27/02/2019

The underappreciated health benefits of being a weekend warrior

Our nephew Christopher died of a heroin overdose in October 2013. It had started with pain pills and experimentation, and was fueled by deep grief. He was charismatic, lovable, a favorite uncle, and a hero to all the children in his life. His death too young was a huge loss to our family. I have always felt that I didn’t do enough to help prevent it, and perhaps, in a way, even contributed.
Good intentions with unintended consequences

My medical training took me through several big-city hospitals where addiction and its consequences were commonplace. Throughout all of it, great emphasis was placed on recognizing “the fifth vital sign,” i.e., pain, and treating it.

I distinctly remember as a medical student wearing a little pin with the word “PAIN” and a line across it. One was considered a bad doctor if they didn’t ask about and treat pain. And so, treat we did. This medical movement, combined with the mass marketing of OxyContin and a swelling heroin trade, has created the current opioid epidemic.

It generally starts with pain pills: Percocet, Vicodin, Oxycodone or OxyContin, either prescribed or given or bought. Quickly, a person finds that she or he needs more and more of the drug to get the same effect. Almost overnight, they need the drug just to feel normal, to stave off the horror of withdrawal. Street heroin is cheaper and easier to come by than pills, and so, people move on to the next level. Just like Christopher.

Recent data from the Centers for Disease Control (CDC) and the National Institute for Drug Abuse (NIDA) show that deaths from overdose of opioids have been rising every year since 1999. (OxyContin came to market in 1996). Deaths from heroin overdose have recently spiked: a 20% increase from 2014 to 2015. And most recently we’re seeing fentanyl, an extremely potent synthetic opioid, where even a few small grains can kill.

So, if we doctors helped everyone get into this mess, we should help them get out of it, no?
Needed: Treatment that works

As the opioid epidemic has exploded, so has the demand for treatment. But treatment is almost impossible to come by. The U.S. is short almost 1 million treatment slots for opioid addiction treatment. And not all treatments offered are that effective.

The “traditional” treatment of detoxification, followed by referrals to individual therapy or group support (think Narcotics Anonymous), may work well for some, but the data suggest that there are more effective approaches. In fact, a growing body of evidence very strongly supports medication, combined with therapy and group support, as the most effective treatment currently available.

“Detox” followed by therapy has consistently shown poor results, with more than 80% of patients relapsing, compared to treatment with medications, with only 15% relapsing. Medications, specifically methadone and buprenorphine, can help prevent withdrawal symptoms and control cravings, and can help patients to function in society. Suboxone (a combination of the drugs buprenorphine and naloxone) has many advantages over methadone. It not only prevents withdrawal and controls cravings, but also blocks the effects from any illicit drug use, making it more difficult for patients to relapse or overdose. In addition, while methadone can only be prescribed through certified clinics, any primary care provider who completes a training course can prescribe Suboxone. That means treatment for opioid use disorders could be much more widely available.

Basically, treatment with medications, and especially Suboxone, is effective, and safer than anything else we have to offer. Yes, relapses can occur, but far less frequently than with traditional treatment. And death from heroin overdose? Far, far less.
Biases against treating opioid use disorder with medications

Despite their effectiveness, there is stigma associated with treating substance use disorders with medication. I admit that I had my own doubts as well. People say, as I did, “Oh, you’re just replacing one drug with another.” But a lot of hard science has accumulated since 2002, when the FDA approved Suboxone for the treatment of opioid addiction.

Think about it. Is shooting street heroin that’s cut with God knows what, using needles infected with worse, really the same as using a well-studied, safe, and effective daily oral medication? Some may claim “Oh, you’re just creating another addiction.” Would you tell someone with diabetes who depends on insulin that they’re “addicted”? Then why say that to someone with opioid use disorder who depends on Suboxone? This is literally the reasoning that played out in my head as I have learned about treating opioid addiction, or, more correctly stated, opioid use disorder.
Stepping up

I’ve decided that it’s time to do something. There’s a great need for doctors willing and able to treat opioid use disorder. In 2016, surgeon general Vivek Murthy issued a strident call to action to all U.S. healthcare providers, asking them to get involved.

This issue has been on my mind and soul since Christopher’s death, so I started educating myself, and contacted our hospital’s substance use disorders specialist with my motivation and concerns. In the few months since then, I’ve taken the training course to become a licensed prescriber, and am working with the team to begin treating a small group of patients.

In my 16 years of clinical training and practice, I have witnessed all of this firsthand: the blatant, medically rationalized over-prescription of pain meds, the stigma and undertreatment of opioid use disorder, and the unnecessary, premature death of a really good kid. I’m just starting off on this, and I’m still learning, but my hope is to keep another family from experiencing unnecessary loss. (For more information see Medication-Assisted Treatment for Opioid Addiction)

Register for the free online course OpioidX: The Opioid Crisis in America. This course challenges common beliefs about addiction and the people who become addicted to opioids. Through an increased understanding of the biology of addiction, the course aims to reduce the stigma around addiction in general, and help people discover the multiple pathways to evidenced-based treatment. A variety of Harvard Medical School clinicians and health policy experts explain these topics and you’ll hear stories first-hand from those who have experienced addiction, or whose lives have been touched by this the opioid epidemic.
Men who have high levels of prostate-specific antigen (PSA) in their blood face troubling uncertainties. While it’s true that prostate cancer can elevate PSA, so can other conditions, including the benign prostate enlargement that afflicts many men as they get older. PSA levels also vary normally from one man to the next, and some men have unusually high levels even when they’re perfectly healthy. To rule out cancer, doctors might recommend a biopsy. Yet prostate biopsies pose risks of infection, and they can also miss cancer in men who truly have the disease. Most prostate biopsies are guided by transrectal ultrasound, an imaging technology that allows doctors to see the gland while taking tissue samples (called cores) with specialized needles. Tumors may not show up on ultrasound, however, so the biopsy needles might never hit a cancerous target.
A more precise way to investigate elevated PSA results

In January, British researchers reported results from the multi-center PROMIS study showing that a different imaging technology, called multi-parametric magnetic resonance imaging (MP-MRI), could allow some men with high PSA levels to safely avoid a prostate biopsy altogether. “If my MP-MRI was negative, I would not have a biopsy,” said Mark Emberton, M.D., director of the Division of Surgery and Interventional Science at University College London, and a co-author on the study. “And I would do that confidently.”

An MRI machine uses a very large magnet, a radio-wave transmitter, and a computer to construct detailed pictures of structures inside the body. MP-MRI is an advanced form of the technology that allows specially trained radiologists to detect prostate tumors. They can also gauge how aggressive the tumor is by looking at how tightly the cells are packed and how blood and water molecules flow through them.
Here’s how the study worked

During the study, researchers looked at how well MP-MRI performs at detecting prostate cancer compared to two different kinds of biopsies: a standard biopsy guided by transrectal ultrasound (TRUS-biopsy), and a “template prostate mapping” (TPM) biopsy that samples the entire gland at 5-millimeter intervals. TPM biopsy is the “gold standard” for diagnosing prostate cancer, but doctors rarely use it because it’s so invasive. If MP-MRI had failed to detect a prostate cancer identified with TPM biopsy, then the result would be recorded as a false negative.

The study enrolled 576 men with PSA levels ranging up to 15 nanograms per milliliter. MP-MRI correctly identified prostate cancers that were confirmed with TPM biopsies 93% of the time. That’s a significant improvement over TRUS-biopsy, which only picked up about half the prostate cancers detected with TPM biopsy. MP-MRI was also effective at identifying men who did not have clinically significant prostate cancers, recognizing them correctly 89% of the time. The results helped to confirm that MP-MRI is better at picking up aggressive tumors than it is at detecting low-grade cancers that might never be harmful during a man’s lifetime. Dr. Emberton emphasized that the cancers missed by MP-MRI were nearly all low-grade. “MP-MRI missed none of the high-grade, dangerous cancers and TRUS-biopsy missed many of them,” he said.
Promising, but proceed with caution

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org said the new study helps to show that MP-MRI provides important diagnostic information in a non-invasive way that protects men from infection and other biopsy-related complications. But he cautioned that all diagnostic methods employed today carry some risk of missing prostate cancers that are truly present. “Moreover, the radiological skills needed to interpret MP-MRIs correctly are in short supply,” he said. “And the technology’s cost must also be considered as its use becomes more widespread.” What do you think of when you hear the term “weekend warrior”? Maybe it’s a person who exercises intensely on the weekend but is otherwise sedentary. I tend to think of an overweight, middle-aged guy resolving for the 100th time to get in shape. But because he only has time to work out over the weekend, that’s when he does it — or overdoes it.
Woe betide the weekend warrior

Weekend warriors with back pain, a pulled muscle, or other “overuse” injuries are a common sight in doctors’ waiting rooms after they’ve tried to do too much in too little time. That’s why most experts recommend regular exercise most days of the week rather than just on weekends.
A new study’s new take

Despite the injuries commonly associated with the weekend warrior, a new study finds that weekend warriors may be on to something. As published in JAMA Internal Medicine, weekend warriors who met recommended exercise guidelines (including those who exercised just once or twice a week but did so vigorously for at least 75 minutes, or at moderate intensity for at least 150 minutes) had a reduced risk of death from cardiovascular disease, cancer, or other causes.

Here’s some more specific information about this study:

    More than 63,000 adults in England and Scotland were surveyed about their health and physical activity between 1994 and 2012.
    Nearly two-thirds of study subjects were considered inactive — 11% were regularly active and about 4% were “weekend warriors.” The rest were “insufficiently active,” meaning they were not inactive but did not meet recommended activity guidelines.
    Data regarding their deaths from any cause, cardiovascular disease, and cancer were also collected over this time period.

Compared to less active adults, weekend warriors had a 30% lower risk of death from any cause, a 40% lower risk of death due to cardiovascular disease, and an 18% lower risk of death due to cancer. While regular exercisers had lower death rates than weekend warriors, the differences were quite small.
Some caveats

Of course, a study of this sort can only describe an association between exercise and death rates, but it cannot prove that the exercise actually caused the health benefits. It’s possible that something other than exercise — perhaps a difference in diet not captured by the surveys — accounted for the lower death rates among the weekend warriors. Activity levels were self-reported and could be inaccurate. In addition, 90% of the study population was white. If other ethnic groups were included, the results might have been different. Other information not included in this study would be of interest, including the type of sedentary activities (such as sitting), effects on other health outcomes (such as mental health, arthritis, or diabetes), and rates of injuries related to physical activity.

Still, this study is among the first to suggest that weekend warriors may get a similar benefit from their schedule of exercise as those working out more regularly. This study also supports current exercise guidelines that recommend 75 minutes of vigorous exercise per week or 150 minutes of moderate intensity exercise per week.
So, what does this mean for you?

In my view, this study is important. In the past, weekend warriors were encouraged to change their ways lest they wind up injured. And it has long been assumed that you can’t get much benefit by exercising just once or twice a week rather than daily or most days of the week. This new study should make us rethink that assumption.

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