Over the Counter Hearing Aids? Sounds great (no pun intended)!

There has been ongoing discussion for some time over how to help people use devices to improve their hearing that is both easy to use and affordable.

One problem is that MediCare actually can't cover hearing aids, barring a literal Act of Congress making such coverage possible.  Additionally, hearing aid technology has been difficult and generally required several visits to a licensed audiologist (hearing specialist) to customize them to each individual user.

Fast-forwarding to the present, the electronics technology for hearing aids has advanced just like electronics and computers in everything else.  Hearing aids that can be fully set up and used by the individual users are now seen to work nearly as well as high-end audiologist adjusted ones, at a fraction of the price (say, $300 instead of $4,000).

Congress is getting set to vote on a piece of legislation that would give the FDA three years to devise a way for hearing aids to be available over the counter after being shown to be safe and effective.  When Elizabeth Warren and Chuck Grassley are supporting the same legislation, then something is definitely up.  Stay tuned for further developments over the next few years!

More on Drugs (or, medications)

I've come across some interesting reading on the subject of drugs and medications, and thought you might be interested since they cover the gamut of pharmaceutical research, clinical medicine and medical ethics.

If you watch TV, you may have already seen ads for a new kind of cholesterol lowering medication called Repatha.  It is injected by the patient every two weeks, and is not a statin and therefore does not have statin side-effects.  So far, so good.  Thing is, while Repatha substantially lowers cholesterol, the reduction in likelihood of heart attack or stroke is minimal, and the reduction in death from heart attack or stroke is zero.  Oh; and it costs over $14,000 every year.  The cost and the number of people who would have to take the medication to improve health is much, much higher than for the statins, and Repatha so far does not appear to be as effective as statins, either.

Mind, the medication has only been around for two years, so it's possible that benefit may become clearer over a ten year period of time.  For now though, Repatha seems like it might mostly be of interest to those who are at high risk of heart attack or stroke and just cannot tolerate statins.

Vox does a good job of summarizing a recent study on Repatha.

On the other end of the spectrum, what about re-thinking placebos? 

We already know that placebos can be very effective.  If a doctor prescribes something and tells you that you'll feel better, there's at least a 30-50% chance you'll feel better.  If pain is involved, the odds improve to 60-75%.  If the treatment is a sham (fake) procedure or surgery for pain, the odds improve up to 90%.  If we reveal to you that the pill or procedure or surgery was fake, the improvement does not go away!

Morphine works 50% more effectively if you know you are receiving it, compared to if it's just in your intravenous line and you can't tell that your getting it.  It works even better if you yourself control giving it to yourself, rather than asking a nurse for it.

There is starting to be open discussion of the use of open-label placebo use for some conditions, in which both the patients and doctors are fully aware of the use of a placebo for treatment.  Certainly not for cancer or life-threatening infection, but for other conditions such as back pain, or irritable bowel syndrome.  If this is both effective and safe, should we really continue to consider placebo use unethical?

And now for something completely different.  Recent studies demonstrate that single or limited treatments with ketamine can result in remission in depression, with MDMA can treat PTSD, and with psyolcibin can significantly aid patients with terminal cancer diagnoses.

Thing is, these are all considered by the FDA to be drugs of abuse characterized by high potential fore abuse with no medical value. 

Additionally, these studies are often initiated based on reports of incidental improvements in medical conditions by recreational drug users.  This raises some interesting questions.

For example, if the only things we can say with any certainty about MDMA (a/k/a Ectasy, X, Molly...) are that it doesn't seem to cause organ damage, withdrawl or life-threatening problems and largely seems to result in the user experiencing a 4-6 hour period of feeling generally happy and trusting of everyone around them, how dangerous exactly is the abuse potential of this?  Should more structured medical study actually be done?

Should the FDA consider rescheduling some of these drugs, which would make clinical testing possible?  As researchers on the clinical benefits of psylocibin ("magic mushrooms") point out, getting research grants is easier with psylocibin because it's not spelled L-S-D.

For that matter, are we going about this research all wrong?  Depression and anxiety are very common.  Certainly, the pharmaceutical industry is researching newer drugs, but really nothing new has come out since Lexapro, which is simply another SSRI and has been out long enough to be generic.  This research is by definition going to be incremental, insofar as side effect potential is intended to be minimized.  The clinical experiences with ketamine, MDMA and psylocibin are incidental to people frankly using them because they have noticeable effects on the brain ("getting high").  The beneficial effects on depression, PTSD or fear of dying seem to be a side-effect, but a noticeable side-effect that may be a result of taking a substance expected to effect the brain in a noticeable way.  This is not to say legalize everything yesterday, but it may point out a different way of looking for effective treatments of common psychiatric problems.

Overactive Bladder doesn't necessarily have to be treated with drugs!

Urinary incontinence is certainly not a new medical problem, but it's messy and inconvenient and can be socially very limiting.

The term "over-active bladder" is a descriptive marketing term for urge incontinence.  This means that there is urinary leakage or loss of bladder control due to the sudden urge, or need to urinate.  This is different than stress incontinence where external pressure or stress on the bladder (such as by coughing, laughing or standing up) can cause leakage of urine.

There are quite a few prescription medications that can treat urinary incontinence, and I'm sure some of them are advertised on TV.  However, it is often not necessary to take medications to improve the incontinence!  Prescription drugs for incontinence can offer some improvement, but generally not completely.  Also, side-effects are not uncommon.

Losing weight and stopping smoking can help.  Using fiber supplements (such as Benefiber) and stool softners (such as Colace) may help, since constipation is pretty common and it can cause urinary problems since the rectum is next to the bladder.

Moderating alcohol, caffeine and carbonated drinks can help, since these can be irritating to the bladder and cause the need to urinate to come on suddenly.

Kegel exercises can also help, and are useful for both women (with illustrations) and men.

If you still have urge incontinence after several months of trying these suggestions, you may want to see me to consider adding a prescription medication to what you are already doing.  Long-acting (also known as extended-release) oxybutynin is a good choice:  it's generic, once a day and works as well as anything newer. The long-acting form is more expensive than the twice a day regular form, but it is also a lot less likely to cause any side effects and may be worth the extra cost.

For stress incontinence, seeing a urologist to discuss surgical procedures can be useful.  You don't have to go forward with surgery if you'd rather not, but if the symptoms are not responding to some of the above suggestions you may at least want to see what surgery would have to offer.

Travel-related medicine

Yes, I know it's right after the holidays. But, it's also summer in the Southern Hemisphere!

Who travels? Actually, over a billion people travel internationally per year. Tourism is the first or second largest income source for 20 of the 48 least-developed nations.

So, what can go wrong?

Well, if you've had a heart attack or a heart bypass, you should avoid travel for 2 weeks to avoid a heart problem in flight.  If your heart attack was at all complicated (for example, heart failure), then make that 6 weeks.

The most common cause of travel-related death in non-elderly travelers is motor vehicle accidents, especially in less developed countries.  Watch carefully when crossing streets, think carefully about how to get around safely.  A bus in the daytime is probably better than a motorcycle or back of an open truck at night.

The most common infection is Traveler's diarrhea which occurs in 30-70% of travelers depending on destination and season, especially within the first 2 weeks of travel.  Interestingly, avoiding street foods, raw foods, ice or tap water don't seem to prevent illness.  Hand washing lowers your risk of diarrhea by 30%.  Pepto-Bismol (2 tablets, 4 times every day) can further reduce risk by 50-65%, if you're prone to such illnesses.  However, you should avoid this if you are allergic to aspirin, have chronic kidney disease, are breast-feeding or are on blood thinners.

As far as shots are concerned, flu and Hepatitis A shots are recommended to avoid getting flu or infectious hepatitis (from contaminated water or foods).  Do check for any need for specific shots such as typhoid or yellow fever.

Also, be aware of whether you will need a prescription for any pills to prevent malaria.  In addition, bring DEET-containing insect repellent, clothes that cover your arms and legs fully and a bed net if you are traveling to malarial areas.

This just covers a few very specific concerns.  Overall, travel is exciting and safe.  Outside of these specific medical tips, the best thing is to exercise common sense.

Feel free to see us about a month or two before travel if we can help you with advice, medications or shots. Have a great trip!