Re: Sometimes It's Better Just to Do Less Harm
- From: "Len Gaasenbeek" <gaasbeek@xxxxxxxxxx>
- Date: Tue, 21 Jun 2005 12:41:08 -0400
To Richard A. Friedman, M.D.
I see your point but isn't risky to substitute one addiction for another?
Because once we reinforce the addictive behaviour trait in a person, won't
he/she be more inclined to become addicted to other narcotics, than a person
with a non addictive personality?
In other words, shouldn't a doctor concentrate on the addictive behaviour of
a patient, rather than on what he/she is addicted to? Because if you don't,
the patient may end up exchanging a smoking habit for a drinking or heroin
habit.
For example, it is a well known that a percentage of people who stopped
smoking start to overeat, which may kill them more quickly than if they had
kept on smoking.
Finally, what about the mental well-being of the patient? Suppose you
convince a 90 year old man, who loves to smoke his pipe, that he should stop
smoking for his own good. He follows your advice and is so miserable
without his pipe, that it kills him!
It seems to me that all to often doctors treat the illness rather than the
patient. I suppose it is easier to prescribe a pill than to take the time
to discover what is really bothering the patient.
Before becoming an engineer, the battery in my car went dead. I took it to
a garage which put in a new battery. A couple of days later the battery was
dead again. The mechanic put in a new generator.
A few weeks later, the battery went dead again. This time the mechanic
replaced the voltage regulator which fixed the problem (by trial and error).
So I ended up paying for a new battery and generator I didn't need, which
was good business for the garage but ended up costing me a couple of hundred
dollars I could ill afford at the time.
Of course a good mechanic, like a good doctor, should start out by
investigating what caused the problem to occur in the first place.
Fortunately, in the mechanic's case, his misdiagnosis didn't kill me. I
haven't been as lucky over the years with several doctors that treated my
family and I, but that is another story.
It reminds me of the saying: "The operation was a success but the patient
died."
Which leaves me wondering how much longer the patient would have lived, if
he hadn't been operated on, or hadn't consulted his doctor.
Len. (P. Eng.)
...................................................
"U. K." <uk@xxxxxxxxxx> wrote in message
news:11bfq9aecethteb@xxxxxxxxxxxxxxxxxxxxx
> Sometimes It's Better Just to Do Less Harm
> http://www.nytimes.com/2005/06/21/health/21beha.html
>
> By RICHARD A. FRIEDMAN, M.D.
> Published: June 21, 2005
>
> Hippocrates' injunction to physicians, "First, do no harm,"
> is not always easy to follow. Sometimes doing the right thing
> medically means risking lesser harm to avoid greater harm.
>
> When I first met Larry, he was 40 pounds overweight, hypertensive
> and in a bind. His internist had just told him that if he could not kick
his
> two-pack-a-day smoking habit, he would surely kill himself.
>
> His doctor was right, Larry said to me, but he also felt he
> could not live without cigarettes, either.
>
> Larry had already tried to quit and failed four times in
> the last five years. Now, he was desperate to succeed.
>
> The last time he supposedly quit, he was sneaking a cigarette
> on the porch in his bathrobe on a freezing winter morning so
> his wife would not discover that he had relapsed, when the door
> accidentally locked behind him. Shivering and chastened,
> he decided when his wife finally let him in that it really was time
> to quit.
>
> But from our first meeting, I knew that his habit would be hard to beat.
> Every aspect of his waking life, from morning coffee to nighttime
television, was
> entwined with smoking. And when he described the effects of smoking,
> he lapsed into a dreamy adoration usually reserved for lovers. He waxed
eloquent
> about its relaxant and pleasurable effects, as well as the positive
> effects it had on his concentration and alertness. To me, he was a
> walking textbook on the pharmacologic effects of nicotine.
>
> I wondered what therapy could even come close to such positive effects.
> A vast majority of medical therapies are intended to remove pain and
> discomfort, not replace a lethal pleasure with a healthier one.
> And patients accept treatments because, on the whole, they are better
> than the disease.
>
> In contrast, the central challenge of treating any addiction is that
> the treatment is almost never as pleasurable as the addiction itself.
>
> Like opiates and cocaine, nicotine is known to stimulate the release
> of dopamine in the reward pathways of the brain. This explains its
> pleasurable and powerfully self-reinforcing effects. Nicotine also
> releases an array of other neurotransmitters like serotonin,
> norepinephrine and vasopressin that mediate its
> other effects, like arousal, alertness and relaxation.
>
> Anyone who doubts the addictive power of nicotine should reflect on the
> fact that 50 percent of smokers who have heart attacks continue to smoke.
>
> One treatment for smoking addiction is bupropion, marketed as the
> antidepressant Wellbutrin, but also sold as Zyban for smoking
> cessation. Like nicotine, it increases dopamine transmission,
> but to a much lesser extent. It is thought to decrease the
> pleasurable effects of nicotine by pre-empting some of them.
>
> Zyban seemed like a good option for Larry. But its cost, or the cost of
> any smoking-cessation treatment, for that matter, is generally
> not covered by health insurance. On the other hand, Larry's insurance
> would generously reimburse him if I wrote a prescription for Wellbutrin -
> same molecule, different name.
>
> Because he was not depressed and felt that a record of having taken
> an antidepressant might be stigmatizing, he opted to pay out of pocket
> for Zyban, which proved minimally effective for him, anyway.
>
> Larry was also using nicotine replacement in the form of nicotine gum
> and the nicotine patch. But they did not come close to matching the
> pleasing effects of cigarettes.
>
> I decided to give him high-dose nicotine replacement, trying to outfox
> his smoking addiction. Only one form of nicotine replacement can approach
the
> delivery system of a cigarette - nasal nicotine spray. Because it
> is absorbed rapidly into the bloodstream through the nasal mucosa,
> it produces a spike of nicotine in the brain, just as inhaled nicotine
> in tobacco smoke does.
>
> Using more sprays than cigarettes, he was finally able to quit smoking.
> It has been more than a year since his last cigarette, but each month
> he calls me to renew his nicotine spray.
>
> In the end, I simply switched Larry's nicotine system from lethal tobacco
> to a plastic spray bottle, but left his nicotine addiction untouched.
>
> And though little is known about the very long-term risks of nicotine
> in humans, I wager that they pale next to the certain lethality of
> cigarettes. After all, it's the smoke that kills, not the nicotine.
>
> Doing no harm is best, but sometimes harm reduction is as good as it gets.
>
> ___________________________________________________________
>
> Relativity Theory that can be fitted nasally. Now there's a thought.
>
>
>
.
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