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Doc's Progress Notes

Week of December 27, 1999

Last Updated: 1/2/2000 at 7:11 PM PST


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Monday December 27, 1999


The last week of this century begins about like all the past weeks after Christmas have begun, busy. Actually, the rush begins Christmas afternoon and continues unabated normally until about the time school is out. Right now, we have an Influenza A going around here among the people who did not get flu shots this year. Since it is Influenza A, there is effective antiviral medication that can be used but it needs to be started within the first 72 hours, preferably within 48 hours. If it is used, and it is type A, it will shorten the length of time someone has symptoms. There is no way to clinically know if it is Type A or B (the medication doesn't work on B) quickly so it is good to know that A is the one going around in this community. Actually, the last statement is not completely accurate, there are now three test kits which are commercially available to tell within 30 minutes if one has Influenza, just not the type I do not believe, and they are not in widespread use yet. We don't have one here yet, hopefully next flu season.

If you come down with nasal congestion, sore throat, fever(and maybe chills),dry cough, and muscle aches this time of the year, talk to your physician early. If it is Influenza A the medications available can shorten the length time you are down with the flu. The true Influenza only very rarely is associated with any vomiting and/or diarrhea. That illness is mistakenly called "stomach flu" when in reality it is a viral gastroenteritis(usually) NOT caused by an influenza virus. Therefore getting a flu shot will not protect you from the "stomach flu" or, for that matter, from the common cold.

My patients today ranged from age three weeks to age 90 years. Actually the three week old was not seen by me. He was the child of a couple visiting across the street at our neighbors and starting running a fever while there today. The neighbor called right after I got home tonight to ask for my recommendation regarding pediatricians here in town. They had already taken him to the Emergency Department here and were wondering who to ask for there. If he really had a fever of 102 degrees(F), he will probably have to be admitted to be sure he doesn't have a serious infection at that age.

The ninety year old wasn't seen either, come to think of it. I talked to her nephew about her because he felt she was becoming depressed due to her end-stage emphysema. I agreed, having seen her just last week, and with her and his permission I restarted her on a small dose of an antidepressant. She is hoping to live long enough to see the new century come in and I hope she will be able to see it also. She has already survived two bouts of pneumonia this fall that I did not think she would survive. She is on oxygen all the time and has to have breathing treatments around the clock as well as being on several medications including inhalers. Every time she comes to the office she asks me how much longer it will be and I tell her only God knows which puts her at peace. I'm betting she will see the new century then her will to live will be gone and she won't survive the next respiratory infection.

Most of the patients today had upper respiratory type infections. Not many had influenza although I did treat one man and his wife for influenza because they had come in within 24 hours of the onset of their symptoms. I did do one sports physical today on a boy who was planning to play basketball and baseball. This time of the year is an unusual time to do a sports physical, most of them are done from May-August before the next school year begins.

The patient from last week with the chronic pain and substance abuse problems is so far complying with the guidelines we gave her. She was back today for her pain medication and then is going to meet with a psychologist and psychiatrist tomorrow. She looked much better today and my staff commented about that after she left. She still has a long way to go to get completely well but I am encouraged. Only more time will tell.

My last patient of the day took the most time {that's one of Murphy's laws isn't it?}. She is twenty-two and came in with a complaint of daily vomiting for two weeks, complete with weight loss but no diarrhea. She mentioned that she had had something similar when she was pregnant and she had not had a real period for a couple of months. I had already done a pregnancy test on her and it was positive so I gave her the news. She was surprised but not particularly shocked and wanted to know if her tubes could be tied after this child who would be her third, all delivered by C-section. I assured they could be if that was her desire. She then mentioned to me that she smoked marijuana to help her anxiety and had done so with her other pregnancies. With her weight loss due to the serious "morning sickness", her previous C-sections, and her admitted use of marijuana while pregnant, hers is a high risk pregnancy so I immediately called the obstetrician in our group she had used before. He remembered her from her last pregnancy and will see her tomorrow to start her on medication to help her nausea and also talk to her about not using marijuana while pregnant. This will be the same talk he gives about not smoking tobacco while pregnant, it leads to small babies with lung problems.

Now, on to a lighter subject. As most of you regular readers of this journal will recall, I have always highly recommended the journal and soon to be available book written by Dave Farquhar, a fellow Daynoter and a fine young man, or so I thought. My opinion is rapidly changing, however, based on what I read in his journal today. Permit me to quote the offending passage: seeing as we're both from Missouri, which isn't quite as backwoods hick as Arkansas but try telling an out-of-stater that. The bold type was added by me, by the way. Now, as anyone who reads this journal regularly knows, I am a native Arkansan {or Arkansawyer, depending on which you prefer} whose favorite college team now and forever is the Razorbacks. Therefore, those words are fighting words. From now on you will not see any mention of Dave What's his name's site or book on this page until I receive a formal apology from him which I will print here for all of you to see.

Another reason to question his intelligence is the very mention that Missouri could be considered backwoods hick. He has now also offended my lovely wife who is a native of Springfield, Missouri so he needs to apologize for offending her too. Isn't it amazing how much trouble a simple written sentence can get one in? <big grin>

That's it for tonight. Must go check my wife's computer again to be sure everything is running correctly after the work I did on it last night. Until tomorrow......

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Tuesday December 28, 1999


I don't believe this! I had been typing an update for more than thirty minutes when it suddenly disappeared while I was typing. I go back and reopen the file with 1stPage 2000 and what I had typed in was gone. I had no chance to save it before it disappeared. And people think only weird things happen with Microsoft software. Do I have to start saving at the end of every sentence or paragraph? I don't think this program has an auto save feature but I will look closer to see if it does. I don't want that to ever happen again. Take my word for it, I had a pretty good update going.

The main part of the update was about influenza again. I am seeing more patients with it than I had even expected. I am seeing patients with complicating infections now. I am seeing bronchitis and sinusitis as complicating bacterial infections in people who began with influenza or colds. Today I saw a five year old with pneumonia which I am sure began as a simple cold but progressed to pneumonia. He had been seen in the Emergency Department the day after Christmas and placed on an antibiotic. I saw him today 48 hours later still having fever but no breathing difficulty. I don't think his pneumonia is any worse but did change his antibiotic more appropriate to cover the possible bacterial causes of pneumonia at his age. I can't prove it is bacterial rather than viral so I can only cover the organisms we can treat. One has to have an idea what the most common bacterial causes of particular infections are based on the age of the patient and the presence or absence of chronic diseases. There is no way to remember everything so you have to know where to look things up. This is where computers come in very handy. I do a lot of searches during the day on appropriate medical reference sites. I used to have to keep a lot of books and journals handy, now I can simply search websites for the needed information.

I forgot to mention yesterday that the antivirals used to treat Influenza A can be used for prophylaxis also. They are used at different doses than for treating acute influenza and for a longer time but are effective. I had occasion to put a couple of healthcare workers who are being exposed to influenza at the present time and did not get their flu shots this year on prophylactic treatment today. All in all, getting the flu shot is a more effective preventive measure, though.

The patient from yesterday who is pregnant and vomiting constantly did not call in today. We did get hold of her this morning and told her to call the obstetrician's office who I talked to yesterday and he will take care of her from here on out until after she delivers. He made sure to tell me that he would return her to me after she delivers. I appreciate a specialist who returns patients to me after they have treated the patient for the problem I referred them for. Hopefully everything goes well with her pregnancy and she has a healthy baby.

I did not finish with my patient callbacks until after 9:30 PM tonight. That is late for me but not unheard of in the past. I used to try and call at set times during the day but invariably there would be people who are never home or near a phone at those times every day so now I just try at various times throughout the day and try never to let the day end until I have tried to return all patient calls. Some of the calls my medical assistant can handle under my direction since she has a lot of experience. I trust her to know when she needs to consult me about a problem that I have not specifically given her instructions about. An experienced medical assistant is a great deal of help for any busy physician.

Finally, I have received the apology I demanded yesterday. For those of you who do not remember, Dave Farquhar had offended me with the following passage in his journal yesterday: seeing as we're both from Missouri, which isn't quite as backwoods hick as Arkansas but try telling an out-of-stater that. Dave wrote back with the following:

Well, OK, I guess Iowans regard us as about equally backwoods hick, so I apologize for saying Arkansas is more backwoods hick than Missour-ah (note spelling).

Ooh! Wraslin's on! I've been fixin' to watch that....

Seriously though, no offense intended. A number of my classmates ended up in Arkansas, and I wouldn't regard any of them as hicks, and on the one occasion I've had to be in Arkansas (for my former college roommate's wedding a couple of years ago), I found the people there to be about as friendly and hospitable as they come. I was writing in jest, and I hope everyone saw it that way.

Dave

Of course I accept his sincere apology and I understood it was written in jest just as my being offended was also in jest. Some of the humor among the Daynoters is quite dry and this is one of those examples. We are still a community who respect each other and I for one am continually amazed by the level of intelligence and talent seen in the members of this group. The humor may be merciless at times but there is genuine respect for each other which comes through loud and clear. More tomorrow........

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Wednesday December 29, 1999


Another day, more influenza. No serious complications today, just pretty routine cases of influenza. Some sinusitis and a little bronchitis among smokers which gave me a chance to urge them to quit smoking. I know I am not always successful in getting them to quit smoking but they at least know I have brought the subject up with them and one day maybe they will come to the realization that they need to quit. Research indicates that if physicians mention it to their smoking patients more will quit than if it is not mentioned.

I did not hear back from the child with pneumonia from yesterday and he is not in the hospital so I take that to mean he is better. Tomorrow will be 48 hours and hopefully he will not be running fever so he will not be back. If he is, we may have to admit him. Then ninety year old lady I mentioned a few days ago with the end stage COPD was back at the Emergency Department but got better with a breathing treatment and a boost of her steroids so went back to the extended care facility where she lives. I still think she will make it to see the new millennium then succumb soon after. I will miss her, she has always been fun to talk to in the office.

Another situation with pain medication came up in the office today. I had seen a new patient Monday with back and knee pain, the knee pain chronic after three operations and the back pain episodic. I had prescribed a small amount of narcotic pain medication which he tried to add a one to the front of the number of pills and then get the prescription filled. I have been around long enough to know how to prevent this particular trick and the prescription looked obviously altered to the pharmacist who promptly called to confirm this. He refused to fill the altered prescription so the patient came in to talk to me. I expected him to say he was innocent but instead he told me that he had indeed altered the prescription without me asking and that it was the first time he had done anything like that. I asked why to which he replied that he was hurting so bad and the medicine seemed to be like candy, he couldn't get enough to stop the pain. I told him that what he had done is a federal offense to which he acted surprised. I then checked with the other pharmacies in town and they had no record of him trying to get medication elsewhere which would be unusual if he had done this before or had a history of drug seeking behavior.

Since he had no local history and maintained he had never done anything like this before, I asked if he would be willing to go to a chronic pain management program in Portland. He said he would and was agreeable to signing a drug contract which stated I would give him a certain amount of long acting narcotic pain medication which he would fill only at the pharmacy he would indicate to us. Further, I would be the only physician who would write prescriptions for him unless I authorized someone else to, he would agree not to call for refills only to come in for a written prescription, and if he failed to uphold any part of this contract, I would no longer write him any prescription nor would anyone else in my group ever. We also called all the pharmacies in town to inform them of this contract and to let us know if he brought in a prescription to their pharmacy. I told him he had already used up his one mistake with me and I would not tolerate another one. We will see if he upholds his end of the bargain.

Meanwhile, at home we are having a stand off with our son. He seems to think we should allow him to have a party for some of his friends here at our house Saturday night and pay for all the snacks. We told him it was OK to have a party here but he would be responsible for providing the food, not us as he had money left over from Christmas and he had done nothing extra beyond his basic chore requirements for us to feel we should reward him. We suggested an alternative, namely they all meet at a local bowling alley but that would cost them money which wasn't fair according to him since we would expect them to pay their own way at the bowling alley. So, either he pays for snacks or there are no snacks here for a party or his friends meet him at the bowling alley and pay their own way. He thinks we are such mean, uncool parents. This really is bothering us (NOT). Stay tuned for further updates.

The lovely Marcia Bilbrey just sent me an e-mail informing me that I had written on below that Friday was my anniversary not OUR anniversary. Of course she is right, it is OUR wedding anniversary but also I am right as it is the two year anniversary of the day I left my old position. So you see Marcia, we are both right. As I am sure Brian already knows, we never question our wives' statements. See below for the change I have made. See you tomorrow.....

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Thursday December 30, 1999


I am glad today at work is over. Everyone is trying to get their medication refilled before Jan 1 because they are afraid that the Y2K bug will somehow prevent them from getting medication. Normally, there is an increase in the requests for refills before the end of the year, but this is worse than normal. I had a huge stack on my desk all day, not just late in the afternoon as usual. We did get them all done today so no one will have to wait until tomorrow.

Otherwise, we had people with influenza today and a lot of infants with colds. None were really sick and the child with pneumonia from Tuesday did not come back today which means his fever has broken and he is better. Next week promises to be as busy or busier.

The rest of today's update will be an exchange of messages between Bob Thompson and myself. I will post his original message and subsequent comments to my return message in block quotes. My comments will be the bold font. I have embedded his comments back to me in the same place as they were returned to me. I will have a short comment at the end.

I notice that preventing people from obtaining the drugs they want seems to be a recurring theme in your posts. I understand that as a physician you are under certain constraints in what you can allow people to have without getting in trouble yourself. However, if I were a physician, I would do as little as legally allowable to prevent people from having access to whatever drugs they wanted, whereas you seem to go out of your way to prevent patients from obtaining drugs they desperately want.

Philosophically, I am against any form of controlling drug use, except perhaps perhaps antibiotics, where there is indeed a compelling social interest in preventing the proliferation of resistent bacteria. I think that people have the right to go to hell in their own way, and if that includes becoming addicted to narcotics or other pain relievers, I think that is their right. Correct me if I'm wrong, but I believe that (a) individual reaction to pain differs greatly, as does individual response to pain-killing drugs, (b) American physicians in general (and physicians from a Judeo/Christian background in particular) have historically undermedicated for pain, and (c) the deleterious effects of addiction to narcotics are relatively minor if those drugs are readily and cheaply available in pharmaceutical purity. Before the Harrison Act in 1906, were not literally millions of Americans addicted to narcotics with little noticeable effect?

I have to wonder if your desire to prevent people from obtaining such drugs is based more on your religious/moral/ethical beliefs than on medical reasons. I don't mean this as an insult, because I am sure that many of my decisions are based on my own moral beliefs, but I wonder how many doctors restrict their patient's use of such drugs for all the wrong reasons. If I were a physican, I'd prescribe such medications to be taken "as needed" as much as was legally permissable. Further, I'd try to change the laws to eliminate any restrictions whatsoever on their use. Narcotics and similar drugs should be freely available over-the-counter to anyone who wants them.

Please feel free to post this letter if you wish.

Best regards.

Bob

My initial response to Bob's letter was to become outraged and say how could he have missed the point of my posts. Then I realized that if he had missed the point it was because I had not made the point very clear. If any of my readers think I am going out of my way to prevent patients from getting the medication they need or want then I am not doing a very good job of explaining myself. Excuse the length of this reply but I will try to cover all the points he brought up.

Bob points out an interesting contradiction. On the one hand he says maybe antibiotic usage should be limited and not given to patients just because they want it but that narcotic usage should not be limited but they should be freely available. He cites social interest in preventing the proliferation of bacterial resistance but what about the social interest in preventing crimes committed by addicts who cannot afford to buy the drugs they are addicted to even if they are over the counter. Just because they are over the counter doesn't mean they would be cheap and affordable by all. What about the cost to society of treating addicts who overdose and have no way of paying for their medical treatment? What about the cost to society of people working or driving under the influence of mind altering drugs or cannot work due to their addiction? Don't we as a society have a great deal of interest in controlling the cost to our society of these addicting drugs?

Misuse of antibiotics risks them becoming useless for everyone. I call that a compelling social interest (or at least I am willing to discuss it; I am still uncomfortable restricting drugs in any way). As far as the social cost of crime, there is no doubt whatsoever that controlling the availability of these drugs causes crime. Junkies may have a $300/day habit. That's actually a $0.25 per day habit with a $299.75 government tax added. Removing all controls from narcotics and other drugs makes them cheap. Junkies would have no need to mug people to pay for a 25 cent fix. There is also the small matter that many of the bad effects on junkies of heroin and similar drugs are due to the illegal nature of what they're shooting. If they could walk into a drugstore or a 7-11 and buy a cheap, pharmaceutically pure fix, they'd be in a lot better shape.

As far as those who overdose, why should anyone pay for their medical treatment? They chose their own road. Let them die in the street. Granted, that increases garbage collection costs somewhat, but that's fairly minor. Most of your arguments here are predicated on the idea that something must be done. I don't concede that. If they can't work, let them starve.

I think that any reasonable person has to admit that the relative costs involved in controlling these drugs versus not controlling them are ridiculously in favor of eliminating controls. If you make these drugs legal, overnight you'll find the violent crime rate will drop by 90% or more. For that matter, although I'm not in favor of any government programs, especially give-aways, why not give away doses to any one who wants one any time he wants it.

Bob knows I am not picking on him anymore than he was picking on me when he wrote me the letter. He is asking questions that need answers as am I. We, as a society, have not been willing to face these questions and come up with answers. We have made up a hodge podge of laws that are Band-Aids at best. We cannot afford to pay for everything for everyone so what do we pay for?

I say that as a society, we pay for nothing. Everyone pays for what he wants and can afford, period.

Now to get back to the points Bob brought up in the letter, he is correct about the history of modern medicine regarding treating pain. We have done an abysmal job especially with chronic pain. This stems from the mistaken belief, taught as fact, that pain is "all in your head". We now have better explanations for what causes pain and why some people perceive it differently than other people. That explains why some people need more pain reliever to relieve their pain than others. I do not agree that physicians from a Judeo/Christian background are less likely to prescribe pain medication than those not from that background, in fact I would argue that it should be exactly the opposite. We Christians are called to help those in need including those who are suffering; our Hippocratic Oath as physicians also calls us to help those who are suffering. American physicians' attitudes toward treating pain are changing and I think we will see less undertreating in the future.

I suggest that it goes much further than that. Consider what happened, for example, when ether was introduced as an anesthetic. There were cries of outrage from clerics and *doctors* that anesthesia subverted God's law. In particular, many (perhaps most) doctors refused to use ether for childbirth, claiming that Genesis dictated that women should give birth in pain, and that any attempt to ameliorate that pain was an offense to God. Give me a break. I am not making this up. I can probably dig out numerous contemporaneous references if you're interested. I think this bias, although perhaps unconscious, remains today.

Addiction to narcotics is very rare in patients who truly have pain we now know. Tolerance occurs, of course, which means that patients need increasing doses of medication to relieve pain after a certain time since the body gets "immune" to the same dose of a narcotic if it is given long enough. Tolerance is not part of addiction, dependence, and abuse. Probably I should not talk about addiction but rather dependence and abuse, those are easier to define and are more specific terms than addiction.

And I would argue that the patient should be the one to determine how much analgesia he requires, and how often. Obviously, there are real limits on how much is safe. But I believe it is the doctor's place to describe those limits clearly to the patient and allow the patient to decide. My mother, for example, has been totally and permanently disabled with stage 4 degenerative rheumatoid arthritis for more than 30 years. She has been in constant pain that entire time, and yet the most effective pain reliever doctors wish to give her is ibuprofen. If she wants morphine, or levo-methorphan for that matter, I say it should be her decision.

Abuse is defined by the National Institute of Health as "repeated use with adverse consequences" and dependence as "opioid tolerance, withdrawal symptoms, compulsive drug-taking". In other words, abuse leads to dependence which is what is thought of as addiction. With this comes the overwhelming physical desire for the opiate (or narcotic, both are the same) leading to adverse consequences including stealing drugs, forging prescriptions, armed robbery, and all the other crimes you hear about on the evening news.

No, no, no. All of the crimes you mention are solely the result of the tight controls on drugs. If drugs were freely available, none of those would be a problem. No one would steal drugs, because they'd be cheap. No one would forge prescriptions (which is a dubious "crime" anyway), because no prescriptions would be needed. No one would need to rob anyone with a daily dose of their drug of choice costing perhaps a dollar. All of those crimes that you hear about on the evening news are not a result of the drugs or of people using those drugs. They are a result of the government putting tight controls on them.

So, Bob, I am not trying to prevent people from getting narcotic pain medication for treatment of their pain, indeed I encourage them to take the medication on an as needed basis. Rather, I am trying to prevent these drugs from being redirected and abused. I have had people come in saying they are in pain, got a prescription, made copies and PRINTED up their own prescriptions, faked my signature, then gone to pharmacies with the fakes. When caught, they confessed to selling the drugs on the street.

Well, once again, this problem occurs because of tight controls, pure and simple.

I try to determine who has legitimate pain (admittedly there is no objective test for that) then monitor their use of pain medication. I am upfront with how we monitor them including contracts not to get pain medication from anyone else but me. I explain we must monitor them closely because of the potential for illegal uses by them, their family, or acquaintances. Whether I believe these drugs should be available by prescription or not is beside the point; they are prescription only and my use of them is monitored by our state medical board and the Drug Enforcement Agency. If I knowingly allow them to be abused I am subject to suspension of my medical license and criminal penalties from the DEA. I explain this to patients but also tell them I will willingly increase their medication as they need it but this need has to be communicated to me so it can be documented to protect me and them.

Again, I recognize your need to protect yourself against these arbitrary government rules. All I was saying was that, if I were a physician, I would do as little as I could legally get away with to monitor and control these drugs. You're not a cop.

One last point, then I will stop; if these drugs were over the counter how many potential curable causes of pain would be missed because a patient could simply cover up the pain with medication rather than be evaluated to find the cause while their pain is being treated. Just today, we found a potentially curable colon cancer in a gentleman who came in simply to get pain medication for his abdominal pain which he was sure was no more than indigestion and had been episodic for some time. If he had waited because he could treat his abdominal pain with over the counter pain medications, chances are his cancer would not have been caught in time to cure it.

This argument essentially boils down to forcing people to do something for their own good. I am always suspicious of any such motivation. Please let me worry about my own good. You worry about your own. If I choose to self-medicate, that should be my business, not yours, and not the government's. If the results of my decision are bad from my point of view, again that's my problem, not yours and not the government's.

Sorry for the length of this discourse. Thanks for writing and causing me to re-examine what impression I was leaving for my readers. Open discussion is what this virtual community is all about. I am not right all the time and you certainly are not right all the time . I respect your opinions and may not agree with them all the time but I certainly support your right to voice them. I am going to post your message and my reply tonight on my page and it may stimulate some more debate. Have a great Y2K.

You're right. We'd better drop this discussion and go make sure our powder is dry.

Yes, quite a dialogue, right? Pardon the length of it but I thought it important to include all of what was written. If you would care to comment please don't hesitate to send them to me and I will try and post them. Have a good night and see you tomorrow, the last day of this century.

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Friday December 31, 1999


No major Y2K problems reported yet. We are ready here but I don't think we will see any problems. We are going to dinner tonight with Stacey to celebrate our anniversary then will go to a millenium watch service being sponsored by several local churches. Afterward we will pick up Stephen and his friend from the youth watch service and bring them home. Tomorrow I need to be up by 8 AM our time to watch the Cotton Bowl. After that maybe I can find some time to sleep but knowing me I will be trying to watch other bowl games.

Yesterday's dialogue with Bob Thompson has generated some mail. I will post some of them now and respond to a couple, the others are pretty self explanatory and I don't think need comment. Remember, if you send me something that you don't want posted just indicate that in the message.

******

Jim,

I just saw the discussion between you and Bob; and had to put in my two cents' worth. I happen to know that in Canada (Hi Tom) one can walk into a drug store or 7-11 and purchase acetometaphime plus codeine at a very reasonable price. Now, I don't hear a lot about codeine addicts in Canada. One would expect with the paternalistic government up there; we would hear of that.

I agree that pain management rarely leads to addiction. During the last year of her life; my sister had a morphine pump (on demand type of pump). To the best of my knowledge, she was not addicted. This in a woman who did get in trouble with Demerol earlier in life. (Dr's problem, not hers)

I do understand your "Cover My Backside" attitude, and your desire to not have addicted patients. However; the end result of the whole regulation fiasco is increased cost to the paying public.

Thanks for letting me rant,

John Vogt
jaydonalds@aol.com

No problem, rant away. As I said yesterday, few people actually get addicted to narcotics unless they are taken to "get high". Canada's experience would fit right with that statement. As you said, people who are in pain do not get addicted to narcotics, even if they have an earlier history of addiction. I agree, anytime the government gets involved in regulating people's lives it ends up costing people more.

******

Jim,

Further to your recent discussion with Bob Thompson regarding prescription drugs, I'd be interested to hear your thoughts on the differences in the availability of commonly prescribed drugs that are OTC in other countries while still Rx-only in the US. For example, Claritin has been OTC in Canada for quite a while while still Rx in the US (as well as more expensive).

Alan Donders
alan_donders at hotmail dot com

I have no problem with drugs like Claritin being over the counter. I wonder if they really are less expensive in Canada and if the dose is the same as the prescription dose here. Our own experience in this country is that the OTC meds like Tagamet, etc. are half the dose of the prescription strength and are not much less expensive if you calculate the cost based on the number of milligrams you get. Any data on this from those north of the US border would be appreciated.

******

I am in the unfortunate position of having had a couple of chances to see pain management up close. My mother died of breast cancer in 1983 and in 1996 I lost my wife to the same malady. In the intervening 13 years, not much had changed in the technology of pain management. The only significant new capability was the use of extended duration patches and pumps to give pain medication on a more steady, continuous basis. The real change (and it made night and day difference) was in the attitude about pain management.

In my mother's case, she was in moderate to severe pain throughout the 6 months of her progress through metastatic disease from bone and then liver mets. In my wife's case her pain was generally reasonably controlled, but there were moments that it was not. She had Carcinoma Meningitis for 7 months. Although she had pain flare ups that sometimes took several minutes to get under control, we had everything we needed and never got any resistance from the doctors when it was time to adjust things. In my mother's case, they were trying to keep doses low to reduce risk of addiction even though her case was terminal. Doesn't that make sense?

The modern attitude about pain management has not entirely won out. My brother had emergency eye surgery the day before Christmas this year and was in an unreasonable amount of pain for nearly 24 hours because of dosages being reduced to quickly for him.

I think you're on the right track and knowing the patient/care giver is essential to deciding the most appropriate course. You'd probably be shocked at what I had in the house after my wife died (not any more, no one come looking).

Scott Kitterman
kitterma@erols.com

P.S. If anyone is looking for a good book on dealing with metastic breast cancer either as a patient or a care giver, I recommend Musa Mayer's Holding Tight, Letting Go: Living with Metastatic Breast Cancer. According to Amazon it is out of print, but I think it's worth looking for. I was one of the contributors, but I have no financial interest in the book.

Thanks for your comments, Scott. I completely agree with you that the really important change has been in the attitude about pain management. I wish this attitude change had come earlier and I remember being "out on the limb" when I suggested to my medical school professors that perhaps we shouldn't worry so much about cancer patients in pain becoming addicted, especially those who were terminal. No, it did not make sense then and it does not now.

Thanks for sharing all this with us and thanks for the book reference. I will write it down and recommend it to people dealing with metastic breast cancer.

******

Dr. Jim:

Your exchange with Bob Thompson on prescribing pain medication highlights a major question in our society with regard to health care: Who knows best? Do the desires of the patient outweigh the concerns of his/her doctor? Or is it government regulations that rule? Or cynically: doesn't money (insurance companies, medicare/caid)!

Ideally, I should have the right to "go to hell in a handbasket" if I want and no one should be able to stop me. But, we do not live alone, but in society and actions DO impact on others. We all know what alcohol consumption (a "controlled substance") leads to when some individuals are left to determine their own limits--does anyone thing drugs are different When I was an EMT trainee years ago on a run with a rescue service I helped pull bodies out of a car wreck--Mom, Dad, twin 6 yr. old boys--AND a 50 year old man who, it was later determined, helped himself to a couple extra painkillers (in addition to his normal dosage) before leaving work. It seems he was "uncomfortable" driving and felt his pain meds didn't "work fast enough" (he had told an office mate) so he decided "more is better" and cut short the lives of 4 people. He got 5 yrs. but they should have hung him (I have a seven year old son--sometimes I see those twins faces in my son).

>From my observations (my wife is a gerentological certified nurse and Nursing Administrator with 20 years experience in Elder care, my two oldest friends are G.P.'s and my consulting is generally for Doctor's offices, Dentist offices, and some Nursing Homes) most good doctors do not seem driven by Judeo/Christian ethics but by something much simpler: "first, do no harm..."

The best doctors I've dealt with have insisted on dialog with me and were quite blunt about the fact that they could do little to help with pain/discomfort if I didn't speak up. None denied adequate medication if they were honestly told what was going on. They always had more suggestions for alternatives than I could research if what I initially was given didn't help, but, were always open to discuss my questions as to alternatives. The worst doctor I ever had contact with (this seconded by my wife from knowledge from the local medical rumor mill) was covering for my family physician when I called about knee pain (old skiing injury): "What were you taking last time?" (two yrs. previous) "How many do you want?" "O.K. I'll call the pharmacy and you can call them when to pick it up." This for a *really* strong narcotic. In fact my wife literally freaked out when she picked it up and saw the amount. Needless to say, we insured that we never, ever dealt with him. In fact, we went to Emergency once rather than deal with him.

I want my physician to treat ME not my condition. So, yes, he should be concerned whether I might abuse medication because he SHOULD be concerned about the whole me, mind and body. Why do I need to buy narcotics over the counter when I have a physician who will work with me to solve my problem, who has my best interests in mind, and whom I've established a relationship of trust. My wife says that your relationship with your physician is like marriage: it takes time, dialog, patience, and a long engagement (and sometimes it ends in divorce).

So, Happy New Year and keep up that concern for your patients.

David Yerka

Your kind comments are appreciated. I won't comment much except to say that like any other profession, medicine has its share of "borderline practitioners", hopefully your experience with one has been the exception rather than the rule. I have been part of letting a couple go during my career. Interestingly, some of the medical students who make the highest grades on tests end up being the borderline clinicans. That's one argument used against grades being assigned during medical school, it should be pass or fail only. Some residency programs are highly sought after, however, and they rank their applicants partly by their medical school GPA and don't know what to do with graduates of medical schools that are "pass-fail".

Thanks to everyone who wrote. I'm sure there will be more messages on this topic and I will try to post all except the ones whose writers ask not to be posted. I feel there is a need to change our laws regarding narcotics but this is a subject that has a lot of emotion tied up in it and meaningful change will come slow. The best way to change the laws, like always, is to contact your senator and representative or run for their seat in the Congress. We need fresh brains and ideas in the Congress. Happy New Year to everyone and GO HOGS, BEAT THE HORNS!!!!!!

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Saturday January 1, 2000


Hogs win!!!!!! Yes, the Razorbacks beat the Texas Longhorns in the first bowl game of the new century this morning. Texas has long been Arkansas's most hated rival since their days together in the Southwest Conference. Now that they are in separate conferences they don't play yearly so this was the renewal of a long rivalry. Texas leads the overall series by quite a lot so this victory is big and should be the springboard for a big year for the Hogs next year. By the way, Arkansas and Texas will be renewing their yearly game again in a couple of years; I think they have signed a four year contract to play every year. A big congratulations goes out to Houston Nutt and his staff of coaches at Arkansas. Now football is over and we Arkansas fans will be suffering through a rebuilding year in basketball. The future is bright there too but not this year.

As all of you know by now, there were no major Y2K problems and no problems here at all last night. We had a nice anniversary dinner last night in a restaurant that was not even half full, at least not early in the evening. We then came home, watched the ball drop in Times Square, and when the lights did not go out in Times Square knew everything was going to be OK. We then went to our own New Year's Watch Service where the New Year was ushered in by fireworks in the street outside the church. Now today, I have two problems. First, the clock on my desk has stopped; needs a new battery. Second, our furnace is not running now. I'd like to blame it on Y2K but I am afraid it is a mechanical problem; the repairman has already been called and will be here sometime in the very near future. I hope it is something very simple (and cheap).

One way to get content for this journal is to write something which generates reader feedback. I am posting an exchange between fellow Daynoters Dan Bowman and Bob Thompson. My only comment about the exchange is that they both have some ideas that I agree with.

First, Dan Bowman:

Hi Jim,

I guess that it would be a forgone conclusion that I would have an opinion on this topic.

Housekeeping first: by way of background for those readers who are not familiar with me, I was an active street paramedic from 1975 though 1990. I worked in a more limited capacity through 1994. I've been in the emergency services since 1969 and taught Emergency Medical Technicians since 1982. I'm also a Christian. Opinions expressed are mine alone and do not express the view of my employer. Permission to reproduce any portion of this letter is hereby given to Jim Crider and Robert Thompson.

Notice my use of the "street" adjective above. I was hospital trained, simply because I was with the first group of medics in my community. The training staff didn't quite know what to do with us, so they threw us in close company with the inaugural group of emergency room residents. They in turn came with us into the streets for our initial internships. Powerful stuff and very good training for everyone concerned. What we found out about the drug culture carries through to this day

Of the several issues raised:

Should people be able to self medicate to control their pain levels?

Should we deregulate narcotics in particular and street drugs in general?

Should there be a checkpoint before someone can receive unlimited analgesics?

Let's deal with the easy one first. Very simply, Bob's mother should have access to a narcotic 'lollipop' any time she'd like (currently available and working well). It's an on-demand system; she is well monitored by Bob and Barbara; and she won't be getting in a car and trying to drive anywhere. There is little difference to my mind between her and a hospice patient; they both can and should be as comfortable as possible. I do not understand why this modality is not used more often; then again, I am not a physician.

...and the physician use of pain medication has improved over the last thirty years. At one point a terminal cancer patient could barely get enough medication to stand to be alive; currently in the local area, medication is titrated to the patient's level of need. The use of PCA (patient controlled analgesia) has also proven out, even in the home environment; it seems that when the patient knows they can directly control the amount of pain medication they want, their use rate drops. They use enough to keep their pain under control and their incidence of overdose is lower than for patients tended to by lay practitioners.

What about the narcotics? Do we make them generally available?

I agree with Bob: legalize heroin or a derivative (and while we're at it let's make it part of the welfare system so they can get it for free if they're on the dole already). There is a certain class of people who will have productive lives and will manage to hold down at least temporary jobs and not be part of the dole. I believe Great Britain has experimented with this and has a program in place (perhaps Chris can comment). Then, there is another class of people who just want to hide in their chemically induced euphoria; perhaps we can recycle them as speed bumps.

But what about ol' "Rat" who just wants to get high? One of the ER docs in the early years seriously proposed setting up a clinic at the county landfill. Charge for the syringes (cost recovery); give away the morphine; and backfill once a day. Well, let's invite "Rat" to the kiosk by the landfill. He's obviously a non-contributing member of society... and he is one of those guys who would steal or commit violent crime to get his "high". ...or is he?

However, when we talk about drugs in the context of crime, we have to talk about all drugs, not just the analgesics. Locally, we supply somewhere between fifty and eighty percent of the speed (methamphetamine) used in the US (depending on your reference source). My problem with the people who use that stuff is that they try to interact with society instead of just laying down and falling asleep. A psychotic speed freak is not someone I want behind the wheel of a car or even living in close proximity to me. Their tendency toward violence prejudices me more against this group than heroin users.

...and what about that already legalized street drug, ethanol. Bob's mention of the Harrison Act recalls Prohibition; we now have a legalized chemical that is poisonous to our bodily processes (I know, so is oxygen di-hydride); is readily available in lethal doses at the corner store and contributes directly to deaths outside it's user community. I don't even pretend a modicum of objectiveness in this case; too many years of dealing with the aftermath of drunken driving has likely scarred me for life (yes, I do imbibe; in moderation).

What about the concept of a checkpoint before people can receive narcotics?

I support the concept of physician intervention for exactly the type of case Jim stated: the patient with colon cancer. Pain is the body's way of saying something isn't right. For patients with long-term diagnosed problems, analgesics can at least make life tolerable. For a person with a new onset of pain in their leg secondary to a fall, self-administered narcotics may mask a fracture that could eventually result in loss of function in that leg (or the leg itself). I submit that a required physician visit prior to receiving narcotics would catch that and give the patient some options.

Or a little closer to home: the male in his late forties or early fifties who develops chest pain. Hopefully he or someone close to him will call 911. I'd like that, as he may be having a myocardial infarction (big words there; it's just some heart muscle is dying due to a blocked artery) and this is often a treatable situation. A little oxygen to turbo charge the bloodstream, nitroglycerine to see if the coronary arteries will open to allow more blood flow; morphine for the pain and to calm the patient; aspirin to thin the blood and maybe help the blood flow; other medications to calm the heart muscle and prevent cardiac standstill; a trip to the hospital to have the blockage dealt with directly and the patient often goes on with life. Contrast that with the same guy with narcotic analgesics available at the 7-11: he's male, so he denies that it's anything but a pulled muscle. He self-medicates; the blockage stays. As soon as about thirty-three percent of his left ventricle is dead, so is he. No problem for me; perhaps a big problem for the people left behind. ...and that is a preventable death.

So we have a few different situations here: those in need, those who wish to recreate and those whose ignorance may harm them.

For those in need, treatment is available. But the current hoops that physicians have to jump through are constraining. When we took over narcotic ordering at my firm, our first step was a meeting with the local DEA agent. Very enlightening; and we set up a separate account for our Medical Director so his regular account wouldn't be red-flagged by our use rates. ...and why the red flags?

The red flags are due to the recreational drug users and their suppliers. They'll do most anything to get high and this poisons the attitudes of many in the medical field: we simply do not believe what some people tell us. The level of cynicism tends to correlate with the personal experience and ability of the provider. Those with good 'patient radar' tend to make good calls; those without get burned and develop a "no one gets anything from me" mentality. Dropping the level of control on narcotics would likely help both the recreational user and the physician. The former could get their buzz and the physician could relax and quit worrying about big brother.

...and I don't like big brother either; on many occasions I have signed out a patient who was clearly making a life-threatening choice not to receive treatment. As long as their options and consequences were clearly understood and they were not under the influence (rational thinking may be impaired), they could go their own way.

As for "people going to hell" in their own way, by all means, let them. While I do not encourage that (and in fact am rather opposed to living life that way), I really don't mind as long as they don't take others out along the way. Recently, I was excused from serving on the jury for a long haul trucker with four times the legal limit on board who crossed the center divide and killed two teenagers. I told the judge that I just could not step outside the realm of subjectivity; seeing the business logo on my shirt, he agreed.

Please don't misunderstand my thoughts about what someone can do with their own life. I've seem the results of enough people who've put a gun to their head to feel saddened they felt that was the only answer; but I'd rather support intervention services in the community than slap controls on handguns. If the gun was not available, they'd likely have used their car and taken someone else along with them.

On the recreation front, the same thoughts apply: "Party on, dude!"; just do it in your own space and on your own time. But we have some other issues here, including that of a sub-culture that simply likes the rush and doesn't really interact well with society. From this crowd we get people who not only like the rush, but will also do most anything to get it. That is addiction in the classical sense (as opposed to dependence). Again, my issue is with those who cannot control themselves or whose judgment is impaired; toasted and driving do not mix. Secondary deaths and violent crime (I include family violence here as well as drug dependent babies) are the routine consequences of this sub-culture.

...and what about people who simply do not know their options and could die from their ignorance. I'd still go with the as physician a checkpoint simply because I believe in people. If someone knows their options and the likely outcomes of their situation, I think most people can make reasonable decisions. If that decision is to go home and die, well and good. I've spoken with many patients and friends over the years on quality of life versus quantity of life and I've seen the decisions go both ways. I do believe that everyone has the right to an informed decision and in fact that is the basis of the "Implied Consent" practice for street medics: If a person is unable to respond or give permission to treat, we follow the premise that a "reasonable person" would want to be cared for in this extreme situation. ...and yes, it has gone both ways; I have had a successful resuscitation on someone whose wife later found his "Do Not Resuscitate" papers.

In short, while there are perhaps some easy answers, I don't think this society is prepared to implement them. I'll leave the Libertarian argument to Bob as he can make it so much better than I can. I do think that well-trained physicians who treat each patient as an individual can at least start to make some changes.

There's obviously more to be said here. Thank you for providing the forum for addressing some of the issues.

and thanks for listening,

Dan

Now, here's Bob's answer:

Thanks, Dan. I like the landfill idea.

As far as the amphetamines, the unspoken assumption is that having them as a controlled substance reduces consumption and thereby reduces the damage to innocent bystanders. That's far from the truth. In fact, per-capita ethanol consumption peaked during Prohibition, and immediately dropped when the Volstead Act was repealed. Many users of illegal drugs use them because they are illegal. Legalizing them and making them freely available reduces that lure.

I can argue all day on practical grounds, because there's at least hope that reasonable people can be convinced by practical arguments. But the fact is that my chief objection to controlling drugs (or anything else) is philosophical. It's not your business what drugs I choose to take, nor is it Jim's. I'll choose for myself. You choose for yourself. As it happens, I don't now and never have used illegal drugs. Neither do I drink, other than perhaps one glass of wine every six months or so. But if you choose to take drugs, or drink, or smoke, that's your business, not mine.

Jim, it makes sense to me that you should post this message on your page with the related materal. If you choose not to post it, please let me know and I'll put it up on my page, although it will be somewhat out of context there. --

Robert Bruce Thompson
thompson@ttgnet.com
http://www.ttgnet.com

And, finally, here's Dan's final commentary:

Thanks in return , Bob.

...and that's exactly the issue with meth locally; the speed and derivatives that were available twenty years ago were mostly mis-directed prescription meds. Now, with the demand up due to increased controls, it is extremely profitable to set up a production facility in the rural and then abandon it when the run is complete. We probably bust better than a lab a week locally and find the same number abandoned. Social problems and haz mat problems all at once. We're now to the point of regulating the sale of bulk Sudafed in yet another futile attempt to regulate the manufacture of illegal substances. Legalize them and several problems disappear.

But we live in a time where the response to stupidity is to regulate to that lowest common denominator. I don't believe that I'm the lowest common denominator and I resent being placed in a cage due to other people's idiocy. But, enough; it's dinner time here.

(My wife on the other hand, would like Jim to come visit long enough to place both you and I on medication for our "anti-social" attitudes. Mary Poppins lives!)

dan

The furnace repair guy was here and we had a wire short out and burn up the transformer to the heating elements. He can get a replacement transformer Tuesday so we do not have a working furnace until then. Good thing I carried up wood last weekend and it is now dry under the eaves of the house. We got out two kerosene heaters and managed to learn how to operate them without instructions. We don't know how old they are, Delanae got them at an estate sale. They have Sharp as the brand name on them but the Sharp website doesn't even list any kerosene heaters. With the fireplace insert downstairs, we will be able to keep the house warm. I guess the minimal Y2K preparations we made will come in handy after all.

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Sunday January 2, 2000


We are surviving without the furnace. These small kerosene heaters actually heat up a room rather nicely. One raised the temperature of our living room and dining room by more than five degrees, from 59 degrees(F) to more than 65 degrees(F). Now I have been given the job of getting up in the cold and turning the one on in our bathroom so my lovely wife will be warm when she gets out from under the electric blanket. Actually, I told her I would do that for her, being the helpful, loving husband type. Meanwhile, I am sitting here in my (now) unheated office typing this update while there is a fire downstairs in the fireplace insert keeping the entire downstairs warm. What is downstairs? Delanae's office and the kids bedrooms. So, I am relegated to sitting here in a sweatshirt wishing I had more than one computer here to put off enough heat to warm the place above 61 degrees(F).

Our weather is cooperating to an extent. We have rain with highs in the mid 40's and lows in the mid 30's. No below freezing weather is expected until late in the week when, theoretically, the furnace will be functioning properly. Delanae got some more kerosene today so we are stocked up in case.

Speaking of Delanae, she now has begun a daily journal also. For the present, it is located here. This is one of those free web hosting services but she has another domain name parked elsewhere that we have plans to migrate this temporary web page to in the future, once we find a permanent home for her domain name. I like the web hosting service I use, Softcom, but we may try a different one for her, depending on if she wants to put up with advertising or not. Personally, I did not want to but I will leave it up to her. Then I will have to set up an editor for her to use that will do most of the HTML for her without her having to learn HTML. She is not as adventurous as me, wants to just be able to type in what she has to say and have it look right without knowing how it got that way.

I have a lot to do tonight before I can go to bed; luckily I went to bed early last night and slept until almost 8 AM before getting up and getting ready for church. I have to add some more addresses to my Palm Pilot, set up my page for next week, update Quicken, and practice some on the bass. I have let the bass practice slip over the holidays, now must get back to it. I must also make some lunch for tomorrow which begins with a breakfast meeting at 7 AM. The kids may have to start riding the bus to school in the morning since I need to start leaving for work earlier so I can get finished a little earlier in the evening.

Before I close tonight, I wanted to post two more letters about controlled drugs. I have now heard from one of my international readers who has an interesting view since he is formerly from the United Kingdom but is now living somewhere in the south of France {presumably where it is warm right now}. Following that is a reply to his letter from Bob Thompson.

Have a look at http://www.doh.gov.uk/ntors.htm which goes into what happened when the UK Department of Health (DoH) did a series of tests on combatting drug taking. I remember at the time the main conclusion the press all leaped on was that spending one pound on drug treatment programs resulted in a saving of at least £3 in the criminal justice system. Unfortunately it was done when the Tories were in power so went nowhere, and although it exists in parts its conculsions have never been properly implemented. I've followed the debate you've had over the past few days with interest. I remember about 10 years ago learning for the first time that it's not taking heroin which usually kills but the crap with which it's been cut, and that indeed some heroin addicts with access to pure ingredients and what have you can maintain lifestyles most would regard as normal. Indeed, there was a fine TV documentary which followed a guy getting up in the morning, eating breakfast with his kids and going to work - it was over five minutes into the programme before you discovered that the guy being filmed was the heroin addict who was commentating, not his care worker who you assumed it was. He was in a test of something like a dozen people who got medicinal-grade heroin - not methadone - from their doctors in a maintenance program. Bob's blunderbuss approach doesn't work as it doesn't when he posits it in other situations because most people aren't willing to take the consequences of their actions in the way he is. Some people need protecting from themselves - I say that in a tree-hugging sort of way - and lots of us need protecting from the idiot minority who would use over-the-counter narcotics like M&Ms and end up killing lots of others as they took themselves out. But I'm definitely in favour of legalistation of all the drugs I've heard of if their use and distribution can be more tightly controlled and supervised than the controls we currently have over alcohol and tobacco. If someone wants to spend their life out of their heads on anything at all that's fine by me, but they have to do so in a manner which doesn't interfere with my life or require me to spend any more of my taxes on it - unless, that is, the Government's going to start subsidising Cuban cigars and fine brandy. However, I really don't think it will ever happen because governments don't have the will to legalise any illegal drugs at all, and I really don't understand that. The attitude towards drugs in the UK is like the attitude towards importing dogs used to be - and largely still is; in the UK we've all been brought up since whenever believing that all, ALL dogs from 'abroad' are rabid monsters, and it's taken several decades to replace the six-month quarantine for ALL dogs and cats with a much safer system of vaccinations. Drugs are the same; you can conclusively prove, as the Government's own Department of Health has done, that it's 66% cheaper AT LEAST to actually GIVE the drugs away than it is to clean up the after effects, but nothing is done and nothing will be done because there're no votes in saying 'Legalise hash'. Well, not many and those who are in favour may not be able to put an X on a ballot paper anyway. The idea that the Government could sell the drugs themselves to cover their costs and wipe out drug-related crimes at a stroke is heinous in the extreme and, I'm afraid, is never going to happen.

Regards

Chris Ward-Johnson
Dr Keyboard - Computing Answers You Can Understand
http://www.drkeyboard.co.uk

The above letter was sent to both myself and Bob Thompson, and here is Bob's reply with one word bleeped at the end since this is a family page. <G>

Tree hugger, indeed. I'm always very suspicious of someone who wants to do something for someone else's own good. People stupid enough to use such drugs recreationally and become drug addicts are no loss anyway. If the government simply legalized drugs today, things would improve dramatically, particularly if they saw to it that large quantities of 100% pure heroin, cocaine, etc. were made readily available. That would take out about 99% of the problem in a day or two, excepting of course the increased costs for garbage collection and disposal.

As far as your worries about irresponsible people hurting and killing others, what do you think happens now? Again, historically when constraints are removed, consumption drops. It's happened at various places and various times with alcohol, coffee, marijuana, and other drugs. As I mentioned earlier, the number of people who drank alcohol actually dropped when the Volstead Act was repealed, and the per capita consumption dropped even more. There's no reason to suppose that drug consumption would not drop if the drugs we are discussing were legalized.

And, as you say, heroin is not particularly malignant anyway. Few realize that Bayer (of aspirin fame) scientists created heroin as a more effective, less addictive substitute for morphine. In fact, it was originally Heroin®. Cocaine is also relatively benign in its pure form. This stuff has been demonized by politicians for their own purposes. Most people buy their bull#*?! without questioning it. --

Robert Bruce Thompson
thompson@ttgnet.com
http://www.ttgnet.com

And so ends the debate this week. Next week, who knows? I'm anxious to see what posting these letters does to my number of page hits. Do the numbers go up or down? This is still a daily journal page and will remain that way. I do like posting reader mail as I feel this page can offer a forum for discussion of topics pertaining to medicine. We might talk about some other topics too, I won't limit the letters I post to only medicine. If you want to write in, be my guest. I will not publish any messages where the writer asks me not to. I will also not attempt to diagnose your medical problems by e-mail, only if I see you personally in my office. Until tomorrow then......

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