In different ways</a>, methadone, buprenorphine and naltrexone all reduce cravings and <a href="https://www.recoveryanswers.org/research-post/better-down-the-road-the-long-term-outcomes-of-opioid-use-disorder-patients-treated-with-medication/">allow people to remain sober</a> and to work, raise their children and engage in activities of healthy productive living – all challenges for people to do well when using opioids to get high. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up photo of a woman's hands holding two small packages labeled Suboxone." src="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Suboxone is a medicine containing buprenorphine and naltrexone. It is most often taken under the tongue.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/susan-stevens-shows-off-a-prescription-for-suboxone-her-news-photo/1134203790">Eamon Queeney/The Washington Post via Getty Images</a></span>
</figcaption>
</figure>
<h2>Medication is an important part of long-term recovery</h2>
<p>We found that people’s overall discomfort with the idea of using medication to treat opioid use disorder led to a belief that such treatment should be used only as a steppingstone on the way to sobriety. A community member we spoke with said, “It’s a way of weaning them off everything. I think that’s just one of the steps they have to take to get clean.” </p>
<p>The belief that medication should be used for only a short time runs counter to <a href="https://doi.org/10.1001/jama.1977.03270390032021">research showing</a> <a href="https://doi.org/10.1016/0002-9343(78)90691-5">higher rates of relapse</a> <a href="https://doi.org/10.1080/10550490701860971">after tapering</a>. <a href="https://www.cms.gov/about-cms/story-page/cdcs-tapering-guidance.pdf">Guidelines from the U.S. Department of Health and Human Services</a> discourage rapid tapers and affirm that long-term use is the best way to prevent relapse, overdose and death.</p>
<h2>Long-term treatment counts as success</h2>
<p>Many of our study participants voiced the belief that long-term use of medication means the treatment did not work. As one family member put it, “If you’re on it for 10 or 15 years, then that’s not really helping you.” </p>
<p>The myth that long-term use of medication means the medicine is ineffective – or has failed – runs counter to both the <a href="https://doi.org/10.1001/jama.283.10.1303">life outcomes of those on maintenance treatment</a> and the <a href="https://doi.org/10.1080/10550490701860971">physiological reality</a> that such drugs may remain <a href="https://doi.org/10.1016/j.jsat.2009.05.003">necessary to normalize brain function</a> for the person in recovery. </p>
<p>Just as those with high blood pressure or diabetes may need to remain on medications for the long term, so might some people with opioid use disorder. Keeping people in treatment and alive through use of medications is treatment success, not failure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man walks in a peaceful demonstration carrying a sign saying 'Treatment is Effective #recoverymatters.'" src="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Marchers celebrate National Recovery Month in Grand Rapids, Mich.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sacredheartrehab/15173561710/in/photolist-p7QtfW-27rXxBC-pnimPN-pp41Va-S3zEL3-CbHjig-2h4m9TE-D96W66-27rXxAL-CFYWwb-2h4oKL5-R9cAic-2h4oL3h-pninfh-2h4nZHE-2h4oKRR-2h4m9ED-R9cESH-pnimDh-2h4m9mN-QXFtr2-pp3ZGt-2h4oL1D-2h4nZTz-2oAQSr8-QyZHBY-LZNzgj-R9cD2i-2cqYiND-PUxY8p-f7izxQ-HRdXWU-R9cFd2-QXB1ix-2ojTUQi-2h4kKJb-2hQGWS3-CbHkg8-2ojUFCF-qsmpB6-D1PbJg-2ojPTAR-uRqk2e-vNhxTz-nCKoZG-2hQLtBT-D6Mppq-pqeL95-9TckNM-QXFtEZ">Sacred Heart/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>An <a href="https://www.ncbi.nlm.nih.gov/books/NBK448203/">estimated 3 million Americans</a> have had or currently struggle with opioid use disorder. The latest data from the U.S. Centers for Disease Control and Prevention <a href="https://blogs.cdc.gov/nchs/2023/05/18/7365/">estimates nearly 83,000 deaths in 2022</a> involved opioids.</p>
<p>Methadone, buprenorphine and naltrexone are lifesaving medications. Myths associated with their use cause avoidable relapse, overdose and death by keeping people from using the most effective tool for entering into and maintaining recovery.</p><img src="https://counter.theconversation.com/content/207682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa S. Fry receives funding from Indiana University Addictions Grand Challenge Program, and provides evaluation services to Substance Abuse and Mental Health Services Administration funded programs. </span></em></p><p class="fine-print"><em><span>Melissa Cyders receives funding from Indiana University Addictions Grand Challenge Program and the National Institutes of Alcohol Abuse and Alcoholism.</span></em></p>Prescription medications can help people with opioid use disorder avoid the risks of relapse and overdose. But stigma based on misperceptions about addiction limits their use.Melissa S. Fry, Director, Applied Research and Education Center & Associate Professor of Sociology, Indiana UniversityMelissa Cyders, Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2080262023-06-23T03:09:20Z2023-06-23T03:09:20ZWe are closer than ever to being able to 3D print medicines. Here’s why that’s important<figure><img src="https://images.theconversation.com/files/533596/original/file-20230622-19-sykymu.jpg?ixlib=rb-1.1.0&rect=0%2C411%2C1509%2C1041&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Liam Krueger</span>, <span class="license">Author provided</span></span></figcaption></figure><p>3D-printed medicine could be the future of personalised healthcare, with research now suggesting printed tablets have reached a sufficient quality to match the standards set for conventionally manufactured tablets.</p>
<p><a href="https://doi.org/10.1016/j.ijpharm.2023.123132">Our new study</a>, published in the International Journal of Pharmaceutics, highlights the promise 3D-printed medicines hold for patients.</p>
<p>If we can scale 3D printing to everyday use, the near limitless potential to have medicines customised to your specific health needs may become a reality sooner than you think. </p>
<h2>One size doesn’t fit all</h2>
<p>For a long time, medicines have been produced with what you might call a “one-size-fits-all” approach, whereby tablets and capsules come in only a set number of doses. But what if those exact doses don’t work for you?</p>
<p>Taking too much or too little of your medication can be hard to avoid when it only comes in set doses. This can have serious consequences when taking important medications such as antidepressants that trigger side effects when the dose is changed too quickly.</p>
<p>The traditional solution to these scenarios has been to try and break the tablet into halves or quarters to get a dose in-between. But this isn’t possible for every tablet, and even if it is, research shows it often ends up with an <a href="https://doi-org.ezproxy.library.uq.edu.au/10.1016/j.ijpharm.2018.04.054">inaccurate dose</a>.</p>
<p>3D printing can take away the guesswork and provide flexibility for health professionals to truly personalise medicine suited to you. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-is-it-ok-to-chew-or-crush-your-medicine-39630">Health Check: is it OK to chew or crush your medicine?</a>
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</em>
</p>
<hr>
<h2>Layer by layer</h2>
<p>You may have seen 3D printers producing toys, <a href="https://theconversation.com/millions-of-products-have-been-3d-printed-for-the-coronavirus-pandemic-but-they-bring-risks-137486">medical devices</a> and even <a href="https://theconversation.com/would-you-eat-a-3d-printed-pizza-70335">food</a>.</p>
<p>The printing of medicines uses the same technology, building a tablet one layer at a time by melting the medication combined with other approved ingredients to help it dissolve in the stomach. Importantly, the tablet can be 3D printed at any required dose by giving instructions to the machine to print it bigger or smaller. </p>
<p>In our proof of concept study we were able to 3D print tablets containing very accurate doses of caffeine, in a way that would be exceedingly difficult with conventional manufacturing methods.</p>
<p>Rather than choosing a dose based on limited commercial options, we selected the dose first and then designed and printed the tablet accordingly.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A pile of yellow coloured oval wafers on a purple background" src="https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533607/original/file-20230623-23-pb14vz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A pile of the finished 3D-printed tablets.</span>
<span class="attribution"><span class="source">Liam Krueger</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>While not often thought of as a medicine, the choice of caffeine in this research is important because it is the most widely used behavioural drug worldwide. Trying to cut down on caffeine often causes headaches and nausea because of the challenges in lowering the dose correctly. This is one of many scenarios where a one-size-fits-all approach would fall short.</p>
<p>Compared to attempts to split a conventional caffeine tablet into the same doses, the 3D-printed tablets proved to have far more accurate dosage.</p>
<p>Our results demonstrate a straightforward process for producing “the right medicine for the right patient at the right time”. This is one of the guiding principles of <a href="https://doi.org/10.1111%2Fj.1752-8062.2008.00003.x">personalised medicine</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-cancer-doctors-use-personalised-medicine-to-target-variations-unique-to-each-tumour-47349">How cancer doctors use personalised medicine to target variations unique to each tumour</a>
</strong>
</em>
</p>
<hr>
<h2>A healthcare evolution</h2>
<p>Although 3D printing has been around for decades, its use for producing medicines – especially in a hospital or pharmacy environment – is very new.</p>
<p>Australia has rigorous quality control standards for medicines thanks to regulation by the Therapeutic Goods Administration, and it is too early to tell how it will regulate 3D printed medicines.</p>
<p>The United States already has one 3D-printed seizure medication, Spritam, approved by the Food and Drug Administration (FDA). The printing process helps the resulting tablet <a href="https://spritam.com/making-medicine-using-3d-printing/">rapidly disintegrate in the mouth</a> for patients who have trouble swallowing, but does not offer dose customisation.</p>
<p>However, it seems we are on the brink of customised approaches in the clinic, with three <a href="https://pharmaceutical-journal.com/article/research/3d-printing-of-pharmaceuticals-and-the-role-of-pharmacy">new 3D-printed medications</a> receiving FDA investigational new drug approval over 2021-22, and several other <a href="https://www.fabrx.co.uk/2019/09/03/fabrx-first-clinical-study-3d-printed-dosage-forms">clinical trials</a> completed in the last few years. </p>
<p>We envision 3D printers in pharmacies and hospitals for <a href="https://doi.org/10.5694/mja2.51381">on-site and true personalisation</a>. However, at this stage that doesn’t necessarily mean replacing or even competing with conventional medicines. </p>
<p>The production speed of current 3D printing technologies is much slower than conventional manufacturing. The greatest benefits will likely be for patients with particularly complicated medication regimens, or those taking certain types of medicines like antidepressants. Thus, the people who need it most could have their own tailor-made medicine.</p>
<p>In fact, the possibilities extend further than just choosing the right dose. The practice of pharmaceutical 3D printing could potentially include combining multiple drugs into a single “<a href="https://theconversation.com/3d-printed-drugs-could-be-a-godsend-for-those-on-multiple-pills-a-day-and-potentially-life-saving-119764">polypill</a>”, and fully customising features like shape, size, colour, or texture.</p>
<figure class="align-center ">
<img alt="Video of a 3D printer laying down different colours in a single oval tablet" src="https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533608/original/file-20230623-25-z1rzbl.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A timelapse video showing the proof of concept for a ‘polypill’.</span>
<span class="attribution"><span class="source">Liam Krueger</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We envision an evolution of digital healthcare where 3D printing is combined with technologies like <a href="https://theconversation.com/why-artificial-intelligence-has-not-revolutionised-healthcare-yet-69403">machine learning</a>, artificial intelligence and <a href="https://theconversation.com/explainer-what-is-big-data-13780">big data</a>, taking our next big step towards truly personalised medicine.</p>
<p>This future will require a collaborative effort between researchers, health professionals, and regulatory bodies to define the place of 3D printing in healthcare, but could see us picking up our personalised medicine from a local pharmacy or hospital with the touch of a button.</p><img src="https://counter.theconversation.com/content/208026/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amirali Popat receives funding from The University of Queensland. </span></em></p><p class="fine-print"><em><span>Jared Miles receives funding from The University of Queensland. </span></em></p><p class="fine-print"><em><span>Liam Krueger does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One size doesn’t fit all – customising your medicines with 3D printing could be a game changer, especially for people with complex medical needs.Amirali Popat, Associate Professor and Director of Research, The University of QueenslandJared Miles, Lecturer, The University of QueenslandLiam Krueger, Research scientist, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1967192022-12-21T19:15:07Z2022-12-21T19:15:07ZLecanemab: Experimental drug is a ray of hope for Alzheimer’s disease<figure><img src="https://images.theconversation.com/files/501936/original/file-20221219-12-30f5kc.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C997%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lecanemab is an antibody that attaches to beta-amyloid proteins accumulated in the brain and allows the immune system to get rid of them.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>On Nov. 30, Eisai and Biogen announced the <a href="https://eisai.mediaroom.com/2022-11-29-EISAI-PRESENTS-FULL-RESULTS-OF-LECANEMAB-PHASE-3-CONFIRMATORY-CLARITY-AD-STUDY-FOR-EARLY-ALZHEIMERS-DISEASE-AT-CLINICAL-TRIALS-ON-ALZHEIMERS-DISEASE-CTAD-CONFERENCE">results of their latest phase 3 clinical trial in Alzheimer’s disease</a>. The verdict: an 18-month treatment with lecanemab slows functional and cognitive loss by 27 per cent in people with mild cognitive impairment or mild dementia due to Alzheimer’s disease. <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2212948">The study results were also published in the <em>New England Journal of Medicine</em></a>.</p>
<p>The pharmaceutical company Eisai claims that unlike the drugs already approved for Alzheimer’s treatment, this one is able to slow down the disease rather than just reduce its symptoms.</p>
<p>This good news, however, is only the first step towards finding a real cure for Alzheimer’s.</p>
<p>As neuroscience experts specializing in the study of Alzheimer’s, we are following the search for treatments for this disease very closely.</p>
<h2>Promising but modest results</h2>
<p>Lecanemab is an antibody that attaches to beta-amyloid proteins accumulated in the brain and allows the immune system to get rid of them. In Alzheimer’s, this protein forms aggregates and is thought to contribute to the <a href="https://pubmed.ncbi.nlm.nih.gov/27025652/">initial progression of the disease</a>.</p>
<p>Eisai therefore selected people with the greatest chance of benefitting from the treatment: those in the early stages of the disease or with mild cognitive impairment who have large accumulations of beta-amyloid. This is the case for about <a href="https://pubmed.ncbi.nlm.nih.gov/35099509/">seven out of eight people with a diagnosis of Alzheimer’s and half of those living with mild cognitive impairment</a>. After 18 months of treatment one-third of those treated were at normal levels of beta-amyloid.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="elderly people make a puzzle" src="https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500815/original/file-20221213-22444-zd3iu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An 18-month treatment with lecanemab slows functional and cognitive loss by 27 per cent in people with mild Alzheimer’s disease or mild Alzheimer’s-related cognitive impairment.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This is <a href="https://pubmed.ncbi.nlm.nih.gov/34151810/">not the first time a product has gotten rid of beta-amyloid</a>, but it is the first time a treatment has led to statistically clear cognitive and functional benefits. However, the effect is small: on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3409562/">the 18-point clinical dementia rating scale</a>, treated people lost half a point. The actual impact on the life of a treated person is therefore modest. As Alzheimer’s symptoms progress slowly in the early stages of the disease, it will be important to determine whether the effect continues after more than 18 months.</p>
<h2>Worrisome side effects</h2>
<p>The treatment is also not all good news. It led to a 25 per cent faster shrinkage of the brain. Researchers have attributed this atrophy to the removal of beta-amyloid. However, this is not a universally accepted idea, as the brain levels of <a href="https://pubmed.ncbi.nlm.nih.gov/34224184/">beta-amyloid are too small to explain such shrinkage</a>. The consequences of such shrinkage are unknown.</p>
<p>One-sixth of those treated developed cerebral edema — a build-up of water indicating inflammation. The treatment also led to twice as many brain hemorrhages — about one in six — compared to those who received the placebo. However, only one in 30 people actually experienced symptoms related to these two abnormalities. Although mild microhemorrhages are quite common in the elderly, these could reduce the brain’s ability to adapt. This could therefore <a href="https://jamanetwork.com/journals/jamaneurology/article-abstract/2526492">increase the brain’s vulnerability to diseases such as Alzheimer’s</a>.</p>
<p>Fortunately, subgroups of patients may benefit more from this treatment. Men and people aged 75 and over had a more than 40 per cent reduction in cognitive decline. People without the e4 variant of the APOE gene, the <a href="https://www.science.org/doi/abs/10.1126/science.8346443">main risk factor for Alzheimer’s</a>, experienced fewer side effects while having a greater slowdown in the progression of the disease.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/m_ryJzQBYOY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The drug lecanemab reduces cognitive decline in people with Alzheimer’s, but it also causes sometimes severe side effects.</span></figcaption>
</figure>
<p>Conversely, people carrying two copies of APOE e4 — from both parents — were six times more likely to develop symptoms from brain hemorrhage or edema. In addition, these people did not, on average, experience any positive effects from lecanemab. Having a single copy of APOE e4 seems to allow people to benefit from the treatment while slightly increasing the risk of side effects.</p>
<p>These data offer hope that health-care professionals will be able to select patients who are most likely to benefit from the treatment.</p>
<h2>A resource-intensive treatment</h2>
<p>All indications are that lecanemab will be resource intensive. First, before giving lecanemab to a patient, we need to ensure that his/her brain contains high levels of beta-amyloid. This will require expensive imaging equipment in addition to a team of well-trained professionals.</p>
<p>The antibody must also be injected once every two weeks, requiring more involvement from patients, their relatives and health professionals. To manage the risk of side effects, follow-up imaging will also be essential. Added to this is the cost of the drug itself, which has not yet been announced. According to analysts, this could be <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/eisai-biogen-alzheimers-drug-could-be-available-some-next-year-2022-11-30/#:%7E:text=Several%20estimated%20lecanemab%20may%20be%20priced%20at%20around%20%2420%2C000%20per%20year">nearly US$20,000 per year</a>.</p>
<p>In short, the health-care system and the research community will have to dedicate significant resources to offer this new treatment equitably to the greatest number of people. More medical and neuropsychological follow-ups will be needed, new brain imaging infrastructures will have to be built and specialized personnel will have to be trained.</p>
<p>We must hope that this new treatment will be worth the effort.</p>
<p>Let’s also hope that future clinical trial results will report greater efficacy in women and in people with APOE e4.</p>
<p>After all, lecanemab is just the beginning, and much more will be needed to truly cure Alzheimer’s disease.</p><img src="https://counter.theconversation.com/content/196719/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frederic Calon has received funding from the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council of Canada (NSERC), the Canadian Foundation for Innovation, the Alzheimer Society of Canada and the Fonds de recherche du Québec - Santé (FRQS).</span></em></p><p class="fine-print"><em><span>Étienne Aumont has received funding from the Canadian Institutes of Health Research.</span></em></p>An 18-month treatment with lecanemab slows functional and cognitive loss by 27 per cent in people with mild Alzheimer’s disease. But this is only the first step towards a real cure.Frederic Calon, Professeur, Université LavalÉtienne Aumont, Étudiant au doctorat en psychologie, Université du Québec à Montréal (UQAM)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1953582022-12-12T10:02:30Z2022-12-12T10:02:30ZWomen are 50–75% more likely to have adverse drug reactions. A new mouse study finally helps explain why<figure><img src="https://images.theconversation.com/files/500254/original/file-20221212-94130-c5cvm1.jpg?ixlib=rb-1.1.0&rect=150%2C18%2C5997%2C4161&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/Y14ONzYtxb4">danilo.alvesd/Unsplash</a></span></figcaption></figure><p>Compared to men, we know <a href="https://cshperspectives.cshlp.org/content/14/4/a039156.full">much less about how women experience disease</a>.</p>
<p>Biomedical research helps us understand the timeline of diseases and how we can treat them. In the past, most of it has been conducted on male cells and experimental animals, such as mice. It has been assumed the results from such “pre-clinical” research on males apply to females too.</p>
<p>Yet men and women experience disease differently. That includes how diseases develop, the length and severity of symptoms, and the effectiveness of treatment options.</p>
<h2>Smaller bodies?</h2>
<p>Although these differences <a href="https://theconversation.com/sex-matters-in-biomedical-research-many-conditions-affect-men-and-women-differently-177240">are now widely acknowledged</a>, they are not fully understood. And women are often worse off as a result.</p>
<p>This is the case for prescription drugs. Women <a href="https://pubmed.ncbi.nlm.nih.gov/11770389/">experience around 50-75% more</a> adverse reactions than men. This results in many drugs being pulled from the market due to concerns over health risks for women. </p>
<p>Drug reactions in women have been argued to be <a href="https://www.pnas.org/doi/abs/10.1073/pnas.1516958112">due to sex differences in body weight</a> rather than <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275616/">differences in how the drug works</a> in the body. </p>
<p>Therefore, it’s thought that if drug doses are adjusted according to body weight, women will often receive lower doses than they do now – which may alleviate adverse reactions. </p>
<p>But that may not be the case. </p>
<p>In new research <a href="https://www.nature.com/articles/s41467-022-35266-6">published today in Nature Communications</a>, we show this basic assumption in biomedicine – that females are “smaller versions” of males – is not supported for most pre-clinical traits (things like glucose levels, for example).</p>
<p>So, drug reactions in women are unlikely to be alleviated simply by adjusting the dose to one’s body weight.</p>
<h2>Adverse drug reactions are common and costly for healthcare</h2>
<p>Basing women’s healthcare decisions based on research conducted on men – and vice versa – has potentially profound consequences. In the case of adverse drug reactions, the impacts are significant from both a clinical and economic perspective. </p>
<p>A <a href="https://link.springer.com/article/10.1007/s40264-021-01144-1">recent study</a> estimated that 250,000 hospital admissions in Australia each year are medication related, costing the healthcare system around $1.4 billion annually.</p>
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Read more:
<a href="https://theconversation.com/as-pharmaceutical-use-continues-to-rise-side-effects-are-becoming-a-costly-health-issue-105494">As pharmaceutical use continues to rise, side effects are becoming a costly health issue</a>
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<p>Drug reactions have also been shown to lengthen hospital stays. In a <a href="https://www.bmj.com/content/329/7456/15">large UK study</a>, patients admitted to hospital with an adverse drug reaction stayed for a median of eight days. </p>
<p>Women often cite adverse reactions <a href="https://pubmed.ncbi.nlm.nih.gov/24155839/">as the reason for discontinuing medications</a>. If weight-adjusted dosing of drugs could reduce adverse drug reactions, we would see women receive greater potential benefit from the healthcare system. </p>
<h2>The weight of evidence</h2>
<p>But what evidence do we have that weight adjustment will work? The US Food and Drug Administration (FDA) has already recommended dosage changes for women for some drugs (such as the <a href="https://www.nejm.org/doi/10.1056/NEJMp1307972?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov">sleep drug zolpidem</a>). Additionally, weight-adjusted dosing for some <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2710.2009.01097.x">antifungal drugs</a> and <a href="https://accp1.onlinelibrary.wiley.com/doi/full/10.1177/0091270009359525">antihypertensive drugs</a> appears to work.</p>
<p>On the other hand, drug reactions are <a href="https://link.springer.com/article/10.1186/s13293-020-00308-5">strongly linked to what the drug does in the body in women </a>, and less so in men. There are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644551/">many documented differences in physiology</a> between men and women that relate to how drugs are absorbed and cleared by the body, and not to body weight.</p>
<p>To get to the bottom of this, a broad scale approach is needed. We borrowed a method routinely used in evolutionary biology, known as “<a href="https://www.nature.com/scitable/knowledge/library/allometry-the-study-of-biological-scaling-13228439">allometry</a>”, where a relationship between a trait of interest and body size is examined on a log scale.</p>
<p>We applied allometry analyses to 363 pre-clinical traits in males and females, comprising over two million data points from the <a href="https://www.mousephenotype.org/">International Mouse Phenotyping Consortium</a>.</p>
<p>We focused on one of the most common disease model animals: mice. We asked whether sex differences in pre-clinical traits – such as fat mass, glucose, LDL cholesterol - could be explained by body weight alone. </p>
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<p>Our analyses recovered sex differences in many traits that cannot be explained by body weight differences. Some examples are physiology traits, such as iron levels and body temperature, morphology traits such as lean mass and fat mass, and heart traits such as heart rate variability.</p>
<p>We found the relationship between a trait and body weight varied considerably across all the traits we examined, meaning that the differences between males and females could not be generalized: females weren’t simply smaller versions of males. </p>
<p>Ignoring these differences in some cases, such as measures of blood cells, bone and organs, could result in missing a lot of the population variation for a particular trait: up to 32% for females and 46% for males.</p>
<p>This complexity means we need to consider sex differences for drug dosing on a case-by-case basis. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A chart illustrating the comparison between male and female mouse body size and the resulting effects" src="https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=348&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=348&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=348&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=437&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=437&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500326/original/file-20221212-96906-krmmcp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=437&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Results of allometry analyses demonstrate that just adjusting the dose for weight is not sufficient to alleviate adverse effects.</span>
<span class="attribution"><span class="source">Szymon Drobniak</span></span>
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</figure>
<h2>One size does not fit all</h2>
<p>In an era where personalised medicine interventions are within reach, and patient-specific solutions are on the horizon, we now know that <a href="https://pubmed.ncbi.nlm.nih.gov/26503700/">sex-based data are much needed</a> to advance care in an equitable and effective manner. </p>
<p>Our study uncovers the ways in which males and females can vary across many pre-clinical traits, indicating that biomedical research needs to focus more closely on measuring how and in what ways the sexes differ. </p>
<p>Particularly, when a relationship between sex and drug dose is uncovered, our data suggest dose-response is likely to be different for males and females.</p>
<p>The methods in our study could help clarify the nature of these differences and provide a path forward to reducing drug reactions.</p>
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Read more:
<a href="https://theconversation.com/the-evolutionary-history-of-men-and-women-should-not-prevent-us-from-seeking-gender-equality-88703">The evolutionary history of men and women should not prevent us from seeking gender equality</a>
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<img src="https://counter.theconversation.com/content/195358/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura A. B. Wilson receives funding from the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Shinichi Nakagawa receives funding from the Australian Research Council.</span></em></p>The assumption that females are just smaller versions of males has been widely used in biomedical research. A new mouse study indicates that’s unlikely to be true.Laura A. B. Wilson, ARC Future Fellow, Australian National UniversityShinichi Nakagawa, Professor of Evolutionary Biology and Synthesis, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1940412022-11-09T00:25:16Z2022-11-09T00:25:16ZHay fever can sometimes be more serious than we think. This is why we should know our treatment options<figure><img src="https://images.theconversation.com/files/493724/original/file-20221107-11-xo27jm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7054%2C3537&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-woman-sneezing-blowing-nose-photo-1366461485">shutterstock</a></span></figcaption></figure><p>Hay fever (also known as allergic rhinitis) is a catch-all term that covers a group of ailments that cause sneezing, a runny nose, and itchy and red eyes.</p>
<p>Hay fever affects <a href="https://www.aihw.gov.au/getmedia/f155276c-b1c1-4bb9-94de-e7e09555bce4/13567.pdf.aspx?inline=true">millions</a> of people in Australia. Ask your friends and colleagues about hay fever and chances are several will report they have it. However, they will probably describe different triggers, symptoms and <a href="https://www.allergy.org.au/patients/allergic-rhinitis-hay-fever-and-sinusitis/guide-to-common-allergenic-pollen">seasons</a> when it occurs. </p>
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<p>Although it may seem like more of an annoyance than anything else, uncontrolled hay fever can have <a href="https://www.sciencedirect.com/science/article/abs/pii/S0091674997800425">economic</a> and further health effects. </p>
<p>Hay fever can reduce people’s ability to concentrate, for example when driving or at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904041/">work</a> or <a href="https://pubmed.ncbi.nlm.nih.gov/17560637/">school</a>. This is made worse with hay fever also leading to <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/410859">disturbed sleep</a>, affecting <a href="https://aacijournal.biomedcentral.com/articles/10.1186/s13223-021-00615-5">mood</a>.</p>
<p>Nasal inflammation from allergies also has a concerning impact on an individual’s defences against infection. The inflammation from hay fever and the need to mouth breathe has a direct <a href="https://thorax.bmj.com/content/67/7/582.short">impact on asthma</a>, leading to worse symptom control and a greater risk of a flare-up that requires unscheduled health care.</p>
<p>To reduce these risks, a range of treatments are available. However, before considering treatment, we need to consider what’s going wrong and why.</p>
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Read more:
<a href="https://theconversation.com/lush-grasslands-higher-allergy-risks-what-hay-fever-sufferers-can-expect-from-another-la-nina-season-189982">Lush grasslands, higher allergy risks – what hay fever sufferers can expect from another La Niña season</a>
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<h2>What is hay fever?</h2>
<p>In addition to genetic factors, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436881">environmental exposures</a> such as airborne pollutants can dramatically predispose people to allergies.</p>
<p><strong>Common causes</strong></p>
<p>Causes of hay fever fall in three main groups:</p>
<ul>
<li><p>seasonal: pollens and plant materials that give symptoms at certain times of the year. Calendar charts of the various pollens are available</p></li>
<li><p>perennial/symptoms year round: however clean your house is, you will be exposed to fungal spores and to faeces from dust mites feeding off your dead skin cells. That sounds unsettling enough, but they can both be potent allergens that can’t be effectively avoided</p></li>
<li><p>intermittent: most typically these are animals’ dead skin. It’s worth noting the culprits are molecules in saliva, sweat and urine, not hair.</p></li>
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Read more:
<a href="https://theconversation.com/pollen-does-more-than-make-you-sneeze-it-can-cause-thunderstorm-asthma-even-if-youre-not-asthmatic-190235">Pollen does more than make you sneeze. It can cause thunderstorm asthma, even if you're not asthmatic</a>
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<h2>What treatments are best for hay fever?</h2>
<p>Given these serious consequences, it’s reassuring to know there are effective treatments for hay fever. These range from common over-the-counter products to specialist medicines. </p>
<p><strong>Antihistamines</strong></p>
<p>Many people will immediately think of antihistamines for hay fever: by tablet, nasal spray or eye drops. Histamine is a key messenger chemical in the allergy process, but it isn’t the only one. Therefore, antihistamines alone are usually usually only sufficient to get on top of mild problems.</p>
<p>There are a large number of antihistamines available with a range of effectiveness. Although many are available without prescription, bear in mind some are sedating, and some are unsafe in pregnancy, or when you have certain cardiac conditions, and may clash with some other medicines.</p>
<p><strong>Nasal treatments</strong></p>
<p>Nasal sprays apply treatment directly to microscopic hairs in the nose, helpfully spreading the medicine around. Many people take over-the-counter nasal corticosteroid spray to dampen down inflammation. </p>
<p>As a physician I’ve found it’s common in clinic for people to say sprays “don’t work” for them but usually this is because they don’t take them properly. These <a href="https://pubmed.ncbi.nlm.nih.gov/29050548/">treatments</a> can take many days to work, and need to be taken regularly every day. The trick is: don’t sniff them (the medicine will end up in the back of your throat), or spray them onto the sensitive middle part of the nose, which can bleed.</p>
<p>Saline sinus rinses can be very helpful in clearing mucus, allergens and inflammatory material (snot, to you and me) before using other medicines. <em>Always</em> use sterile liquids for this or nasty sinus infections can occur.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/sneezing-with-hay-fever-native-plants-arent-usually-the-culprit-190336">Sneezing with hay fever? Native plants aren't usually the culprit</a>
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<p><strong>Decongestants</strong></p>
<p>Decongestants might seem like a good idea when you can’t breathe, but are associated with a rebound worsening of swelling when they wear off (this has the excellent name of rhinitis medicamentosa). </p>
<p>As for many chemicals, if you take them long enough the body switches off its own supply (negative feedback) so when the drug is removed, the body is worse off. Think about how someone feels if they haven’t had a coffee all day and normally drinks four or five cups. There is a rebound of blood vessel dilation and mucus production. Use them sparingly.</p>
<figure class="align-center ">
<img alt="A person is standing outside using nasal spray. They wear glasses." src="https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493735/original/file-20221107-23-zcbtt7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A lack of success of allergy treatments such as nasal sprays are often due to them not being used correctly.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-africanamerican-ethnicity-using-nasal-spray-2155318875">shutterstock</a></span>
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<h2>Prescribed therapies</h2>
<p>If your hay fever is more severe, your doctor could consider a course of higher-strength nasal steroid drops, but these aren’t to be used for longer than a month as they can cause erosion of the nasal lining. </p>
<p>Adding a medicine that acts on other key messengers of inflammation (leukotrienes), such as montelukast, can sometimes be helpful. These tablets are usually well tolerated but can have side effects such as headache which lead to their discontinuation. </p>
<p>Validated scores that ask a standard set of questions about aspects of someone’s symptoms (such as “SNOT-22”) are helpful in assessing who needs extra prescription-based treatment for hay fever and their response to it.</p>
<h2>Specialist treatments</h2>
<p>For people with hay fever alongside asthma or other allergic disease, there are now effective medicines that block messengers of allergy in a highly specific manner, such as the <a href="https://pubmed.ncbi.nlm.nih.gov/29355679/">monoclonal antibody</a> Dupilumab, and more are <a href="https://erj.ersjournals.com/content/52/suppl_62/PA5248">coming soon</a>. Although too costly to be prescribed in hay fever alone, they show our understanding of the relevant mechanisms has improved.</p>
<p>Giving people a regular small dose of something they are sensitised to can make their immune system more tolerant of it. This is often referred to as immunotherapy, and can be by regular tablet or injection. </p>
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Read more:
<a href="https://theconversation.com/im-considering-allergen-immunotherapy-for-my-hay-fever-what-do-i-need-to-know-190408">I’m considering allergen immunotherapy for my hay fever. What do I need to know?</a>
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<p>Although <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(21)00261-1/fulltext">potentially very helpful</a>, this treatment takes years and many people <a href="https://www.ingentaconnect.com/content/ocean/aap/2021/00000042/00000001/art00015;jsessionid=18yqw4ncvah8.x-ic-live-01#">don’t complete their course</a>. The improvements seen are incremental rather than a complete <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132438/">permanent resolution</a>.</p>
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<p><em>This article does not constitute specific medical advice. Please do speak to your GP, specialist or pharmacist about using the medicines mentioned here. You may also wish to review the helpful information and videos from <a href="https://asthma.org.au/about-asthma/triggers/hay-fever/">Asthma Australia</a></em></p><img src="https://counter.theconversation.com/content/194041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Blakey and/or his employer has received funding for research or educational activities from companies that produce treatments for asthma, including Astra Zeneca, Boehringer Ingelheim, Chiesi, GSK, Novartis, Sanofi and Teva. He is affiliated with Asthma Australia and Asthma WA in a medical advisory capacity for which his organisation receives income. He is the WA branch president of the Thoracic Society of Australia and New Zealand. None of these entities had any input into or influence on this article.</span></em></p>Hay fever treatment options range from common over-the-counter products to specialist medicines.John D Blakey, Adjunct Clinical Associate Professor - Curtin Medical School, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1915742022-10-04T19:06:35Z2022-10-04T19:06:35ZADHD medications have doubled in the last decade – but other treatments can help too<figure><img src="https://images.theconversation.com/files/487926/original/file-20221003-24-1m0vbv.jpg?ixlib=rb-1.1.0&rect=16%2C48%2C3581%2C1844&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-checking-ingredient-bottle-drug-1163725534">shutterstock</a></span></figcaption></figure><p>A recent detailed analysis of prescribing trends for ADHD medications in Australia found prescriptions for ADHD medications <a href="https://pubmed.ncbi.nlm.nih.gov/35999695/">doubled</a> from 2013 to 2020. While this is clearly an important finding, it needs to be considered within the context of overall rates of prescribing, the recommendations of guidelines and, importantly, the prevalence of ADHD. </p>
<p>ADHD stands for attention-deficit hyperactivity disorder. About 5% of children and adolescents and 2.5% of adults worldwide <a href="https://www.sciencedirect.com/science/article/pii/S014976342100049X/">have ADHD</a>. While ADHD is a neurodevelopmental disorder that generally begins in childhood, the symptoms and/or difficulties associated with the disorder <a href="https://www.sciencedirect.com/science/article/pii/S014976342100049X">continue</a> into adolescence and adulthood. </p>
<p>In Australia, and many countries outside of North America, ADHD is still under-diagnosed in childhood. This means that for many, ADHD will be first diagnosed in adulthood.</p>
<p>International <a href="https://link.springer.com/article/10.1007/s00787-021-01871-x">ADHD guidelines</a> list medications as the most effective approach to reduce core ADHD symptoms. But non-medication treatments can provide additional support to minimise the daily impact of ADHD symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1576501799938183170"}"></div></p>
<h2>So, what is ADHD?</h2>
<p>The main features of ADHD are having real and substantial difficulty keeping attention and focus (particularly for activities that aren’t of high interest), poor organisational skills, forgetfulness, impulsivity (making decisions before thinking) and overactivity (restless, fidgety, always on the go). </p>
<p>We all experience some of these symptoms from time to time, but for those with ADHD, these symptoms are experienced at a high level most of the time, and impact negatively on daily life. ADHD is not new; reports of the condition we now refer to as ADHD can be traced all the way back to <a href="https://www.sciencedirect.com/science/article/pii/S014976342100049X">the 1700s</a>.</p>
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Read more:
<a href="https://theconversation.com/should-adhd-be-in-the-ndis-yes-but-eligibility-for-disability-supports-should-depend-on-the-person-not-their-diagnosis-191576">Should ADHD be in the NDIS? Yes, but eligibility for disability supports should depend on the person not their diagnosis</a>
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<h2>Why are prescriptions for ADHD medication in Australia increasing?</h2>
<p>Current <a href="https://link.springer.com/article/10.1007/s00787-021-01871-x">ADHD guidelines</a> recommend medication as a first line treatment for ADHD. It would therefore not be surprising to see rates of prescription increasing, as as recognition improves and the rates of diagnosis track more closely with actual rates of ADHD. </p>
<p><a href="https://journals.sagepub.com/doi/abs/10.1177/00048674221114782">Current data</a> suggest around 4% of children and adolescents are being treated for ADHD, which is reasonable considering a prevalence of around 5%.</p>
<p>For adults, however, the rates are much lower, <a href="https://journals.sagepub.com/doi/abs/10.1177/00048674221114782">around 0.4%</a>. This means that fewer than one in five adults with ADHD are currently receiving ADHD medication. While this is an improvement on 2013 – when the rates were less than half of this – there is clearly some way to go.</p>
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Read more:
<a href="https://theconversation.com/i-think-i-have-adhd-how-do-i-get-a-diagnosis-what-might-it-mean-for-me-190239">I think I have ADHD, how do I get a diagnosis? What might it mean for me?</a>
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<h2>What are the main medications for ADHD?</h2>
<p>Several medications have been shown to be very effective at <a href="https://pubmed.ncbi.nlm.nih.gov/30097390">reducing</a> the core symptoms of ADHD in children, adolescents and adults. </p>
<p>Medications which are stimulants such as methylphenidate, dexamfetamine and lisdexamfetamine are now considered to be the <a href="https://pubmed.ncbi.nlm.nih.gov/34677682/">first line</a> medications for ADHD. These medications are thought to work by increasing the efficiency in several key brain circuits through their action on the neurotransmitters dopamine (the chemical in the brain that makes you feel good) and noradrenaline (the chemical that when released increases alertness and attention). The effects of these medications are rapid and can be seen <a href="http://cpo-media.net/ADHD/2019/ebook/HTML/92/">almost immediately</a>.</p>
<p>Two non-stimulant medications are licensed for the treatment of ADHD, atomoxetine and guanfacine. The non-stimulants are less effective than the stimulants and typically take several weeks to have a clinical effect. For these reasons they are generally reserved as <a href="http://cpo-media.net/ADHD/2019/ebook/HTML/92/">second line</a> treatments.</p>
<p>ADHD medications are not easy to obtain. They can only be prescribed to people who have received a diagnosis of ADHD. For many people this can be a long process due to a shortage of properly trained clinicians. Current guidelines require ADHD be diagnosed by a health professional who has <a href="https://www.nice.org.uk/guidance/ng87">experience</a> in the area such as a paediatrician, psychiatrist or psychologist.</p>
<p>The diagnostic process for ADHD should involve a detailed clinical history that explores when the symptoms started and how they impact on daily life. As part of the assessment of ADHD in children, information should be collected from parents and school. For adults seeking a new diagnosis, there is a need for evidence of symptom onset in childhood. This may involve the health professional reviewing old school reports or speaking with the adults’ parents.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/we-cant-solve-australias-mental-health-emergency-if-we-dont-train-enough-psychologists-here-are-5-fixes-190135">We can't solve Australia's mental health emergency if we don't train enough psychologists. Here are 5 fixes</a>
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<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1573834481026449411"}"></div></p>
<h2>What other non-medication supports should be offered?</h2>
<p>Supports will differ for children/adolescents and adults. Regardless of age, modifications to the environment should be considered to best support the person. This could involve making modifications to the environment at school or in the workplace for adults. </p>
<p>Sleep deprivation can exacerbate the symptoms of ADHD and so lifestyle modifications may be considered to help reduce the impact of ADHD such as <a href="https://pubmed.ncbi.nlm.nih.gov/30654852/">getting a good night’s sleep</a> and regular physical activity. Most people with ADHD also have one or more additional mental health difficulties (such as <a href="https://www.sciencedirect.com/science/article/pii/S014976342100049X">anxiety or depression</a>). These additional challenges need to be considered when planning treatment and supports. </p>
<p>For children with ADHD, the main evidence-based non-medication support that can be offered is <a href="https://www.sciencedirect.com/science/article/pii/S0890856721002331">support for parents</a>. This is not because ADHD is caused by bad parenting; there is no evidence to suggest this. Rather, parents often need the option for support because parenting a child with ADHD can be challenging at times. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0890856721002331">Research shows</a> providing support for parents of children with ADHD is associated with more positive parenting behaviours and less strained parent-child relationships. For older adolescents and adults with ADHD, the main non-medication support that can be offered are cognitive behavioural therapies, which can help to <a href="https://pubmed.ncbi.nlm.nih.gov/27554190">minimise</a> the day-to-day impact of ADHD. </p>
<p>The treatment of ADHD should be comprehensive and will usually include <a href="https://www.sciencedirect.com/science/article/pii/S014976342100049X">both</a> medication and non-medication interventions. However, which treatment works best for which patient, depends on the individual and how ADHD affects their life.</p>
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<strong>
Read more:
<a href="https://theconversation.com/adhd-looks-different-in-adults-here-are-4-signs-to-watch-for-178639">ADHD looks different in adults. Here are 4 signs to watch for</a>
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<img src="https://counter.theconversation.com/content/191574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Coghill receives funding from The National Health & Medical Research Council and the Medical Research Future Fund. He consults to Takeda, Medice, Novartis & Servier. He is a board member and director of the Australian ADHD Professionals Association.</span></em></p><p class="fine-print"><em><span>Emma Sciberras receives funding from the National Health and Medical Research Council, the Medical Research Future Fund, veski, the Waterloo Foundation, and internal research funding from Deakin University. She is a member and director of the Australian ADHD Professionals Association.</span></em></p>Prescriptions for ADHD medications have doubled in the last decade in Australia. Medication is the best treatment for ADHD, however non-medicated treatments are also helpful.David Coghill, Financial Markets Foundation Chair of Developmental Mental Health, The University of MelbourneEmma Sciberras, Associate Professor, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1880412022-09-28T20:13:23Z2022-09-28T20:13:23ZWhy Viagra may be useful in treating lung diseases<figure><img src="https://images.theconversation.com/files/487160/original/file-20220928-6321-to39aq.jpg?ixlib=rb-1.1.0&rect=52%2C70%2C910%2C589&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The blood vessel dilation caused by sildenafil (Viagra) can be beneficial in lung diseases such as pulmonary arterial hypertension or idiopathic pulmonary fibrosis.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>You may be surprised to learn that the medication sildenafil — better known by its brand name Viagra — has other medical purposes aside from treating male erectile dysfunction. It can also be used to treat lung diseases that often have poor prognoses.</p>
<p>Sildenafil works by inhibiting an enzyme called phosphodiesterase. Through <a href="https://doi.org/10.1038/nrd2030">a complex pathway involving other molecules</a>, sildenafil ultimately helps smooth muscles relax and blood vessels dilate. The latter effect is known as vasodilation. Vasodilation results in more blood flow to organs — whether that organ is the penis or the lungs.</p>
<h2>Lung diseases</h2>
<p>The vasodilation caused by sildenafil can be beneficial in lung diseases such as pulmonary arterial hypertension (PAH) or idiopathic pulmonary fibrosis (IPF). People living with PAH and IPF experience progressive shortness of breath and chronic cough. In addition to lungs, PAH and IPF can affect many other organ systems. </p>
<p>PAH is a disease causing breathing difficulties and heart strain due to elevated pressure in the arteries of the lung, which were designed for much lower pressures. Thankfully, <a href="https://rarediseases.org/rare-diseases/pulmonary-arterial-hypertension/">it is a rare disease, affecting one or two individuals per 1,000,000 persons each year</a>. </p>
<p>IPF is a more common lung disease with between <a href="https://rarediseases.org/rare-diseases/idiopathic-pulmonary-fibrosis/">two and 29 people per 100,000 developing the condition per year</a>. It occurs due to repeated and chronic thickening, stiffening and scarring (fibrosis) of the lungs. </p>
<p>Both diseases often do not have a clear etiology, meaning that doctors and researchers do not fully understand why these diseases begin and progress. Both diseases are incurable, and frequently get worse over time despite our best treatment options. There are currently few effective treatments, and there is always interest in finding more. </p>
<h2>Evidence for sildenafil in PAH</h2>
<figure class="align-center ">
<img alt="Illustration of human respiratory system with lungs in red and yellow against a blue background" src="https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487162/original/file-20220928-8992-z4f7qh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">There are currently few effective treatments for pulmonary arterial hypertension or idiopathic pulmonary fibrosis.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>The use of sildenafil in PAH is already well established, effective and approved in Canada. There are several high quality randomized controlled trials that have demonstrated its efficacy to <a href="http://doi.org/10.1056/NEJMoa050010">improve exercise capacity and symptom burden</a>. Sildenafil is usually branded as Revatio in PAH (instead of Viagra for erectile dysfunction), although there is little difference between Viagra and Revatio except that patients typically take Revatio <a href="https://www.drugs.com/revatio.html">three times per day in smaller doses</a>. </p>
<p>Our recent publication <a href="http://doi.org/10.1183/16000617.0036-2022">synthesized the evidence for multiple PAH treatments</a>. We looked at combinations of sildenafil or another drug in the same class — such as tadalafil (brand name Cialis) or vardenafil (brand name Levitra) — with another commonly used PAH medication. </p>
<p>The results showed the number of clinical worsening events such as disease progression or hospitalization were reduced by 12.7 per cent compared to placebo. Markers of exercise capacity, measured by a six-minute walk test, were also improved by almost 50 meters. </p>
<h2>Evidence for sildenafil in IPF</h2>
<p>The use of sildenafil in IPF is much less certain, as there have been few randomized controlled trials, which are considered the gold standard of evidence. Just four trials have investigated its use in IPF. <a href="http://newzcap.com/does-viagra-reduce-mortality-in-pulmonary-fibrosis-does-viagra-reduce-mortality-in-pulmonary-fibrosis/">A meta-analysis of this small number approached statistical significance, which suggests that benefits would become evident if more trials were completed</a>.</p>
<p>The most recent <a href="https://www.thoracic.org/education-center/ild/pdf/ATS%20Pocket%20Guide_v1.pdf">European Respiratory Society / American Thoracic Society guidelines</a> addressing the question recommended against the use of sildenafil in IPF due to a lack of data. </p>
<p>However, recently a drug (treprostinil) that acts similarly to sildenafil showed promise in patients with combined interstitial lung disease (an umbrella term of lung diseases that includes IPF) and pulmonary hypertension. The <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2008470">greatest effect seen in patients with diagnosed interstitial lung disease</a>. </p>
<p>This further demonstrates the potential promise of drugs like sildenafil or similar vasodilation mechanisms in managing IPF.</p>
<h2>Why this matters</h2>
<p>For conditions like PAH or IPF that are incurable, re-purposing drugs like sildenafil has merit. For one thing, it is very expensive to develop new drugs. For another, there are more concerns about safety with new drugs; since Viagra is widely used, the side-effect profile is well known in the medical community. </p>
<p>For example, sildenafil is known to cause low blood pressure and should be avoided in people with conditions making them susceptible to hypotension or taking specific anti-high blood pressure medications. Other common side-effects include flushing, headaches and vision changes, among others. </p>
<p>While sildenafil may not be the magic pill for all lung diseases, it’s clear that it has promising uses that go beyond erectile dysfunction.</p><img src="https://counter.theconversation.com/content/188041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dena Zeraatkar receives funding from the Banting postdoctoral scholarship. </span></em></p><p class="fine-print"><em><span>Jasmine Mah is an Internal Medicine resident with Nova Scotia Health and receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Foundation, and the Pierre Elliott Trudeau Foundation. She is affiliated with the Canadian Consortium on Neurodegeneration in Aging (CCNA) Team 14, which investigates how multi-morbidity, frailty and social context modify risk of dementia and patterns of disease expression. The CCNA receives funding from the Canadian Institutes of Health Research (CNA-137794) and partner organizations (<a href="http://www.ccna-ccnv.ca">www.ccna-ccnv.ca</a>). The affiliations/funders had no input into any aspect of this subject or article.</span></em></p><p class="fine-print"><em><span>Tyler Pitre does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sildenafil — better known as Viagra — may be helpful in treating lung diseases like pulmonary arterial hypertension and idiopathic pulmonary fibrosis, for which there are few effective treatments.Tyler Pitre, MD (Internal medicine physician), McMaster UniversityDena Zeraatkar, Assistant professor, Health Research Methods Evidence and Impact and Anesthesiology, McMaster UniversityJasmine Mah, MD (Internal Medicine Resident) & PhD candidate (Focus on Geriatrics), Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1904762022-09-23T15:08:55Z2022-09-23T15:08:55ZHere’s why so many medications are out of stock — and what to do if it affects you<figure><img src="https://images.theconversation.com/files/486240/original/file-20220923-19-x9h30l.jpg?ixlib=rb-1.1.0&rect=17%2C0%2C5973%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's unlikely shortages will go away anytime soon.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/empty-blister-packs-medicines-lack-treatment-1697197933">asobov/ Shutterstock</a></span></figcaption></figure><p>Millions of people worldwide who use certain common medicines may be finding it more difficult to get their normal prescriptions dispensed. This comes after pharmacies across the UK, <a href="https://www.ashp.org/drug-shortages/shortage-resources/drug-shortages-statistics?loginreturnUrl=SSOCheckOnly">the US</a> and <a href="https://www.ema.europa.eu/en/human-regulatory/post-authorisation/availability-medicines/shortages-catalogue#ema-shortages-catalogue-section">Europe</a> have all reported shortages of <a href="https://www.chemistanddruggist.co.uk/CD136364/Worse-than-ever-Which-medicines-are-pharmacists-struggling-to-stock?utm_medium=email&utm_source=sfmc&utm_campaign=2022_02_09_CDDaily&utm_id=4420017&sfmc_id=88991113">many different drugs</a>, including those often prescribed for menopause, dementia, depression and pain.</p>
<p>There are <a href="https://psnc.org.uk/dispensing-and-supply/supply-chain/medicine-shortages/">many reasons why</a> disruptions in the pharmaceutical supply chain occur, including manufacturing issues, supplier and price changes, increased demand, stockpiling and panic buying. For example, both reduced supply and growing demand may partly explain why <a href="https://www.gov.uk/government/news/vaccine-taskforce-director-general-will-harness-lessons-from-pandemic-to-address-hrt-supply-chain-issues">hormone replacement therapy</a> (HRT) products have faced recent shortages. </p>
<p>There is no one clear root cause of the current global medicines shortages, and each country will face different challenges with supplies. But factors such as the pandemic, Brexit, reduced supplies from over-used supply routes (such as India) and the Ukraine conflict, all have widespread effects on the availability of medicines. </p>
<p>But disruptions in the supply chain can be more than just a minor annoyance for patients trying to get their prescriptions. It could potentially lead to delays in patient treatments and <a href="https://www.eahp.eu/sites/default/files/report_medicines_shortages2018.pdf">even fatalities</a>. </p>
<p>People unable to get their usual prescription may try swapping medications, accessing products online, or even buying them over-the-counter. Not only can this be <a href="https://news.sky.com/story/hrt-to-be-sold-over-the-counter-without-prescription-for-first-time-12692505">more expensive</a>, it may also <a href="https://www.theguardian.com/society/2022/apr/26/women-risking-their-health-to-source-hrt-amid-shortages-uk-gp-chief-warns">put patients at risk</a> of adverse effects. </p>
<h2>What’s being done</h2>
<p>When supplies are restricted, pharmacy staff will try to source stock from suppliers or other pharmacies. Where an alternative product already exists, pharmacy staff will contact GPs to ask for prescriptions to be changed to give this to patients. But patients should be made aware if their medication is switched to <a href="https://pharmaceutical-journal.com/article/news/some-patients-switched-to-edoxaban-without-being-properly-informed-pharmacists-say">avoid confusion</a> and any negative side effects.</p>
<p>When major product shortages are reported, serious shortages protocols <a href="https://psnc.org.uk/dispensing-and-supply/supply-chain/ssps/#:%7E:text=SSPs%20may%20be%20used%20to%20reduce%20the%20quantity,a%20branded%20product%3B%20or%20rarely%20an%20alternative%20product">can be enacted</a>. These help pharmacies to manage medicine shortages without needing to refer patients back to prescribers. For example, if these protocols are enacted pharmacists may supply alternative products (if a patient agrees to this), or adjust prescription quantities – such as giving patients only a one-month supply at a time.</p>
<figure class="align-center ">
<img alt="An elderly man speaks with a young female pharmacist about his prescription." src="https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486241/original/file-20220923-2077-rb428h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your pharmacist may be able to help you understand any medication changes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/filling-prescriptions-customers-needs-shot-young-2117022104">PeopleImages.com - Yuri A/ Shutterstock</a></span>
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<p>Manufacturers are also <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/979531/DHSC_Reporting_Requirements_for_Medicines_Shortages_and_Discontinuations.pdf">legally required</a> to report supply disruptions to the Department of Health and Social Care. This information is fed into the <a href="https://www.sps.nhs.uk/">Medicines Supply Tool</a> that advises healthcare professionals on supply issues, actions to take, alternatives to use and expected resolution dates. Local pharmacy staff and GPs will also report any product shortages to government agencies and with patients. </p>
<h2>Patient information</h2>
<p>While some might argue that patients shouldn’t have to get involved in accessing their own medications, it can be very helpful when there are shortages. Here are some things you can do if your medication is becoming more difficult to source.</p>
<p>If you take a particular medication on a repeat basis, you can request your prescriptions earlier, before your current supplies run out. There are also online resources you can check, which explain more about medication shortages and <a href="https://www.northgatemedicalcentre.nhs.uk/pharmacies-and-nhs-medicine-supplies/">what you can do</a>. </p>
<p>If your local pharmacy doesn’t have your medication, you can try other pharmacies to find the medication before the prescription has to be changed to an alternative product. </p>
<p>You can also work with your GP or pharmacist to better understand what’s happening and what you can do. If you can’t get an appointment with your GP or speak to your local pharmacist team in person, there are apps which <a href="https://airmidcares.co.uk/">allow direct messaging</a>. This can help dispel any confusion and allow you to discuss concerns you may have. </p>
<p>It’s worth noting that product changes in community pharmacy are only allowed when serious shortage protocols are in place. At the moment, serious shortage protocols are only in place for <a href="https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/serious-shortage-protocols-ssps">16 UK medications</a> – mainly those used as hormone replacement therapy. These protocols are only enacted if a serious shortage of a particular medication has been declared. </p>
<p>It’s unlikely that medicines shortages are going to be resolved anytime soon. As such, it’s important you speak with your pharmacist or GP about any concerns you have, how shortages affect your medication supply, and what course of action you may need to take. It’s important you don’t use an alternative product without speaking to your pharmacist, nurse or doctor to avoid adverse side effects.</p><img src="https://counter.theconversation.com/content/190476/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many common medications – including those prescribed for menopause, dementia, and depression – are currently seeing shortages worldwide.Liz Breen, Director of the Digital Health Enterprise Zone (DHEZ), University of Bradford, Professor in Health Service Operations, University of BradfordJonathan Silcock, Associate Professor in Pharmacy Practice, University of BradfordZoe Edwards, Research Fellow in Medicines Optimisation, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1851932022-06-22T02:00:37Z2022-06-22T02:00:37ZHow digital tech can help people with asthma manage their meds and reduce the risk of attacks<figure><img src="https://images.theconversation.com/files/469922/original/file-20220621-15-g76syn.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2748%2C1992&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Modern medical science has made remarkable progress in the treatment of asthma. <a href="https://www.healthnavigator.org.nz/health-a-z/a/asthma-medication/">Inhalers containing steroids</a> are particularly effective in preventing an asthma attack. But getting people to take these preventive medicines long-term remains a challenge. </p>
<p>Because asthma is an ongoing condition, many people struggle to take their medication regularly, due to busy schedules or because the medication <a href="https://pubmed.ncbi.nlm.nih.gov/19995138/">may not seem to work right away</a>. </p>
<p>One potential solution lies in digital technologies that can reduce the risks associated with not taking medication as prescribed. These technologies include text message reminders, web-based apps, interactive voice response systems and smart inhalers.</p>
<p>The benefits could be considerable, given that asthma is one of the commonest health problems. It affects as many as <a href="http://globalasthmareport.org/">339 million people worldwide</a>. New Zealand has one of the highest rates of asthma, with one in seven children and one in eight adults <a href="https://www.hqsc.govt.nz/our-data/atlas-of-healthcare-variation/asthma/#:%7E:text=Internationally%2C%20New%20Zealand%20has%20a,reporting%20taking%20current%20asthma%20medication.">diagnosed</a>. </p>
<p>Asthma attacks are also the commonest cause of days off school and work for people with the condition. In the UK it’s <a href="https://www.nhs.uk/conditions/asthma/asthma-attack/">estimated</a> someone has a potentially life-threatening asthma attack every ten seconds, with similar data in New Zealand. Asthma mortality is <a href="https://www.hqsc.govt.nz/our-data/atlas-of-healthcare-variation/asthma/#:%7E:text=Internationally%2C%20New%20Zealand%20has%20a,reporting%20taking%20current%20asthma%20medication.">highest for Māori and Pacific peoples</a>, with rates 4.3 and 3.2 times higher than for other groups. </p>
<p>While there are inhalers that work well on immediate symptoms, preventive medicines are key for long-term asthma control. These need be taken as prescribed, often once or twice a day. What’s known as “non-adherence” to such regimes is a major health problem and can lead to more symptoms and attacks. </p>
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<img alt="" src="https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469924/original/file-20220621-13-930myg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Preventive treatments can be very effective, but sticking to a prescription is challenging for many.</span>
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<h2>Medication adherence strategies</h2>
<p>Achieving adherence is therefore very important to reduce the risk of death. With increasing investment in digital technologies designed to improve health, the research focus with asthma is on improving how existing medications are used and therefore improving outcomes. </p>
<p>Research in New Zealand has shown <a href="https://www.news-medical.net/health/What-are-Smart-Inhalers.aspx">“smart” inhalers</a> – devices that monitor when doses are taken and can provide reminders and feedback – <a href="https://www.nzherald.co.nz/nz/smart-inhaler-gives-asthma-kids-improved-quality-of-life/IWRT4UUO6XXLX6QKT2Z7UO6P2I/">improved medication adherence</a> by 50% and improved control in children with asthma. </p>
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Read more:
<a href="https://theconversation.com/time-in-hospital-sets-back-tens-of-thousands-of-childrens-learning-each-year-but-targeted-support-can-help-them-catch-up-184313">Time in hospital sets back tens of thousands of children's learning each year, but targeted support can help them catch up</a>
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<p>But we still don’t know whether digital technologies in general can improve the situation for all people with asthma and, even if they do, whether this will have a positive impact on asthma symptoms or attacks.</p>
<p>To learn more, we looked at all the randomised controlled trials of digital technologies and their impact on medication adherence in asthma. We found <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013030.pub2/full">40 studies</a> around the world, with a collective sample base of more than 15,000 adults and children with asthma. </p>
<p>By pooling the data from all the separate trials, we were able to measure whether people who used digital technologies to improve their medication regime had better adherence – and fewer asthma symptoms and attacks – than those who did not.</p>
<h2>How digital technologies can help</h2>
<p>In a nutshell, digital technologies <em>can</em> work to improve asthma medication taking. </p>
<p>On average, 15% more people took their medication as prescribed when they had the technology, compared to those who did not (who took 45% of the prescribed amount of their medication). </p>
<p>This 15% increase can have significant impacts on people’s asthma management, as more <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681064/#:%7E:text=Studies%20have%20shown%20that%20higher,asthma%20exacerbations%20(Table%201).">regular medication use</a> can reduce symptoms and cut the risk of attacks. </p>
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Read more:
<a href="https://theconversation.com/listening-to-asthma-and-copd-an-ai-powered-wearable-could-monitor-respiratory-health-175301">Listening to asthma and COPD: An AI-powered wearable could monitor respiratory health</a>
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<p>Looking at all the studies, people with access to the digital technology had fewer asthma symptoms and, on average, half the risk of asthma attacks compared with people who did not get the technology. These benefits could reduce the risk of asthma-related deaths. </p>
<p>We also found that people who had the technology had better quality of life and lung function, although the effect on lung function was small and may be of limited clinical importance.</p>
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<img alt="" src="https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469925/original/file-20220621-11-iswo86.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Digital technologies can help, but they may not be for everyone and some may work better than others.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>Everyday asthma care</h2>
<p>For people with asthma who find it hard to take their medication regularly, digital technologies are likely to help improve their medication taking, which in turn can reduce asthma symptoms and attacks. </p>
<p>But we need more research into how these technologies can be integrated into routine asthma care. The available studies don’t tell us enough about the effects on time off work or school, the cost-to-benefit ratio, or whether there are any harmful outcomes. </p>
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Read more:
<a href="https://theconversation.com/passive-smoking-synthetic-bedding-and-gas-heating-in-homes-show-the-strongest-links-to-asthma-176677">Passive smoking, synthetic bedding and gas heating in homes show the strongest links to asthma</a>
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<p>Also, digital technologies may not work for everyone. While research shows users generally accept the technologies, people didn’t actually finish the full study in about 25% of the studies we examined. </p>
<p>Some technologies may also work better than others. We found smart inhalers and text message systems seemed better for improving medication taking than other technology types. But the small number of studies means we can’t be completely certain these technologies definitely work better.</p>
<h2>Future tech potential</h2>
<p>Digital technologies are constantly evolving and are likely to play an even bigger role in future asthma care. Devices like smart watches can monitor changes in a person’s physiology in real time. </p>
<p>These changes could be used to <a href="https://www.auckland.ac.nz/en/news/2022/06/03/empowering-patients-to-avoid-asthma-attacks.html">predict a change</a> in a person’s risk of asthma attacks when put together with information from the environment such as changes in air temperature and humidity. </p>
<p>This risk prediction is the subject of current research funded by the<a href="https://www.medicalresearch.org.nz/"> Auckland Medical Research Foundation</a> and <a href="https://www.auckland.ac.nz/en/news/2022/06/03/empowering-patients-to-avoid-asthma-attacks.html">Health Research Council</a>. </p>
<p>If proven to work, we could see a substantial change in how asthma is managed. Users might one day be able to monitor their asthma control status simply by looking at their phones.</p><img src="https://counter.theconversation.com/content/185193/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Chan has received asthma research funding from the Health Research Council, Asthma UK, and the University of Auckland. She is the Auckland Medical Research Foundation Senior Research Fellow. She has provided subject matter expertise to Active Healthcare Ltd, and is a Board member of Asthma NZ. </span></em></p>Asthma is a huge health challenge, and many people struggle to stick to a medication regime to control their condition. Digital technologies can help, but we need to know more about what works best.Amy Chan, Senior Clinical Research Fellow, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1785032022-05-24T12:28:00Z2022-05-24T12:28:00ZScientists at Work: How pharmacists and community health workers build trust with Cambodian genocide survivors<figure><img src="https://images.theconversation.com/files/463796/original/file-20220517-13-z54dgh.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C766&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Community health workers assist patients as they gather their medications and supplements to discuss them during remote visits with pharmacists.</span> <span class="attribution"><span class="source">Photo courtesy of Khmer Health Associates</span></span></figcaption></figure><p>Wartime trauma paired with starting over in a new country make getting health care particularly challenging for immigrant refugees. Talking to a doctor or getting prescriptions filled in an unfamiliar language is hard enough. But for refugees, the physical and psychological scars of escaping war or genocide can complicate their health needs and getting them met.</p>
<p><a href="https://pharmacy.uconn.edu/person/christina-polomoff/">I am a clinical pharmacist</a> trained in improving medication safety and effectiveness in the outpatient setting. Starting in 2019, I was with a team of pharmacists serving Cambodian American patients in Connecticut and Rhode Island. I spent 15 months there studying the role of pharmacists and <a href="https://www.nhlbi.nih.gov/health/educational/healthdisp/role-of-community-health-workers.htm">community health workers</a> in helping disadvantaged immigrants get medications they need and learn to <a href="https://doi.org/10.1016/j.japh.2021.10.031">take them consistently and safely</a>. </p>
<p>Many of them had fled the <a href="http://doi.org/10.1001/jama.1993.03510050047025">Khmer Rouge</a>, a brutal political party and military force operating under the regime of <a href="https://www.history.com/topics/cold-war/pol-pot">Pol Pot</a> in 1970s Cambodia. They had witnessed executions, survived starvation or suffered <a href="http://cambodialpj.org/article/justice-and-starvation-in-cambodia-the-khmer-rouge-famine/">famine-related diseases</a>. </p>
<p>As pharmacists, we learned that the best way to care for these patients was by listening to and learning from the community members they trusted. It’s a lesson for health care providers that could prove useful as the U.S. <a href="https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees">welcomes new refugees</a> from countries like Afghanistan, Sudan, Myanmar and Ukraine. </p>
<h2>Unsafe medicine</h2>
<p>As a traumatized population, Cambodian refugees might be wary of strangers. They may avoid anyone thought to be a government or other official. Consequently, they often rely on their own beliefs and assumptions, even about health. </p>
<p>Our research team learned that some Cambodians expect to receive medications for every illness. It reassures these genocide survivors that something is being done about whatever’s wrong.</p>
<p>If a doctor doesn’t give them a prescription, they might seek out one who will prescribe medicine. Still, they may take the medicine for only as long as they’re feeling sick. If side effects occur, they may decide the dose is too large and reduce how much they take. And medications are often shared among friends and family. </p>
<p>Limited English proficiency can keep immigrants from seeking medical care. When they do, language barriers make it difficult for health care providers to understand a patient’s symptoms and to prescribe the right medication, especially since interpreters are not always available. So, in immigrant communities, translating often falls to family members, sometimes children.</p>
<p>The presence of family members, especially children, can influence what patients and pharmacists say, particularly with sensitive subjects like mental illness or reproductive health. And translating in a medical setting can be a tremendous burden on children. During our research, we learned about a 7-year-old daughter who had been the one to translate her mother’s cancer diagnosis. </p>
<h2>Established relationships</h2>
<p>Locally based community health workers have been addressing these problems. With language interpretation skills and health information, they help residents in their own communities manage their mental and physical health.</p>
<p>Our research team of four pharmacists worked with five community health workers from <a href="https://khmerhealthadvocates.org/">Khmer Health Advocates</a>, a West Hartford, Connecticut-based organization for Cambodian American survivors of the Khmer Rouge genocide and their families. After four decades in the area, Khmer Health Advocates knew its community best. That’s why we followed the organization’s lead as it directed recruitment for our study.</p>
<p>The health workers introduced us and our research project at churches, temples and events like the Cambodian New Year celebration. They also went to health clinics Cambodians use and put up fliers at Cambodian businesses. </p>
<p>The health workers also reached out to residents individually, connecting with people on a personal level. As genocide survivors themselves with training in trauma-informed care, they met patients in safe, familiar locations like their homes. They ate together and discussed not just the study, but familiar concerns like the financial hardship of restarting life in a new country and having to accept low-paying service jobs. In all, the community health workers helped recruit 63 patients to work with the pharmacists.</p>
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<img alt="A man and two women sit at a table where health information, checklists and other papers are spread out." src="https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462313/original/file-20220510-545-834gu.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">With training in trauma-informed care, the community health workers work directly with residents to help them improve their mental and physical health.</span>
<span class="attribution"><span class="source">Photo courtesy of Khmer Health Associates</span></span>
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<h2>Cross-cultural problem solving</h2>
<p>The health workers schooled us in Cambodian culture, which greatly values showing respect. The “sampeah” greeting, for example, consists of palms pressed together in a praying gesture while bowing the head. The higher the hands and lower the bow, the greater the degree of respect being shown.</p>
<p>We also learned idioms to help us understand the patients’ descriptions of their symptoms. For example, “spuck” is what they call neuropathy or nerve damage. It’s a common symptom among those who <a href="https://doi.org/10.1177%2F1536504220920197">endured beatings</a> during the conflict. Another phrase is “kdov kbal,” meaning “hot head,” to describe a feeling of heat in the brain interfering with thinking. And “phleu” refers to losing the train of thought, like with cognitive impairment.</p>
<p>Community health workers also helped the patients trust us pharmacists to help them manage their medications.</p>
<p>When it was time to meet with pharmacists, the health workers had already interviewed the patients to document the medications, herbal products, traditional Khmer medicines and dietary supplements they were taking. The patient would gather them all in preparation to talk with the pharmacist as the health worker sat with them.</p>
<p>When I met with patients over video from my office, the health worker held each medication to the camera. Then I talked with the patient about doses, side effects and any questions they had. I explained ways to take medicine to avoid side effects, and I noted possible drug interactions for my recommendations to their doctors. Through all of this, the health worker translated from English to Cambodian, from medical jargon to culturally appropriate terminology and back again.</p>
<p>We helped the 63 patients resolve <a href="https://doi.org/10.1016/j.japh.2021.10.031">more than 80%</a> of their medication-related issues, a good resolution rate for any community, English speaking or not. Patients also got better at remembering to take medications, taking the correct doses and in taking them more consistently. Our study found that community health workers and pharmacists working together were crucial to these patients getting better at managing their medicines. </p>
<p>I saw up close how a cross-cultural team can effectively resolve medication-related problems in an immigrant community. With war and genocidal conflicts driving international migration, this model is applicable now when the health of the most vulnerable is increasingly at risk.</p><img src="https://counter.theconversation.com/content/178503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The funding for this work was supported by the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases (Grant DK103663).</span></em></p>Studying medication use in a traumatized population of immigrants required pharmacists to listen to and learn from trusted community health workers.Christina Polomoff, Assistant Clinical Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1619302021-06-03T10:19:13Z2021-06-03T10:19:13ZHow well your immune system works can depend on the time of day<figure><img src="https://images.theconversation.com/files/404215/original/file-20210603-25-1cbh2js.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4160%2C2775&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our body clock has evolved over millions of years to help us survive.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/circadian-rhythms-controlled-by-clocks-biological-1391347448">kanyanat wongsa/ Shutterstock</a></span></figcaption></figure><p>When microorganisms – such as bacteria or viruses – infect us, our immune system jumps into action. It’s highly trained to sense and eliminate infections and clear up any damage caused by them. </p>
<p>It’s typically assumed our immune systems work the exact same way regardless of whether an infection occurs during the day or at night. But research spanning over half a century now shows our bodies actually <a href="https://www.nature.com/articles/s41577-018-0008-4">respond differently</a> at day and night. The reason for this is our body clock, and the fact that each cell in the body, including our immune cells, can tell what time of day it is.</p>
<p>Our body clock has evolved over millions of years to help us survive. Every cell in the body has a collection of proteins that indicate the time depending on their levels. Knowing whether it’s day or night means our body can adjust its functions and behaviours (such as when we want to eat) to the correct time. </p>
<p>Our body clock does this by generating 24 hour rhythms (also termed <a href="https://www.sleepfoundation.org/circadian-rhythm">circadian rhythms</a>) in how cells function. For example, our body clock ensures that we only produce melatonin as night falls, as this chemical makes us tired – signalling it’s time for sleep. </p>
<p>Our immune system is composed of many different types of immune cells that are continually patrolling the body looking for evidence of infection or damage. But it is our body clock that determines where those cells are located at particular times of the day. </p>
<p>Broadly speaking, our immune cells migrate into tissues during the day and then circulate around the body at night. This circadian rhythm of immune cells may have evolved so that immune cells are directly located in tissues at a time when we are more likely to be infected, primed for attack. </p>
<p>At night, our immune cells circulate around the body and stop off at our lymph nodes. Here, they build up memory of what was encountered during the day – including any infections. This ensures they can <a href="http://dx.doi.org/10.1016/j.immuni.2012.05.021">respond better to the infection</a> the next time they encounter it. </p>
<figure class="align-center ">
<img alt="Sick man lying on the couch blows his nose with a tissue." src="https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404217/original/file-20210603-19-1b7hd3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When we’re infected with a virus may determine how sick we get.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-man-lying-on-sofa-home-754646167">baranq/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Given the body clock’s control over our immune system, it’s hardly surprising to learn that some research has shown that the time we’re <a href="https://www.pnas.org/content/113/36/10085">infected with a virus</a> – such as <a href="https://www.nature.com/articles/s41467-019-11400-9">influenza</a> or <a href="https://www.nature.com/articles/s41467-021-21821-0">hepatitis</a> – can impact how sick we become. The exact timing is likely to differ depending on the virus in question.</p>
<p>Other research has also shown that the time we take our medicines can affect how well they work – but again, this depends on the drug in question. For example, since we make cholesterol when we sleep, taking a <a href="https://journals.sagepub.com/doi/10.1177/0748730419892099">short-acting statin</a> (a cholesterol-lowering drug) just before bedtime provides the most benefit. It’s also been shown that time of day impacts <a href="https://www.pnas.org/content/117/3/1543">how well certain types of immune cells work</a>.</p>
<h2>Body clocks and vaccines</h2>
<p>There’s also an increasing body of evidence showing vaccines – which create an immune “memory” of a particular pathogen – are impacted by our body clock, and the time of day that a vaccine is administered. </p>
<p>For example, a 2016 randomised trial of over 250 adults aged 65 and older showed having the <a href="https://pubmed.ncbi.nlm.nih.gov/27129425/">influenza vaccine in the morning</a> (between 9am and 11am) resulted in a greater antibody response compared to those vaccinated in the afternoon (between 3pm and 5pm). </p>
<p>More recently, people in the mid-twenties who were immunised with the BCG (tuberculosis) vaccine between 8am and 9am had an enhanced immune response compared to those vaccinated <a href="https://www.jci.org/articles/view/133934">between noon and 1pm</a>. So for certain vaccines, there’s evidence that early morning vaccination may provide a more robust response.</p>
<p>One reason for seeing improved immune response to vaccines in the morning may be due to the way our body clock controls sleep. In fact, studies have found that sufficient <a href="https://www.jimmunol.org/content/187/1/283">sleep after vaccination</a> for hepatitis A <a href="https://journals.lww.com/psychosomaticmedicine/Abstract/2003/09000/Sleep_Enhances_the_Human_Antibody_Response_to.17.aspx">improves the immune response</a> by increasing the number of vaccine-specific immune cells which provide long term immunity compared to those who had restricted sleep following vaccination.</p>
<p>It’s still not fully understood why sleep improves vaccine response, but it might be because of how our body clock directly controls immune cell function and location during sleep. So for example, it sends the immune cells to our lymph nodes while we sleep to learn about what infections were encountered during the day, and to build a “memory” of this. </p>
<p>Of course this raises the question of how this might all relate to the current pandemic and worldwide vaccination programmes. How our <a href="https://pubmed.ncbi.nlm.nih.gov/33480287/">immune body clock</a> works might be important in terms of <a href="https://pubmed.ncbi.nlm.nih.gov/32875944/">whether we develop COVID-19</a>. Intriguingly, the receptor which allows the COVID virus, SARS-CoV-2, to gain entry into our cells is under control of our body clock. </p>
<p>In fact, there are higher levels of this receptor on the cells which line our airways at <a href="https://www.biorxiv.org/content/10.1101/2021.03.20.436163v1">distinct times of day</a>. This could mean we’re more likely to get COVID-19 at certain times of the day, but further research will be needed to determine whether this is the case. </p>
<p>Whether the time of day we’re vaccinated against COVID-19 impacts immune response remains to be answered. Given the high effectiveness of many <a href="https://www.yalemedicine.org/news/covid-19-vaccine-comparison">COVID-19 vaccines</a> (with both Pfizer and Moderna reporting over 90% efficacy) and the urgency with which we need to vaccinate, people should be vaccinated at whatever time of day is possible for them. </p>
<p>But current and future vaccines which do not have such high efficacy rates – such as the flu vaccine – or if they’re used in people with poorer immune response (such as older adults), using a more precise “timed” approach may ensure better immune response.</p><img src="https://counter.theconversation.com/content/161930/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annie Curtis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our immune system is controlled by our “body clock” – an intricate 24-hour system which controls how cells function.Annie Curtis, Senior Lecturer, Medicine and Health Sciences, RCSI University of Medicine and Health SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554102021-02-18T10:13:47Z2021-02-18T10:13:47ZAppetite drug shows promise in treating obesity<figure><img src="https://images.theconversation.com/files/384739/original/file-20210217-23-1j1ovx4.jpg?ixlib=rb-1.1.0&rect=47%2C0%2C5245%2C3494&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Participants lost around 15% of their body weight on average. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pair-female-feet-standing-on-bathroom-193998131">Rostislav_Sedlacek/ Shutterstock</a></span></figcaption></figure><p>A <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2032183?query=featured_home">recently published</a> clinical trial of the anti-obesity drug, semaglutide, has produced a degree of weight loss which has led some to dub the medication a “<a href="https://www.irishexaminer.com/news/arid-40227398.html">game changer</a>” in the treatment of obesity. </p>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/appetite-drug-shows-promise-in-treating-obesity-155410&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p>The trial looked at 1,961 adults who were overweight or obese. Approximately 75% of participants were female. Participants were given a weekly injection of semaglutide, a drug normally used to control blood sugar in the treatment of diabetes. Participants were also advised on how to manage their weight through dieting and exercise. </p>
<p>After 68 weeks of treatment, participants lost an average of 15.3kg (around 15% of their body weight) with semaglutide compared to just 2.6kg in those who received the placebo injection, alongside diet and exercise advice. This is the largest effect ever observed with an anti-obesity medication. The weekly dose was administered via subcutaneous injection – which is unusual, as most anti-obesity drugs are given as a tablet taken by mouth.</p>
<p>But while the degree of weight loss is certainly promising, there’s still much researchers don’t know about semaglutide – including whether the drug was effective on its own, or whether it was the combination of the drug, how it was administered, and whether it would produce the same magnitude of weight loss without the lifestyle changes.</p>
<h2>Appetite control</h2>
<p>Semaglutide is a molecule that works by controlling appetite. This has been shown in numerous studies, including research conducted in 2017 by the University of Leeds which found that, in people with obesity, a once-weekly injection of semaglutide (the same dose as used in this recent study) was able to <a href="https://dom-pubs.onlinelibrary.wiley.com/doi/full/10.1111/dom.12932">reduce daily calorie intake</a> by 24% and reduce some meal sizes by more than 30%. Despite consuming less food, people experienced no increase in hunger and reported feeling fuller. This study also showed that semaglutide decreased cravings for (and consumption of) high-fat foods, and made people feel more control over their appetite. </p>
<p>Semaglutide controls appetite by acting on the brain’s <a href="https://diabetes.diabetesjournals.org/content/diabetes/63/12/4186.full.pdf">GLP1 receptors</a>. GLP1 is a hormone which influences appetite and is released from cells in the gastrointestinal tract where it stimulates the release of insulin and slows emptying of the stomach. Research shows that GLP1 receptors are located widely throughout the brain, including in regions involved in aspects of appetite such as <a href="https://diabetes.diabetesjournals.org/content/diabetes/63/12/4186.full.pdf">hunger and enjoyment of food</a>. </p>
<p>Interestingly, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213778/">recent research</a> in rodents has shown semaglutide acts on brain areas responsible for both satiety and pleasure. However, the actions of semaglutide on brain processes are complex and remain to be fully worked out.</p>
<p>Although semaglutide appears to be effective in controlling appetite over a long period, there are three factors which might have influenced how effective it was: the semaglutide molecule itself, the route of administration (injection) and having participants change their diet and exercise habits.</p>
<p>There’s no doubt that the semaglutide molecule is potent in and of itself. But delivering it by injection could have affected how effective it was. The authors believe the weekly injection may make it easier for patients to stick to treatment than if they had to take it as a tablet, because they saw it as a “medical” procedure. It may also make patients more likely to conform with the dietary and exercise advice as well because an injection is perceived as a more serious medical intervention than taking a pill. This could remind people of the seriousness of obesity and motivate them to stick to dietary and exercise advice.</p>
<figure class="align-center ">
<img alt="Man taking medication with glass of water." src="https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/384740/original/file-20210217-13-18rzdwa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research will need to investigate whether semaglutide is as effective in tablet form.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-taking-medication-171528317">Image Point Fr/ Shutterstock</a></span>
</figcaption>
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<p>It’s uncertain whether semaglutide would be as effective for weight loss if it was given orally as a daily tablet, as opposed to an injection. In a 12-week study on people with diabetes, research showed a daily oral dose of semaglutide is clearly <a href="https://dom-pubs.onlinelibrary.wiley.com/doi/full/10.1111/dom.14255">effective in controlling appetite</a> – resulting in a loss of body fat. This indicates that oral dosing could be effective for weight loss but should be tested in a long-term trial in people with obesity.** </p>
<p>Patients in the trial were also instructed to diet and exercise to ensure they burned at least 500 calories more than they consumed. This lifestyle modification was enforced through monthly individual counselling sessions. The authors of the study state the drug should be delivered alongside a lifestyle modification programme – so it’s uncertain if the drug would have been as effective without making lifestyle changes. </p>
<h2>Game changer?</h2>
<p>This isn’t to say the study’s results aren’t promising. Semaglutide controls appetite by inhibiting the drive to eat and increasing feelings of fullness. All of this may be particularly effective at reducing body weight, especially in a society which promotes unhealthy lifestyles and overeating – and where unhealthy high-calorie foods are everywhere.</p>
<p>This suppression of appetite is also long-lasting. In the clinical trial, body weight continued to decline for more than a year – body weight was at its lowest around week 60. Semaglutide’s continued action on the brain’s GLP1 receptors effectively inhibited the drive to eat at a level far beyond what’s been seen in the past. Of course, if a person stops taking the drug, appetite will return to normal. And if no lifestyle changes are made, this could result in weight regain. </p>
<p>It’s also worth pointing out that although participants lost around 15% of their body weight on average and one-third lost 20% of their bodyweight, half lost less than 15%. This means that semaglutide can’t guarantee a specific amount of weight loss, which will vary from person to person. Another limitation of the study was that 75% of the participants were female. Future research will need to investigate if gender affects semaglutide’s efficacy.</p>
<p>Nevertheless, when semaglutide is approved for use in the UK, it could very well be a promising new treatment for managing obesity – when combined with healthy lifestyle changes.</p><img src="https://counter.theconversation.com/content/155410/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Blundell has in the past received research funding from Roche, Servier, Sanofi, Lilly, Merck,Nestle, Danone Glaxo, Abbott and Novo Nordisk. JB has served on Obesity Advisory Committees or been a consultant for Servier, Sanofi, Merck, Nestle. Danone, Abbott, and Novo Nordisk. JB is currently a scientific governor of the British Nutrition Foundation and a member of the Scientific Advisory Board of Zoe Global. </span></em></p>Semaglutide works by controlling appetite.John Blundell, Professor of Psychobiology, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1487212020-12-21T13:05:44Z2020-12-21T13:05:44ZNew antidepressants can lift depression and suicidal thoughts fast, but don’t expect magic cures<figure><img src="https://images.theconversation.com/files/374930/original/file-20201214-20-vhn4py.jpg?ixlib=rb-1.1.0&rect=302%2C33%2C2899%2C1918&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alleviating major depression for the long term involves more than just drugs.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/worried-woman-royalty-free-image/563853729">Rafa Elias via Getty Images</a></span></figcaption></figure><p>Depression is the <a href="https://www.who.int/news-room/fact-sheets/detail/depression">most common cause of disability</a> in the world. Chances are high that you or someone you know will experience a period when depression gets in the way of work, social life or family life. Nearly two in three people with depression will experience <a href="https://www.nimh.nih.gov/health/statistics/major-depression.shtml#part_155030">severe effects</a>.</p>
<p>As a <a href="https://scholar.google.com/citations?user=5DzjK7QAAAAJ&hl=en">psychiatrist</a> specializing in behavioral neuroscience, I help patients who suffer from mood disorders. Many have “<a href="http://doi.org/10.1016/s0193-953x(05)70283-5">treatment-resistant</a>” depression and are on a nearly constant search for relief. </p>
<p>There have been some exciting developments in treating depression recently, particularly new rapid-acting antidepressants. But it’s important to understand that these medications aren’t cure-alls.</p>
<p>The new treatments for depression <a href="https://www.nytimes.com/2019/03/05/health/depression-treatment-ketamine-fda.html">promise</a> to relieve distressing symptoms, including <a href="https://www.npr.org/sections/health-shots/2020/08/07/900272454/nasal-spray-is-a-new-antidepressant-option-for-people-at-high-risk-of-suicide">suicidal thinking</a>, faster than any previous treatment. They include ketamine, an anesthetic that is also abused as a street drug, and a derivative of ketamine called esketamine. These drugs have been shown to help relieve symptoms of depression <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534172/">within hours</a>, but each dose only works for a few days. <a href="https://doi.org/10.1080/15622975.2020.1836399">They also carry risks</a>, including the potential for drug abuse.</p>
<p>With the <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm">coronavirus pandemic taking a toll</a> on mental health, patients are looking for fast relief. Medication can help, but to effectively treat depression long term, with its mix of biological, psychological, social and cultural components, requires more than just drugs. </p>
<h2>Depression medications have evolved</h2>
<p>The early history of depression treatments focused on the psychological components of illness. The goal in the early 20th century was for a patient to understand unconscious urges established during childhood. </p>
<p><a href="http://library.law.columbia.edu/urlmirror/CJAL/14CJAL1/shock_i.htm">Biological treatments at the time</a> seem frightening today. They included insulin coma therapy and primitive, frequently misused versions of a modern lifesaving procedure – electroconvulsive therapy.</p>
<p>In the middle of the 20th century, medicines that affected behavior were discovered. The first medicines were sedatives and antipsychotic medicines. <a href="https://pubmed.ncbi.nlm.nih.gov/16433053/">Chlorpromazine</a>, marketed as “Thorazine,” led the way in the 1950s. In 1951, imipramine was discovered and would become one of the first antidepressants. The <a href="https://archive.fortune.com/magazines/fortune/fortune_archive/2004/06/28/374398/index.htm">“blockbuster”</a> antidepressant Prozac, a selective serotonin reuptake inhibitor, or SSRI, was approved in 1987. </p>
<figure class="align-center ">
<img alt="Man in therapy session." src="https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/374921/original/file-20201214-15-6n0f22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The physician-patient relationship can help ensure all components of major depression are being addressed.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/youre-not-alone-royalty-free-image/1048189084">SolStock via Getty Images</a></span>
</figcaption>
</figure>
<p>It’s been over 30 years since we’ve seen a novel class of antidepressant medicine. That’s one reason rapid-acting antidepressants are exciting.</p>
<h2>What depression looks like inside the brain</h2>
<p>Medical treatments for depression affect certain processing cells in the brain area above your eyes and under your forehead. This area, called the prefrontal cortex, processes complex information including emotional expressions and social behavior. </p>
<p>Brain cells called neurons are chemically controlled by <a href="https://thebrain.mcgill.ca/flash/i/i_01/i_01_m/i_01_m_ana/i_01_m_ana.html">two opposing messenger</a> molecules, glutamate and gamma-amino-butyric acid (GABA). Glutamate works like a gas pedal and GABA is the brake. They tell the neurons to speed up or slow down.</p>
<p>Rapid-acting medicines for depression decrease the action of glutamate, the gas pedal. </p>
<p>Other treatments have been developed to rebalance GABA. A neurosteroid called <a href="https://doi.org/10.3389/fendo.2020.00236">allopregnanolone</a> affects GABA and applies the brake. Both allopregnanolone and esketamine have federal approval for treatment of depression, allopregnanolone <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-post-partum-depression">for postpartum depression</a> and esketamine for <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified">major depressive disorder and suicidal thinking</a>.</p>
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<h2>Not so fast</h2>
<p>Around 2016-2017, young psychiatrists like myself were rushing to implement these novel antidepressant treatments. Our training supervisors said, “not so fast.” They explained why we should wait to see how studies of the new drugs turn out.</p>
<p>Several years before, the medical community experienced similar excitement over Vivitrol to treat opioid addiction. Vivitrol is a monthly injected form of naltrexone, an opioid-blocking medicine. </p>
<p>Clinical trials are executed in a highly controlled and clean environment, while the real world can be highly uncontrolled and very messy. Without risk reduction, education and psychosocial treatment, the potential <a href="https://www.vivitrol.com/important-safety-information">risks of medications like Vivitrol</a> can be magnified. Vivitrol can help reduce relapses, but isn’t a panacea on its own. The National Institute on Drug Abuse <a href="https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment">recommends integrated treatment</a> for addiction. </p>
<p>Treating depression may be <a href="http://doi.org/10.1176/appi.ajp.2015.15040476">similar</a>. Medication and psychological support together work better than either on its own.</p>
<h2>The risks</h2>
<p>In depression, the more treatments a person tries that don’t work, the less likely that person is to have success with the next treatment option. This was a main message of the largest clinical trial studying depression medications, the <a href="https://www.nimh.nih.gov/funding/clinical-research/practical/stard/index.shtml">National Institutes of Health-directed STAR-D study</a>, completed in 2006.</p>
<p>Providing a more effective option for patients who don’t respond to a first or second antidepressant may turn that STAR-D message on its head. However, when dealing with an illness that is affected by <a href="http://doi.org/10.2174/1570159x1304150831150507">external stress</a> like trauma and loss, treatment is more likely to succeed with both medication and psychological support. </p>
<p>A real-world treatment approach called the <a href="https://www.psychiatrictimes.com/view/can-we-salvage-biopsychosocial-model">biopsychosocial paradigm</a> accounts for the wide range of relevant biological, psychological and social components of mental illnesses. The patient and physician work together to process the patient’s problematic experiences, thoughts and feelings. </p>
<p>A hyperfocus on novel drugs may overlook the importance of addressing and monitoring all those components, which could mean problems surface in the future. Medications like opiates or other substances that provide rapid relief of physical or psychological pain can also be physically and psychologically addictive, and novel rapid-acting antidepressants <a href="http://doi.org/10.1177/0897190014525754">can have the same risks</a>.</p>
<p>Rapid-acting antidepressants can be powerful tools for treating major depression when used with other forms of therapy, but are they the answer? Not so fast.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/148721/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Mischel receives or has received funding from the American Heart Association, National Institutes of Health, and Wayne State University. He is employed by Wayne State University and member of the American Psychiatric Association, Society of Biological Psychiatry, North American Neuromodulation Society, the Clinical TMS Society, and the American Society of Ketamine
Physicians, Psychotherapists & Practitioners.</span></em></p>Drugs like ketamine can relieve depression symptoms, including suicidal thoughts, within hours, but they also carry risks that patients need to understand.Nicholas Mischel, Assistant Professor of Psychiatry and Behavioral Neurosciences; Director, Interventional Psychiatry and Neuromodulation Research Program, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475502020-12-06T13:17:48Z2020-12-06T13:17:48ZWithout pharmacare, Canadians with disabilities rationing drugs due to high prescription costs<figure><img src="https://images.theconversation.com/files/372049/original/file-20201130-19-fy5oys.jpg?ixlib=rb-1.1.0&rect=790%2C49%2C7452%2C5438&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For people with disabilities, prescription drug costs are often layered on top of other health-related costs.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Up to a third of Canadians with disabilities may skip doses of medication or neglect to get their prescriptions filled because of the cost of prescription drugs. One of the aims of pharmacare is to remove financial barriers to prescription drugs, and overcome inequities among Canadians for this important aspect of health care. </p>
<p>While the federal government reiterated its commitment to implementing pharmacare in the <a href="https://www.canada.ca/en/privy-council/campaigns/speech-throne/2020/speech-from-the-throne.html">speech from the throne</a> in September, a <a href="https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/implementation-national-pharmacare/final-report.html">key task</a> for implementation will be to ascertain who needs it most, ensuring that tax dollars are spent where they can do the most good. </p>
<h2>Myths about medication costs</h2>
<p>Recent <a href="https://qspace.library.queensu.ca/handle/1974/27908">research</a> from investigators at Queen’s University exposes two myths that could interfere with making sure the right people get the help they need from a pharmacare or public drug benefit program.</p>
<p><strong>Myth No. 1</strong>: People with disabilities are either seniors or welfare recipients, and therefore already receive their drugs free of charge. </p>
<figure class="align-right ">
<img alt="A young black woman using a wheelchair" src="https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372080/original/file-20201130-23-jw7o3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sixty per cent of Canadians with disabilities are under age 65.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The <a href="https://www150.statcan.gc.ca/n1/pub/89-654-x/89-654-x2018002-eng.htm">Canadian Survey on Disability (2017)</a> shows that 60 per cent of disabled adults are under the age of 65, and therefore are not eligible for seniors’ benefits. Furthermore, between 30 and 60 per cent of working-age disabled adults are employed (depending on the severity of their disability), and thus may be ineligible for government drug programs. In our research, 27 per cent of our sample received coverage for prescription drugs from government sources exclusively. Many were covered only by private health insurance (47 per cent) or by a mixture of private and public health insurance (17 per cent).</p>
<p><strong>Myth No. 2</strong>: Drug insurance alleviates the financial burden of prescription medications.</p>
<p><a href="https://doi.org/10.1038/s41393-019-0406-x">The study</a> also showed that although 92 per cent of our sample had some type of drug insurance, they still experienced extraordinary out-of-pocket costs for prescription medications — more than five times the national average.</p>
<h2>Multiple medications</h2>
<p>Like many people with disabilities and chronic illnesses, members of our sample took a number of prescription medications. The average in our sample was five, which is <a href="https://www150.statcan.gc.ca/n1/pub/82-003-x/2014006/article/14032/tbl/tbl2-eng.htm">significantly more than most Canadians take</a>, particularly those under age 65. For each of these prescriptions, there may be co-payments, dispensing fees or other point-of-purchase costs. These costs added up to an average of $197 per month in our sample, with some people bearing costs near $3,000 per month for their medications. </p>
<p>There were also often deductibles and/or premiums that had to be paid on a monthly or annual basis to maintain coverage. Deductibles are typically calculated as a percentage of net income, and range from $100-$400 annually. Catastrophic coverage of high-risk patients is intended to prevent financial hardship for people with high drug costs. However, deductibles for these patients can be as high as 20 per cent of annual income plus a co-insurance of up to 35 per cent — a percentage of prescription costs that patients pay directly while making a purchase.</p>
<p>Prescription drug costs were often layered on top of other health-related costs, such as over-the-counter medications, expendable health supplies such as catheters, gloves and skincare supplies, dietary supplements and adaptive devices such as wheelchairs and special cushions. These additional costs added up on average to $600 per month in our sample.</p>
<figure class="align-center ">
<img alt="Pharmacist discussing a product with a man using a wheelchair" src="https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372081/original/file-20201130-13-1yix81z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Thirty-seven per cent of people with disabilities ration medications because of prescription drug costs.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The excess costs of prescription drugs for disabled people are particularly problematic when we take into account that disabled people are typically significantly less well off than non-disabled Canadians. <a href="https://www150.statcan.gc.ca/n1/pub/89-654-x/89-654-x2018002-eng.htm">National data</a> show the average income for someone with a disability is $20,000 lower than for those without a disability ($19,000 versus $39,000 per year). Twenty-eight per cent of people with a severe disability live below the poverty line, compared to 10 per cent of the non-disabled. Even among those who are employed, many work part-time, work for small employers or are self-employed.</p>
<h2>Rationing medication</h2>
<p>When we <a href="https://doi.org/10.3390/ijerph16173066">surveyed 160 people with disabilities for a study</a>, we found that the high cost of medications led 37 per cent of individuals to ration their medications by taking a smaller dose, taking medications less often or simply not filling prescriptions. Many resorted to cutting back on essentials such as food, shelter or other disability-related expenses in order to be able to pay for their drugs. These measures caused their symptoms to get worse, which ultimately affected their quality of life and caused them to use more health-care services.</p>
<p>Given this rising burden of prescription drug costs on patients, a national pharmacare program for Canada needs to respond to the breadth (who is covered, or population-coverage), depth (what services are covered, or cost-coverage) and scope (how much of the cost is covered, or service-coverage) of drug insurance. In particular, the extraordinary needs of people with disabilities need to be taken into account. </p>
<p>Our study demonstrated that paying for medications is a significant issue for many Canadians, but especially for those who live on a precarious margin of health. If we are to find a workable solution for pharmacare for Canadians, it needs to prioritize the needs of people who need it most.</p><img src="https://counter.theconversation.com/content/147550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shikha Gupta receives funding from Mark S Lodge Foundation. </span></em></p><p class="fine-print"><em><span>Mary Ann McColl receives funding from Mark S Lodge Foundation; Social Sciences & Humanities Research Council</span></em></p>Any pharmacare plan that aims to remove financial barriers to treatment and eliminate inequities should prioritize those who face the highest out-of-pocket drug costs, such as people with disabilities.Shikha Gupta, Research Coordinator, Centre for Health Services and Policy Research and School of Rehabilitation Therapy, Queen's University, OntarioMary Ann McColl, Professor, School of Rehabilitation Therapy, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1456052020-09-04T12:22:01Z2020-09-04T12:22:01ZSteroids cut COVID-19 death rates, but not for everyone – here’s who benefits and who doesn’t<figure><img src="https://images.theconversation.com/files/356451/original/file-20200903-14-1pq21eh.jpg?ixlib=rb-1.1.0&rect=643%2C333%2C1841%2C1066&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Steroids could do more harm than good in patients with milder cases of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patient-lies-in-bed-connected-to-medical-equipment-in-the-news-photo/1223660331">Go Nakamura/Getty Images</a></span></figcaption></figure><p>New studies show that treating critically ill COVID-19 patients with inexpensive steroids can cut their risk of dying from the illness by a third. The results are so clear that the World Health Organization changed its advice on Sept. 2 and now strongly recommends corticosteroids as a first-line treatment for the sickest patients.</p>
<p>Steroids aren’t risk-free, however. They can have side effects, and they could do more harm than good in patients with milder cases of COVID-19.</p>
<p>I am <a href="https://scholar.google.com/citations?user=z6NOSbcAAAAJ&hl=en">a pulmonologist and critical care physician</a> and co-author of <a href="http://doi.org/10.1001/jama.2020.17022">one of</a> <a href="https://jamanetwork.com/journals/jama/fullarticle/2770279">three new studies</a> that analyzed data from clinical trials involving the effect of steroids on thousands of critically and severely ill COVID-19 patients. Here’s what people need to understand about steroids as a treatment for COVID-19.</p>
<h2>Who benefits from taking steroids?</h2>
<p>It’s important to understand that steroids can benefit the sickest patients hospitalized with COVID-19, but they’re <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1">not a treatment for relatively mild cases</a>. </p>
<p>With COVID-19 and other infectious diseases, there are two key components: the infection itself and the body’s response to that infection. </p>
<p>In the sickest patients, the body’s immune system response is <a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">so robust it can injure organs</a>. So, calming the immune response may be important. But someone who is less severely ill may need the body’s immune response to prevent the infection from getting worse. You wouldn’t want to interfere with the immune response unless it was harming the patient.</p>
<h2>How do corticosteroids help critically ill patients?</h2>
<p>When an infection triggers an <a href="https://www.merckmanuals.com/home/immune-disorders/biology-of-the-immune-system/overview-of-the-immune-system">inflammatory response</a>, specialized white blood cells are activated to go find the virus or bacteria and destroy it. It’s more of a bomb effect than a targeted missile strike – the immune cells attack broadly, and the inflammation created can damage other cells in the vicinity.</p>
<p>That response can get <a href="https://theconversation.com/coronavirus-cytokine-storm-this-over-active-immune-response-could-be-behind-some-fatal-cases-of-covid-19-136878">out of control</a> and continue even after the infectious agent is gone. In a really exuberant immune response, the patient can have respiratory failure and end up on a ventilator, or have circulatory failure and end up in shock, or they could develop kidney failure from the shock.</p>
<p>In patients with severe COVID-19, corticosteroids are likely able to calm that inflammatory response and prevent the progression of organ damage, potentially in the lungs. </p>
<p>Scientist aren’t yet certain that that is how steroids are working. What we do know from the new studies is that people with severe COVID-19, particularly those with respiratory complications, benefit from relatively low-dose courses of corticosteroids. A combined analysis of the recent studies found the death rate four weeks after infection was <a href="http://doi.org/10.1001/jama.2020.17023">significantly lower</a> in patients with severe COVID-19 who received steroids than those who did not.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/PSRJfaAYkW4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Why does the World Health Organization recommend not using steroids for cases that aren’t severe?</h2>
<p>No treatment comes without risk.</p>
<p>Steroids are well-known immune-suppressing medications that have been used for decades. They’re commonly used for treating chronic diseases that are inflammation-related, like asthma, or autoimmune disorders such as lupus or rheumatoid arthritis. But there may be consequences.</p>
<p>The potential harms from using steroids in a hospital include an increased risk of bacterial or fungal infections, hyperglycemia, acquired muscle weakness and gastrointestinal bleeding.</p>
<p>For people with milder cases of COVID-19, taking steroids could mean increasing their risks with little potential benefit.</p>
<p>Taking steroids long-term also carries other risks, including predisposition to infection and developing osteoporosis, cataracts and glaucoma. So, to take steroids as a potential preventive measure against COVID-19 could come with significant potential risk to otherwise healthy people.</p>
<h2>Do steroids carry risks for critically ill patients?</h2>
<p>It’s common for ICU patients, particularly those on ventilators, to develop hospital-acquired infections such as pneumonia or bloodstream infections related to intravenous catheters. Being on corticosteroids can increase a patient’s risk of developing secondary infections, or it can contribute to muscle weakness which may impact the patient’s ability to come off of a ventilator when the disease resolves.</p>
<p>Still, the benefits of steroids for treating critically ill COVID-19 patients appear to outweigh the harms.</p>
<h2>How large should the dose be?</h2>
<p>Part of the challenge in treating critically ill patients with steroids is determining the dose and timing of the medication.</p>
<p>In the context of this study, the dose of steroids is relatively low and it’s also a short duration. The trials haven’t shown a significant increase in adverse events in the context of using the short-course, relatively low dose of steroids. So, in that patient population, the benefit outweighs the risk, but the risk is not zero.</p>
<p>The risk profile increases with higher doses. So, the recommendation would be to start with the relatively low doses that have been studied. <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1">The WHO recommends</a> low doses for 7-10 days.</p>
<h2>Which steroids are most effective?</h2>
<p>I don’t think it matters which corticosteroid is used as long as the steroid has some glucocorticoid activity.</p>
<p>The REMAP-CAP study <a href="http://doi.org/10.1001/jama.2020.17022">looked at hydrocortisone</a>. Another trial <a href="http://doi.org/10.1001/jama.2020.17021">involved dexamethasone</a>, the steroid the president was given. Others <a href="http://doi.org/10.1001/jama.2020.17023">studied methylprednisolone</a>, though they were smaller and provided less data. The trials all point in a similar direction, suggesting the anti-inflammatory <a href="http://tmedweb.tulane.edu/pharmwiki/doku.php/glucocorticoids">glucocorticoid</a> activity is the important feature and not the specific steroid. </p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p>
<h2>How will this new advice change treatment?</h2>
<p>Based on the studies to date, hospitalized patients with COVID-19 pneumonia and requiring oxygen should be started on a low-dose course of steroids. That should certainly be the case if they’re in the intensive care unit and require more intensive organ support, such as being on a ventilator, receiving non-invasive ventilation, or receiving high-flow oxygen.</p>
<p>Importantly, however, steroids have not been shown to benefit asymptomatic patients with COVID-19 or patients with mild disease without pulmonary problems based on the data we’ve seen so far. </p>
<p>Physicians should think of steroids at low doses as the standard of care for critically ill patients with COVID-19 pneumonia.</p><img src="https://counter.theconversation.com/content/145605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bryan McVerry receives funding from the National Heart Lung and Blood Institute and from Bayer Pharmaceuticals. Inc. </span></em></p>Three new studies show corticosteroids can reduce deaths in critically ill COVID-19 patients. But what about other patients?Bryan McVerry, Associate Professor of Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1401562020-07-09T12:13:52Z2020-07-09T12:13:52ZWhen Trump pushed hydroxychloroquine to treat COVID-19, hundreds of thousands of prescriptions followed despite little evidence that it worked<figure><img src="https://images.theconversation.com/files/346160/original/file-20200707-26-imzchz.jpg?ixlib=rb-1.1.0&rect=0%2C68%2C4587%2C2977&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As public figures and some in the media touted hydroxychloroquine, prescriptions skyrocketed. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/white-pills-spilling-out-of-prescription-bottle-royalty-free-image/1161234835?adppopup=true&uiloc=thumbnail_same_series_adp&uiloc=thumbnail_same_series_adp"> Grace Cary / Moment via Getty Images</a></span></figcaption></figure><p>In late March and early April, <a href="https://www.huffpost.com/entry/trump-fauci-coronavirus-hloroquine-azithromycin_n_5e768e4fc5b6eab77949660d">President Trump repeatedly proclaimed that hydroxychloroquine</a> could prevent or treat COVID-19. Within days, the number of prescriptions for the drug skyrocketed even though evidence it could safely prevent or treat the disease was at the time very weak. </p>
<p>A casual remark by a president who is not in any way a medical expert somehow led thousands of U.S. physicians to write prescriptions for a drug that had never before been used to treat a viral illness. What could be happening here? </p>
<p>As a <a href="https://health.ucdavis.edu/team/internalmedicine/373/richard-kravitz---health-policy---internal-medicine-sacramento">general internist</a> at the University of California, Davis health center, I have seen thousands of patients in both inpatient and outpatient settings. As a researcher, I have focused on how <a href="https://scholar.google.com/citations?user=u8ZMXTMAAAAJ&hl=en&oi=ao">patients influence what physicians do</a>, and consequently, I often find myself asking how the larger world influences what patients think. </p>
<p>Through my research, I’ve found that the process of prescribing medication is more complicated than most people realize. In the real world, it’s a mix of the current state of medical knowledge and a negotiation between what the patient wants or asks for and the habits and beliefs of the physician. It is a human experience, and can be influenced by things like advertising, media and even politics. </p>
<p>I think the hydroxychloroquine situation perfectly illustrates how much the outside world shapes patients’ views of their own health care. It also shows how, particularly when the science is uncertain, patients’ views strongly affect what their doctors do.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346161/original/file-20200707-194418-1qu50y5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">President Trump has repeatedly and consistently touted the effectiveness of hydroxychloroquine despite shaky scientific evidence at best, even going so far as to announce that he was taking it as a preventative measure against the coronavirus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Trump/3357c55019e6411687156a1db305332c/22/0">AP Photo/Evan Vucci</a></span>
</figcaption>
</figure>
<h2>The hydroxychloroquine boom</h2>
<p>On March 21 President Trump touted hydroxychloroquine – and its biochemical cousin, chloroquine – as <a href="https://thehill.com/homenews/administration/488796-trump-steps-up-effort-to-tout-malaria-drug-as-coronavirus-game">potential “game changers”</a> in the battle against COVID-19. Two months later, he announced on national television that he had been <a href="https://thehill.com/homenews/administration/498375-trump-says-hes-been-taking-hydroxychloroquine">taking the drug himself</a> as a preventative treatment.</p>
<p>During the 10-week period between Feb. 17 and April 27 doctors wrote approximately <a href="https://dx.doi.org/10.1001/jama.2020.9184">483,000 more prescriptions for hydroxychloroquine</a> than in the same time period in 2019. The week after President Trump mentioned the drug during a press conference, prescriptions were up more than <a href="https://dx.doi.org/10.1001/jama.2020.9184">200% compared to the previous year</a>. The vast majority of excess prescriptions were written between March 14 and April 4, but as news spread about shortages of the drug and the lack of evidence to support its use, prescribing returned quickly to normal. </p>
<p>Research now shows that this once-promising drug likely <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">isn’t effective for preventing or treating COVID 19</a>, but the damage was already done. Hundreds of thousands of Americans unnecessarily took medicine that <a href="https://www.who.int/publications/m/item/targeted-update-safety-and-efficacy-of-hydroxychloroquine-or-chloroquine-for-treatment-of-covid-19">can have dangerous side effects</a>. Additionally, many people with an actual medical need to take hydroxychloroquine – like those living with lupus and related autoimmune diseases – found themselves <a href="https://www.washingtonpost.com/business/2020/03/20/hospitals-doctors-are-wiping-out-supplies-an-unproven-coronavirus-treatment/">unable to obtain the drugs they needed</a>.</p>
<p>What explains the sharp rise, and equally precipitous fall, of hydroxychloroquine prescriptions?</p>
<h2>Amplification of shaky science</h2>
<p>The hydroxychloroquine story is in part connected to the way information about prescription drugs in the United States is produced and disseminated. This process greatly influences what the public thinks about drugs. </p>
<p>First, the clinical research supporting the use of hydroxychloroquine for COVID-19 was <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">shaky from the start</a>. The initial studies were very small, and likely because of the pressure from the pandemic, the research was <a href="https://theconversation.com/coronavirus-research-done-too-fast-is-testing-publishing-safeguards-bad-science-is-getting-through-134653">rushed through the usual safeguards like peer review</a>.</p>
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<p>Second, influential individuals and organizations played on the public’s perceptions. President Trump was certainly a factor, but media outlets – notably <a href="https://www.foxnews.com/opinion/sean-hannity-gov-cuomo-stop-denying-new-yorkers-hydroxychloroquine">Fox News</a> and <a href="https://nypost.com/2020/04/02/hydroxychloroquine-most-effective-coronavirus-treatment-poll/">the New York Post</a> oversold the apparent benefits and downplayed the ample uncertainty surrounding the treatment at the time. Even The New York Times may have inadvertently contributed to the <a href="https://www.nytimes.com/2020/04/01/health/hydroxychloroquine-coronavirus-malaria.html">initial prescribing stampede</a> by covering the science before it was peer–reviewed, even though they clearly stated the shortcomings of the research.</p>
<p>The truth is that researchers, academic institutions, medical journals and the media all face powerful incentives to portray the latest research findings as more earthshaking than they actually are. Under normal circumstances, numerous mechanisms exist to blunt some of the worst overhyping and many sources of medical information do their best to be accurate in what they report. But in the midst of a pandemic, the urgency of the moment can overwhelm these defenses and good intentions. Bad science can be spread far and wide by normally credible sources.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346162/original/file-20200707-194405-hv9un6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Why were doctors prescribing hydroxychloroquine to patients when the science was still so shaky?</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-talking-to-patient-royalty-free-image/532726150?adppopup=true">LWA-Dann Tardif / Stone via Getty Images</a></span>
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<h2>From public interest to actual prescriptions</h2>
<p>It would be one thing if patients could get unproven medications like hydroxychloroquine for COVID-19 on their own. But physicians are supposed to be the guardians at the gate of medicine. Why were doctors writing prescriptions for a drug to fight COVID-19 without evidence that it worked?</p>
<p>Some physicians were likely overeager early adopters. Additionally, some hospitals – including my own at the University of California, Davis – made hydroxychloroquine available to COVID-19-positive inpatients during the early days of the epidemic. However, early adopters constitute a low percentage of all prescribers - generally <a href="https://www.jstor.org/stable/3768086">less than 10% according to one study</a> – and cumulative U.S. hospitalizations through April 25 totaled <a href="https://gis.cdc.gov/grasp/covidnet/COVID19_3.html">no more than 150,000</a>. With almost a half million extra prescriptions filled over that time, these explanations cannot fully explain the surge.</p>
<p>Substantial research, including my own, shows that when patients ask for drugs by name, <a href="https://dx.doi.org/10.1001/jama.293.16.1995">doctors will frequently prescribe them</a>. A reasonable hypothesis is that many of the excess hydroxychloroquine prescriptions filled in the weeks after President Trump’s remarks resulted from patients asking about or explicitly requesting hydroxychloroquine from their primary care physicians.</p>
<p>Over a decade ago, my colleagues and I ran an experiment where we sent actors pretending to have symptoms of depression to see physicians. Some of the actors explicitly asked for drugs while others did not. The results were striking. Patients requesting antidepressants were more than <a href="https://dx.doi.org/10.1001/jama.293.16.1995">twice as likely to receive them</a>, regardless of whether their symptoms warranted the drugs or not.</p>
<p>These results should not be overinterpreted - we would not have found the same results in a study where patients with broken bones asked for chemotherapy, for example. But much of medical practice occurs in the gray zone of limited evidence. It is these gray areas where <a href="https://doi.org/10.1136/bmj.324.7332.278">media and advertising most influence patients</a>, who in turn influence physicians. With research on treatments for COVID-19 coming out at an incredible rate, the health effects of the virus still largely a mystery and people’s lives on the line, the gray zone for COVID-19 treatments is massive.</p>
<p>In the case of hydroxychloroquine, the combination of shaky science, loud public proponents like the president and the influence patients have on physicians likely resulted in close to half a million prescriptions before the public health benefits and risks were adequately understood.</p>
<p>Research on hydroxychloroquine has accumulated, and now most experts agree that <a href="https://theconversation.com/hydroxychloroquine-for-covid-19-a-new-review-of-several-studies-shows-flaws-in-research-and-no-benefit-137869">it likely isn’t effective</a> as a COVID-19 treatment – with some studies even suggesting that it <a href="http://dx.doi.org/10.1016/j.medj.2020.06.001">may be harmful</a>. But new drugs and treatments to fight this deadly virus are going to continue to emerge in the coming months and years. The media, politicians, doctors and patients must all maintain a critical stance and acknowledge the influence they have on each other.</p>
<p>Waiting for solid evidence in the form of randomized studies takes patience. But the alternative is to wander into a therapeutic fog where potential harms lurk alongside potential benefits. This is never a good idea, and it is especially dangerous now.</p><img src="https://counter.theconversation.com/content/140156/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard L. Kravitz received funding from the National Institutes of Health.</span></em></p>When news reports tout a drug, people get interested, even if the benefits are unproven. Patient hopes, requests and demands can easily turn into real prescriptions in their doctor’s office.Richard L. Kravitz, Professor of Health Policy and Internal Medicine, University of California, DavisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1378912020-05-06T19:50:33Z2020-05-06T19:50:33Z1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering<figure><img src="https://images.theconversation.com/files/332996/original/file-20200506-49542-99e45m.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6679%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>Around 1.6 million Australians aged 45 or over have been living with persistent pain, according to newly released data from the Australian Institute of Health and Welfare.</p>
<p>The figures, which cover 2016-17, reveal that GP consultations for chronic pain increased by 67% in the preceding decade. The number of visits for lower back pain increased by 400,000. </p>
<p>Dealing with chronic pain also means you are likely to face longer hospital stays, much poorer mental health and are three times more likely than normal to be taking painkillers regularly. About 105,000 people were hospitalised with chronic pain in 2017-18, with a typical hospital stay three times longer than average. </p>
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Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
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<p>Behind those figures lies the human cost. As a clinical specialist in pain medicine, I see the jobs lost, the mortgage defaults, the superannuation withdrawals, and the family roles given up because of debilitating pain. </p>
<p>Lower back pain, migraine and pain following trauma are among the top 10 causes of years lost to disability worldwide, and this has <a href="http://www.healthdata.org/gbd">barely changed over the past 20 years</a>. Because chronic pain can happen at any stage of life, many people have to live with it for decades.</p>
<p>A <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">2019 Deloitte Access Economics report</a> commissioned by advocacy group <a href="https://www.painaustralia.org.au/">Painaustralia</a> estimated the annual cost to Australia’s economy at A$139.3 billion per year, more than A$20 billion of which comes directly out of the pockets of pain patients. </p>
<h2>A fresh approach</h2>
<p>The most expensive and inefficient way to manage this national crisis is pretty much the way we are currently doing it. Chronic pain care <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">is too fragmented</a> and too often delivered by those without the most up-to-date training.</p>
<p>Yet most of the really effective treatments can be delivered at a relatively low cost and with low-tech means. Here are some potential solutions that pain doctors and researchers are confident will work.</p>
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<li><p>Medications need to be carefully chosen and ruthlessly abandoned if they are not helping. The <a href="http://www.pbs.gov.au/statistics/expenditure-prescriptions/2018-2019/PBS_Expenditure_and_Prescriptions_Report_1-July-2018_to_30-June-2019.pdf">Pharmaceutical Benefits Scheme</a> (PBS) currently spends more than A$170m a year on drugs such as sustained-release opioids and pregabalin. This could be reduced if more doctors prescribed them in accordance with <a href="https://www.nps.org.au/professionals/opioids-chronic-pain">best practice</a> knowledge. This would help patients and taxpayers alike. </p></li>
<li><p>Skilled interventions such as inpatient infusions of medications like ketamine, or invasive procedures such as <a href="https://www.mayoclinic.org/tests-procedures/radiofrequency-neurotomy/about/pac-20394931">radiofrequency neurotomy</a>, need to be provided according to <a href="http://fpm.anzca.edu.au/documents/fpm-procedures-in-pain-medicine-ccs-v1-0-20191003.pdf">appropriate quality standards</a> so resources are not wasted and patients are not put at risk.</p></li>
<li><p>PBS funding should be extended to cover effective treatments for specific conditions such as <a href="https://link.springer.com/article/10.1007/s11916-019-0768-y">migraines</a>. </p></li>
<li><p>Proven treatments such as group pain programs and individual therapy sessions with credentialed allied health specialists need to be supported by Medicare. These are essential for building the self-management skills needed to reduce patients’ reliance on pain medication. </p></li>
<li><p>We need a massive investment in training and service redesign for agencies that deal with chronic pain as a result of work or transport injuries. </p></li>
<li><p>High-quality pain care should be viewed not as a luxury for hospitals, but an essential part of the health-care ecosystem. Pain care should be integrated throughout the public health system, in both acute and subacute care, where it can shorten inpatient stays and improve rehabilitation. </p></li>
<li><p>We should restrict access to low-value treatments like repeated surgery or medications that have not been working.</p></li>
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Read more:
<a href="https://theconversation.com/needless-treatments-spinal-fusion-surgery-for-lower-back-pain-is-costly-and-theres-little-evidence-itll-work-91829">Needless treatments: spinal fusion surgery for lower back pain is costly and there's little evidence it'll work</a>
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<p>In the void created by the huge unmet need and the limited availability of expert pain care, an industry of highly dubious usefulness has been allowed to flourish. Social media is full of false hope. Supplements such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/27477804">glucosamine</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/28470851">curcumin</a> and <a href="https://journals.lww.com/jclinrheum/fulltext/2017/09000/omega_3_fatty_acids_in_rheumatic_diseases__a.6.aspx">fish oil</a> are not supported by credible studies, yet they are still promoted commercially as effective. </p>
<p>Dodgy arthritis “cures” and devices that claim to relieve pain using magnets or electricity are everywhere. Despite <a href="https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-treatment-chronic-non-cancer-pain-australia">dismal supporting evidence</a>, the medical cannabis industry continues to sell itself to chronic pain patients.</p>
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Read more:
<a href="https://theconversation.com/im-taking-glucosamine-for-my-arthritis-so-whats-behind-the-new-advice-to-stop-131648">I'm taking glucosamine for my arthritis. So what's behind the new advice to stop?</a>
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<p>While the COVID-19 pandemic continues, it can be hard to focus on other health issues. But Australia already has a path to improving life for many thousands of chronic pain sufferers. The federal government has developed a <a href="https://www.painaustralia.org.au/static/uploads/files/national-action-plan-11-06-2019-wftmzrzushlj.pdf">strategic plan for pain management</a> that offers a blueprint for future action. </p>
<p>The plan calls for upskilling of all primary care health professionals to help them recognise the early stages of a chronic pain problem and nip it in the bud. If implemented, it will bring the dream of timely access to well-resourced expert interdisciplinary pain teams in the regions and outer suburbs closer to reality. </p>
<p>Most importantly, we need a community-wide effort to destigmatise persistent pain and those who suffer from it. After all, the chances are you either have it or you live or work with someone who does.</p><img src="https://counter.theconversation.com/content/137891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Vagg is the current Dean of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists</span></em></p>Chronic pain is everyone’s problem. It’s costly, debilitating and, according to new statistics, increasingly common. Reversing the trend is achieveable but far from easy.Michael Vagg, Conjoint Clinical Associate Professor, Deakin University School of Medicine and Specialist Pain Medicine Physician, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.