Nicotine

Great question, William.

Let me first answer more broadly. It is EXCEEDINGLY difficult for a practicing physician to be able to critically read all research studies, all clinical trials, all subject reviews, all the time for all areas they need to practice. In other words, the changing field of medicine is one that presents a constant challenge. Furthermore, the newest study isn't necessarily the best study, so we need to approach new research with some temperance.

(I remember when they used PCR and amplified chlamydia genomes out of coronary artery plaques, so cardiologists around the country started throwing people on erythromycin to try and kill the chlamydia -- an intervention that proved completely useless. Way too premature for them to start changing their practice. As they say, the early bird gets the worm, but the second mouse gets the cheese).

Doctors have been shown to be susceptible to changing their practice in response to information from industry representatives. For this reason, right around when I graduated from medical school (in 2000), there was a national ban on industry sponsored marketing to medical students and residents (residents being the junior physicians in a specialty training program). That meant no more free meals at your case conferences, no more drug dinners, no more free pens, etc. Just this year industry reps have been restricted in their direct marketing to attendings as well (attendings are fully trained, boarded, licensed physicians).

So if doctors will change prescribing practices because the Lipitor rep tells you how much better Lipitor is than Zocor, then you can imagine that pressure from patients will do the same. Patients these days are often educated, have access to the internet, and sometimes have read more about a topic than you have. That doesn't mean their information is complete or uncontaminated with garbage, but as a physician you're in a tough spot if a patient is requesting (or demanding) this or that drug they saw on TV.

I generally think direct-to-consumer marketing is an abomination, but there are some caveats to my opinion. For instance, I do NOT think that a patient should be demanding what kind of blood pressure pill they should be on -- there are multiple classes of blood pressure agents, and it's a nuanced decision (and there are some VERY cheap blood pressure pills that work great). I think it's utterly absurd that erythropoeitin (ProCrit) is marketed to patients, I mean this is an IV medication that is generally only used by nephrologists and oncologists. On the other hand, I have no problem with Viagra being marketed to patients, because there are no decent alternatives (Viagra, Levitra, and Cialis are all in the same class of drug), and a patient might never volunteer that they need a medicine like that if they didn't know there was an option for them. Of course I hope that in that case it's not inducing doctors to forget that a man with erectile dysfunction needs to get their vascular disease risk factors addressed and not just get a pill.

Paul, that's precisely my point. How many patients come in and "tell" the doctor what to prescribe? Unless you know different, speaking from a patient's point of view, even though I am highly critical critic, I never question a doctor's advice as to what he should prescribe. Perhaps Viagra was the beginning of "name brand" pharmaceutical marketing and this is an offshoot of it. You would know. Are your patients telling you what to prescribe? The pharmaceutical industry is not stupid. They need to make a profit as much as the next "business". I honestly think has to do with "brainwashing". Please check out this link BRAINWASHING and see if you think it plays a part in those decisions doctors make. I have a feeling some of them are not as dedicated as you and could be swayed by this marketing ploy.
Thanks,
William

Seldom, but they may ask a doctor and plant the seed in his mind. Think about it --

I'm watching TV. The ad for Pravachol comes on.

I think "hey, I have high cholesterol" so I pay attention to the ad.

At my next doctor's visit we're talking about if I should be on a cholesterol-lowering agent. I say "What do you think about Pravachol? I've heard good things about it."


If all else is equal in this doctor's mind, this may get me a script for Pravachol as opposed to any of the other drugs in its class (most of which are more potent).



As for my patients, yes some do tell me what to prescribe. I work in two capacities -- I do adult inpatient hospital medicine, and I do pediatric infectious diseases. (Don't ask me how I got to this combination). In the adult world, there are a lot of demands and requests for various things. In the pediatric infectious disease world, with a couple controversial exceptions I rarely see people demanding a specific kind of therapy.

hi paul-
i am one of those patients who reads up on my illness and whatever treatments are available. of course i realize the time and work i spend in research cannot equal a doctor's knowledge. but there are all kinds of doctors, and unless we try and be informed we would never know which are the good ones. i find that some are more willing to work with me than others, in fact some simply refuse and i dont go to them. i can understand their point of view, but at the same time i want to take part in my medical decisions, and there are doctors who dont mind that.
even 30 years ago when my son was born i read up on every single thing-like the standard immunizations given, and other procedures usually not questioned by parents, but i never ran across anything that was strongly recommended that i didnt agree with. people today are less willing to hand their bodies, health, lives and children over to someone without paying attention to what is happening. i think that is good for the doctors as well as the patients.

Health Costs in U.S., World?s Highest, Jumped 47% in Six Years - Bloomberg.com

"The cost of health care in the U.S., the highest in the world, jumped 47 percent from 2000 to 2006, a study said. That didn't buy Americans the longest lifespan.

Americans paid $6,719 a person for doctors, medicines and hospital visits in 2006, up from $4,570 in 2000, according to a report released today by the World Health Organization in Geneva. The yearly spending is more than nine times the global average. With a life expectancy of 78 for a person born in 2007, the U.S. trails at least 27 other countries among 193 in the report ."


Infant mortality is also among the worse among developed nations.

University of Maine report: The U.S. Health Care System: Best in the World or Just Most Expensive?



The Wall Street Journal reports "as much as half of the care provided to U.S. citizens is unnecessary, including procedures that don't do any good, tests that are repeated, and drugs for which there is no evidence of benefit." Hospitals have a financial self-interest in increasing medical procedures. So do fee-for-service doctors and specialists who completely dominate U.S. health care. The Journal explains, "Since doctors and hospitals are paid only for procedures and treatments they provide, they are actually penalized if they eliminate unnecessary procedures or practice preventive care."


Rising Health Costs U.S. health care: expensive and less effective at keeping people healthy

Rich

My Father died of Kidney cancer in 1984. At that time hospitals' were restricted as to how much 'treatment' they could offer patients as the "insurance companies" put caps on what it cost to treat various illnesses. If the medical institutions kept the cost under those caps, they were reimbursed by the said "insurance companies" the difference. My dad was sent home one week after he was cut in half to remove the kidney. He was home one week and began to bleed from the wound and was taken back to the hospital where he lasted one more week before he died. Of course they knew he was going to die as we know now invasive surgery is not how you treat cancer. What made me see red was the fact that they actually sent him home to save money. To hell with any hippocratic oath. Medicine is all about money. Again I am not blaming doctors, for one day we will finally get our heads out of the sand and realize the body will heal itself over time once we begin to focus on eliminating the real causes that created the illnesses in the first place. Our focus on costs renders us inhumane. This is but one example.

William

I think patient empowerment is good for them as well. The "paternalistic" model of medicine, in which our treatment plan isn't really up for discussion, is going out of favor. Patient care is a collaboration between doctor and patient. There are cultural issues, though. In Connecticut and Boston, where I did all of my training, patients were overall much more autonomous and participatory than here in North Carolina where I find they are much more deferential -- especially the older patients. Even when I offer them choices, they don't really want them -- they want me to decide for them, or at least to make a strong recommendation.

While that is true, you need to keep two things in mind.

#1, The US infant mortality rate, if I recall correctly, is about 12/1000. The best rates in the world are about 7/1000, and I believe they're mainly in Scandinavia. In other words, the absolute risk reduction that an infant has being from Scandinavia versus the US is 0.5%. By comparison, Ethiopia, Afghanistan, Niger, Mali, Burkina Faso, Somalia, etc have infant mortality rates of around 150/1000. Even stable, developing countries with good health care infrastructure have far higher infant mortality than here (Ghana is around 60/1000 if I'm not mistaken). So let's not go overboard here.

#2, the total national infant mortality rate is a misleading figure because we have major health disparities. In other words, people who are socially and economically advantaged have health statistics that are no worse (and perhaps better) than anywhere in the world. People who are socially disadvantaged are indeed worse off. The US has a very large immigrant population, very poor urban populations, and very large underprivileged minority communities.

It would be a more productive conversation to learn how to correct health disparities than it would to address the entire infant mortality rate as if it applies equally across the board.

Funny then that this is incorrect. I CANNOT bill for treatments. There is no mechanism by which treatments can be billed. I have to submit a bill for every patient encounter, and ALL I can bill for is 1) the type of visit (i.e. initial consult, subsequent visit, discharge, admission, observation, etc), and 2) the level of the visit (based on the length of time and level of decisionmaking). I need to link my visit to a diagnostic code. There is NO MECHANISM for me to bill for the tests I order or the treatments I offer. And this is true across the board. Procedures (like surgery) can be billed for, but since the only procedure I do is a spinal tap (and I hardly ever do them), it doesn't make a lick of difference for my revenue.

The hospital has an additional billing system called DRGs (diagnosis related groups) but this is based on the patient's medical complexity (i.e. a patient admitted with septic shock, requires a higher level of nursing care, and is thus in a higher DRG).


And as for being penalized for eliminating tests, you couldn't be further from the truth. The hospital LOSES money if I spend more on tests and treatments per patient. I have a contractual incentive to keep my costs per patient under a certain level.

Paul, thank you for your candidness. It seems as if the drug companies have all the control; the doctor is the legitimizer and the patient is the guinea pig unless there are volunteers who participate in double blind studies. It seems, to me anyway, today we are prescribing more and more drugs just to counteract the effects of other drugs. Now I am going to put you on the spot here a little, if you don't mind. I have congestive heart failure due to atrial fribrillation. What medications, in your limited knowledge of just that, what would you prescribe. If you need more information I will provide it. Then I will tell you what I am taking and you can tell me why and which drugs are for counter measures. If you don't want to, I will understand. I am taking seven different medications. What are they?

Thanks,
William

PS; Prior to the diagnosis 6 years ago, I was taking no medication, not even aspirin. There wasn't a "pill bottle" in my home.

william,
why dont you look on the internet? that's what i always do. i was having an episode of atrial fibrillation here and a doctor prescribed a pill which when i looked it up said it was so potent and dangerous that it was only given to people when everything else failed and they were admitted in a hospital where they could be observed carefully because of the danger involved. i always do that before i take anything, here in india especiallly because i notice the doctors never ask what medication i am on in case it would conflict. there are lots of medical and medication websites.

I think an old adage applies, to each his/her own. I posted a similar thread in general discussions, and there is an array of answers to that. In the end, though, there is no clear black and white answer.
In the place I study and live, a college town setting, nicotine is abound with males and females alike, which is no surprise.

The cases in which that is true are fairly rare in my experience, though it certainly happens. We try very hard when possible to not use additional medications to treat the side effects of others.

I treat both these conditions a lot, I'm quite familiar with them.

But before going on, let me make one thing clear. In my response I am not offering any kind of specific assessment of your medical condition, your medical care, or the appropriateness of your medications. All I'm saying should be regarded as general, and to come up with a rational care plan for you would require a lot of knowledge (including a physical exam and a detailed history) that I have not obtained.

So, with that disclaimer, let me answer this way. If congestive heart failure is being attributed ONLY to a-fib, this is from one of two factors. Number one, in a-fib, your atria do not contract effectively, so about 10% of the blood that normally enters the ventricles does not. This decreases the "cardiac output". Second, in a-fib, the heart cannot control its intrinsic pacemaking, so the heart always beats irregularly and it can go way too fast or way too slow. If it's too slow, then your cardiac output will diminish. If it's too rapid, then the left ventricle doesn't have enough relaxation time to fully fill. When cardiac output goes down, the kidneys erroneously think that you're dehydrated because they're not receiving enough blood flow from the heart -- so the kidneys hold onto every last drop of fluid and this can accumulate in the lungs. Voila, that's congestive heart failure.

So the mainstay of treating CHF due to a-fib would be controlling the heart rate -- either with drugs that slow the rate if it's too fast, or with a pacemaker if it's too slow. You can also use a diuretic (like furosemide, aka Lasix) to get the body to pee out more fluid.

Treating the underlying a-fib with rhythm-controlling drugs (i.e. things that put you into a normal sinus rhythm) are sometimes used, but they are more toxic and long term outcomes aren't necessarily improved.

Now, CHF may be multifactorial. For instance, a history of hypertension can also lead to CHF, or a history of heart attacks, or a history of valvular heart disease. So is the a-fib the only cause of your CHF, or is it part of a whole spectrum? All good questions for your doc.

I'd guess:

1) A drug to control your heart rate, probably a beta blocker like metoprolol (Toprol or Lopressor) or atenolol (Tenormin). The generics all end in "-olol".

* alternatives would be diltiazem (cardizem) or digoxin (lanoxin), some people are on a combination

* some people take amiodarone to control the arrhythmia itself rather than the rate, but this is less common

2) Warfarin (Coumadin) to prevent the fibrillating atria from generating blood clots

3) Lasix (furosemide) to prevent fluid accumulation

4) Aspirin

5) A cholesterol-lowering medication (Lipitor, Zocor, Crestor, Pravachol, etc)

Can't guess the rest. I'd need more information that you need not supply. The aspirin and the cholesterol-lowering medication would be mainly for the prevention of a heart attack, because smoking is a major risk factor.

---------- Post added at 09:47 PM ---------- Previous post was at 09:45 PM ----------

Use either WebMD.com or eMedicine.com. Definitely the most consistently reliable info for laypeople.

There are some of those. We have a lot of safe medications for A-fib, though.

Thank you, Paul. Excellant. I don't have a cholesterol problem and my lungs are clear. Shortness of breath because of fluid of which I can keep in balance with the lasix. A truly life saving drug, though kidney function has to be closely observed. Metoprolol was the first medication and went to sotalol and then to amioderone during the three cardioversions I had done and were part of the loading drugs none of which worked and was anticipated by my doctors because my heart had been beating this way for so long. Please excuse the spelling. The afib was not acute. I have had an irregular heart beat for as long as I can remember. It never bothered me up until 6 years ago when I started retaining fluid to the point I couldn't breath. It's all under control now though the atria is still doing it's dance. The pacemaker/defibrillator is from St. Jude's. I forget what it is called. Warfarin, digoxin, spironolactone, lasix, potassium (lasix counter), lisinopril, carvedilol has replace the loading medications; metoprolol, amioderone and sotalol. I don't understand the two blood pressure medications though, the lisinopril and the spironolactone. Perhaps you can tell me. Nice going though. And thanks for your responce.

william

Sotalol is another antiarrhythmic, it's used a bit less frequently than amiodarone.

The combination of spironolactone, carvedilol, and lisinopril is generally used for CHF due to a very weak left ventricle (aka systolic heart failure, i.e. failure from a weak pump), which would not be an effect of afib. An echocardiogram demonstrating a low "ejection fraction" would be the diagnostic test to demonstrate it.

Spironolactone is a diuretic like lasix, but it acts in a different way, and can actually prevent the potassium loss that lasix causes. But spironolactone and lisinopril act to block a certain hormonal process in the kidney that causes massive salt (and therefore fluid) retention in the setting of a weak heart. Angiotensin and aldosterone are two hormones released by your kidney under these conditions, and lisinipril and spironolactone (respectively) block the activity of these hormones.

The only drug in your list that seems to be an antidote for another's side effects is the potassium supplementation -- but keeping your potassium under good control is very important when you've got heart rhythm problems, and when you're on drugs like digoxin (or sotalol or amiodarone).

Sounds like you've been through quite an ordeal with this. Good for you for keeping your spirits up and maintaining interest in it!

Paul, thank you for helping me reach a better understanding. I do appreciate it, and I will regard your advice as general and informative. My doctors and you are definitely in sync; and that is what I was looking for although they did "electrocute" me 4 times. Ha. I was in good hands and I trusted them implicitely.
Again, thanks.
William

Now, back to the thread. It is not about smoking; it is about nicotine. Here is were I need a lot of help. Will one of you, more scholared than I, Kj, Rich, or Paul and many more please tell me what this link is saying, if possible translate it for me: Acta Pharmacologica Sinica - Nicotinic mechanisms influencing synaptic plasticity in the hippocampus

Thank you so very much,
William

Nicotine and other chemical relatives (nicotinamide) have numerous roles in the body (and in all eukaryotes), including receptors on muscle for acetylcholine and as a proton carrier in cellular metabolism (NADH and NADPH). But it's tightly regulated by the body, so exogenous nicotine is a different matter...

Here's the article that lead to that link:
Metanews: could nicotine be beneficial?

Thanks,
William

Heroin is beneficial for pain control. Cocaine is beneficial for ophthalmologic surgery. There are all sorts of things out there that have therapeutic promise, potential toxicity, and potential for abuse or dependence or addiction.

It should hardly surprise that a beneficial effect of nicotine might be found. The important questions are in what form exogenous nicotine should be used therapeutically, how can it be used safely, and is it necessary to develop it for therapeutic use (if we have alternatives that are better and/or safer).

Paul, that is exactly my point. Perhaps nicotine should be a part of our diet. Just like sugar cane. We can abuse sugar too. Just look the abuse that addiction causes. To carry it even farther, there are foods that are ideal for men; and foods that are ideal for women. IMO as it would only enhance what it is to be male and what it is to be female. Yes, as far as we have determined there are no distinctions as to the separations of these food groups as we have concluded all are metabolized the same way physiologically. Where we are now it seems more and more research is being devoted to the brain chemistry as a result of the foods we eat and the effects of those foods on the male brain and the female brain that affect that physiology. If we can determine what it is in the food we eat and the affect it has on our brain, we can "cure" those maladies by simple diet adjustment, rather than resorting to genetic manipulation. For instance, I will not eat califlower I don't care how it is prepared. But lets say it is very beneficial use as far as the body's metabolism is concerned. It can be mixed with other food to make it, as far as I am concerned, "edible". When I was a wee tike, I loved carrots to the point of my skin turning yellow and the doctor told my mother it was the amount of carrots I was eating. To this day, I don't like carrots either. I commented that to my mother-in-law one day and she was bound and determined to prove me wrong and for dessert one day she gave me a piece of cake. I loved it. It was carrot cake. What I am saying is if cabbage had an ingredient in it that "made us high" or feel good so to speak, we'd be smoking it too.

In my opinion we have a lot to learn and invasive measures to discover why we get sick and addicted can be simply remedied by diet adjustment. Vitamin C for instance. it is already known eating an orange is much better than taking the supplement. Zest and all. Of course eating the peal by itself is not too appetizing. But in combination with other food, it can be. Chemical derivitives don't get it. The taste buds are all the doctor we need. Of course they too are becoming tantalized to where they can become ineffective. Overdose is rampant in all we consume, by and large. It is again about balance. Man are we out of balance. Perhaps there is something about tobacco that is meant to be ingested through the lips and over the gums into the machine that is the human body that will keep it in prime working condition mentally and physically; smoking it, in lieu of the natural taste is much more preferrable yet, as we have determined, not advisable and addictive and harmful. Yet because of the "costs" involved we need to take short cuts. Bad news all the way around. That is why we abuse the fruit of the poppy, the thc in cannibis and the nicotine in tobacco and so forth. The all have something the body needs mentally and physically and in the proper diet can be administered in balance with other food the can achieve that balance. Thinking out loud.

William

PS, In other words when we determine what we should ingest naturally but in the right mixtures, we can seal the body and do not disturb it and it will begin to heal itself. To hell with genetic manipulation.

Salima,

On the 15th of June I made you a promise. Thought it has not been a month, not quite, I would like to report my findings. I told you I would try to go a month without smoking and I failed miserably. I went only 2 days. Taking into consideration all that physiologically and mentally that occurs in demanding a stop to something my mind and body have come "accustomed" to, I did not argue with the stress the mind and body were leveling at me. I relented, but in the past few weeks I have come up with a way to ease off and eventually quit or at least ease the addiction by minimising the consumption. In that process I also realize something far more critical. I wll explain as I go along.

It truly depends on how much of a dependency the body has or how long one has been smoking or using tobacco. The body will effort to find a way to "live" with that in which it consumes. The more "natural" that it is, IMO the more compatible it is with the efficiency of the mind and body, the more the body benefits. Now, I am still unsure of what it is about the male physiology and brain chemistry that creates that lust for nicotine once it is imbibed. Whether it is a good thing or a bad thing. It truly depends on how much and method of introduction into the body. Now I am not going to beleaguer this point.

What I have come to learn, in my thinking that began when I made that promise, was a plausible alternative to those who, like me, did not have the wherewithall to quit cold turkey. Which I think has it's strong points and weaknesses at the same time also dependent on how long the body has been "dependent". Now here is where I go out on limb and introduce that which seems to be working for me and I will relate it to those of you who do smoke as a way to smoke less, and those who wish to quit a means of weaning off until you do.

First: Stop buying processed cigarettes (mystery cigarettes). Find the purest cigarette tobacco and start "rolling your own". Forget menthol, filters and the lot. What you will find, tobacco in it's purest form will in and of itself dictate how much you need as you will notice you will start smoking less and less. Tobacco is much cheaper to buy "bulk". Now don't go crazy and buy 50 pounds of the stuff because you will soon discover your dependency on it becoming less and less. *And it will save you a small fortune as opposed to what you are spending on "mass produced, processed cigarettes". I will not mention any brand names of tobacco, but they are all available on line along with all you will need to "roll your own" in the shortest amount of time.

What will transpire is amazing. Not only will you save money, you will not create excess waste in that you will not discard your "butts' but save that "excess tobacco" to be "recycled" in another rolling session in that all that is waste is the small amount of paper. Now this "recycled" tobacco has the greatest amount of nicotine and tar and you mix it in with the "fresh tobacco" to dilute it's strength, but lessening the flavor of the entire mixture until you no longer receive the satisfaction you were dependent upon until your consumption wanes to the point that will allow you to simply "lay them down" altogether. It's working for me. You will get to the point in which one or two puffs is all you need and you will put that cigarette out. Even the purest tobacco becomes antagonistic to your bodies processes that will allow you to smoke and smoke even less. I have gone from burning up to two pack a day, to less that 10 cigarettes per day and it is dwindling as I speak.

Now for all of you have quit "cold turkey" let me salute you. Bravo, though I think being able to do that really depends on how long one has smoked and the strength of the addiction and the body's processes it has become "accustomed" to, to deal with the affect of the smoking itself.

Now let's just assume for the sake of argument, this is a sure fire way to quit or at least cut drastically back in smoking itself and the industry that is "big tobacco" gets wind of it and are dependent on tobacco that is their livelihood. Here is were the perversion of the "golden rule" comes into play, "HE WHO HAS THE GOLD, RULES".

Every measure to seek and control those who produce the best tobacco will be swallowed up by those who have the means to do so, either to maintain their control, or profit from it as the use of tobacco eventually becomes a thing of the past. Which do you think will occur?

Now I have no idea if this process will work for all, I just know it is working for me and I have been smoking since I was 11 years old. If this is a way to quit and is altruistic, here is what will happen, I guarantee it.

The powers that be will swallow up those existing companies that produce the finest of any product and adapt it to their own eliminating any competition. In that process they will "increase" the price of their own stock to take advantage of the demand as people everywhere take advantage of buying their tobacco in bulk. Also all the paraphenalia that is essential with this "new" idea. Getting the picture now of how the "status quo" operates.

Now those pure tobacco farmers are forced to comply with an offer they cannot refuse or suffer the consequences of power who will "squeeze" them out all together if they don't. You can take this scenario and apply it to any situation you wish. Just the fact that what I am doing "saves a hell of a lot of money", is enough alone to get the attention of the powers that be. Saving money is not a part of what feeds their greed; spending money is. That's the whole point. For what it's worth, Hmmm?

William

Thanks Salima. Your the one who helped me find my solution. :a-ok: