Twenty-five years have passed since the first cases of AIDS were recognized. During the first two decades, the epidemiology and clinical presentation of the disease were established, and potent antiviral therapies were developed -- for use in patients who could afford them. The progress of the past five years has been less dramatic. Indeed, the most salient change was a widening of the gap between the haves and the have-nots, so that today a single virus is responsible for two distinct public health calamities. [continues 1455 words]
On February 20, 2006, when Dr. John Hoey, editor-in-chief of the Canadian Medical Association Journal, returned to the Ottawa headquarters of the Canadian Medical Association after a vacation, his journal was in excellent shape. It ranked as the fifth leading general medical journal in the world, and it received more than 100 original research papers per month, allowing the editors to be highly selective in what they published. It had nearly 70,000 subscribers -- representing the more than 85 per cent of Canadian doctors who are CMA members. Yet Dr. Hoey's decade as editor would end abruptly that afternoon when the journal's publisher fired him and his senior deputy editor, Anne Marie Todkill. [continues 1780 words]
What role should physicians have in defining the purposes of their profession -- the functions that medicine should and should not serve? Many observers hold that medicine's aims are for doctors and patients to decide, without interference from the state. But in fact, government limits medicine's purposes in many ways. Doctors cannot prescribe mind-altering substances for recreational use or anabolic steroids to enhance athletic performance. Physicians were once barred from terminating pregnancies, and today, in 49 states, they are not allowed to assist the terminally ill in ending their lives. [continues 1632 words]
On October 5, 2005, the U.S. Supreme Court heard oral arguments in Gonzales v. Oregon. On the surface, this case is about the legitimacy of physicians' prescribing of medications under Oregon's Death with Dignity Act and whether the federal government can overrule the states in defining "legitimate medical practice." Just beneath the surface, however, lies the risk of empowering agents of the Drug Enforcement Agency (DEA) - whose traditional role is to prevent drug abuse and diversion - to evaluate the end-of-life practices of physicians whose patients die while receiving prescribed opioids or barbiturates. A finding in favor of the Justice Department would not only nullify the Death with Dignity Act, permitting the DEA to penalize physicians for providing medications to hasten the deaths of terminally ill patients, but also have a chilling effect on physicians' willingness to treat patients' terminal symptoms. [continues 1610 words]
NEW YORK - Researchers from the US Centers for Disease Control and Prevention (CDC) are reporting that 26 patients in an intensive care unit at one hospital contracted a rare bacterial infection through infusions with the pain killer fentanyl. The infusions are believed to have been contaminated with Serratia marcescens bacteria by a staff respiratory therapist who was apparently taking the drug illicitly. Fentanyl is a powerful opiate narcotic 80 times more potent than morphine. Hospital administrators became concerned during the summer of 1998 when nine patients became infected with S. marcescens. After initial testing failed to identify the cause, and new infections were discovered, the CDC was invited to assist in the investigation, which lasted until March 1999. [continues 210 words]
To the Editor: As part of our research on the relation between the Internet and substance abuse, we have identified several Web sites that promulgate information about illicit drugs. These "partisan" Web sites are easily identified by common search engines if one uses the names of illicit substances as search terms.1 With some pages viewed more than 160,000 times per day, partisan sites appear to be effective in reaching adolescents and young adults. In a recent study, 24 percent of college students used the Internet to obtain information on illicit substances, and 27 percent of Internet-using college students reported that Internet use increased the likelihood that they would use drugs.2 [continues 686 words]
In 1989, Supreme Court Justice Thurgood Marshall surmised that "declaring a war on illegal drugs is good public policy . . . [but] the first, and worst, casualty of war will be the precious liberties of our citizens."1 The same year, in the midst of President George Bush's "war on drugs," the Medical University of South Carolina initiated a program to screen selected pregnant patients for cocaine and to provide positive test results to the police.2 At a time of high public concern about "cocaine babies," this program seemed reasonable to the university and local public officials. Drug-screening programs in other groups of people had been found constitutional by the Supreme Court,1,3 and it was beginning to appear that the war on drugs would claim the Fourth Amendment, which prohibits unreasonable searches, as one of its first casualties.4 [continues 3660 words]
To the Editor: The article by Johnson et al. on the treatment of opioid dependence (Nov. 2 issue) (1) and the accompanying editorial by O'Connor (2) serve an important purpose in making physicians and, one hopes, the public more aware of the effectiveness of methadone maintenance for heroin dependence. It is discouraging, however, that the ineffectiveness of low-dose methadone therapy still has to be demonstrated. The effectiveness of methadone, at an average dose of 100 mg per day, was shown by Dole et al. (3) more than 30 years ago and has been repeatedly confirmed since then, with some patients needing a dose higher than 100 mg per day. (4) If the high-dose group in the study by Johnson et al. had actually received a high dose of methadone (i.e., higher than 100 mg per day), its effectiveness might have been even more impressive. The low-dose group received a daily dose of 20 mg of methadone, which would not even be an analgesic dose if used for chronic pain. Unfortunately, most programs are using inadequate doses of methadone with, not surprisingly, poor results. [continues 1569 words]
By Sally Satel. 285 pp. New York, Basic Books, 2000. $27. ISBN 0-465-07182-1 In PC, M.D., Satel deplores the "political correctness" (the PC of her title) advocated by some physicians, academics in the fields of nursing and public health, psychologists, social workers, and health lawyers. She defines political correctness as the assumption that the health problems of the poor, members of minority groups, women, and persons with mental illness are mainly a result of their oppression by dominant groups in society. "Indoctrinologists" for political correctness in the health professions have what the author calls a "social empowerment agenda" that "will divert resources from strategies that really work" and is already "making some people sick, or sicker than they need to be." [continues 832 words]
By Dwight B. Heath. 240 pp., illustrated. Philadelphia, Brunner/Mazel, 2000. SBN 1-5839-1047-6 Americans have a long history of ambivalence about the role of alcohol in their society. This vacillation turned to mayhem in 1919, when the 18th Amendment to the Constitution (later repealed) introduced Prohibition, which banned the manufacture and sale of alcohol nationwide. Today in the United States, a person legally becomes an adult at the age of 18: he or she becomes a citizen who can vote, serve in the military, sign a contract, marry, buy a gun, or buy a pack of cigarettes, but who cannot buy a beer or a glass of wine. Out of this gloomy picture shines a bright light: Dwight Heath's eminently sensible, intelligent, and hopeful book, Drinking Occasions: Comparative Perspectives on Alcohol and Culture, in which he describes the variety and versatility of drinking in many other parts of the world. In contrast to the negative view of alcohol in the United States, the reader is treated to descriptions of relaxed and positive experiences of drinking. [continues 646 words]
Heroin use in the United States has grown considerably over the past decade. Approximately 3 million Americans have used heroin, (1) a fact that has led to increasing concern about heroin-related problems such as overdose, human immunodeficiency virus (HIV) infection, unemployment, and crime. Finding effective treatments for heroin dependence is critical. The report by Johnson et al. in this issue of the Journal (2) represents an important step toward expanding the options for treatment. Patients who are dependent on opioids may come to physicians with health problems and may request help finding treatment. The first step is careful screening to identify underlying substance-abuse problems. Screening may be hampered by several barriers, including reluctance on the part of patients and physicians to discuss a problem that is considered stigmatizing. Once opioid dependence is identified, the patient should be assessed for the medical and psychosocial problems that typically accompany it. It is also important to determine whether the patient is motivated to change his or her drug-use behavior and enter treatment. Patients who lack such motivation should be counseled about the risks of continuing to use drugs and the benefits of treatment. Patients who are so motivated should be promptly referred to treatment programs. [continues 1583 words]
By a Working Party of the Royal College of Psychiatrists and the Royal College of Physicians. 291 pp., illustrated. London, Gaskell, 2000. UKP9.50. ISBN 1-901242-44-7 The abuse of psychoactive substances is among the leading causes of disability and criminal activity in the world. Drug addiction is difficult to study. Most drug transactions are effected illegally, which limits the acquisition of accurate data on drug abuse. However, in 1997, the United Nations International Drug Control Programme estimated that illicit drug trade accounts for about 8 percent of all international trade and shows no worldwide trend toward a reduction. In the United Kingdom, where drug addiction is less of a problem than in the United States, there has been a steady increase in drug use in the past 40 years, with the use of heroin reaching epidemic proportions. [continues 795 words]
To the Editor: At the end of his review of Marihuana and Medicine, Benson (Sept. 9 issue) (1) states, "The editors' drug-control bias obscures the promise of drug development." Dr. Benson is the senior editor of the 1999 report by the Institute of Medicine, "Marijuana and Medicine: Assessing the Science Base," (2) which recommends medicinal use of marijuana smoking, after describing its scientific basis. This scientific basis involves the assumption that there is an endogenous anandamide cannabinoid system, D9-tetrahydrocannabinol (THC), having a basic physiologic role. This rationale is described by Lichtman and Martin, in what Benson calls "the most compact and yet comprehensive chapter" in the book. However, it is not supported by our work and that of other investigators, described in other chapters of the book (Waser and Martin, (3) Sutin and Nahas, (4) and Nahas et al. (5)). This work challenges the cannabinoid hypothesis. [continues 471 words]
The medical use of marijuana has polarized public opinion, particularly because of its widespread recreational use over the past 30 years. Those in favor of its medical use point to the apparent safety of this ancient and "natural" remedy, the profusion of anecdotal and survey-based evidence of marijuana's effectiveness, and the importance in today's culture of personal choice. This view has been expressed at the ballot box since November 1996 by referendums in several states. Those opposed, troubled by this potential gateway to serious drug abuse, especially among adolescents, regard acceptance of the medical use of marijuana as the camel's nose under the tent, legitimizing a dangerous relaxation of the nation's "war on drugs." Both sides come from all age groups and levels of society, and both claim their own scientific evidence. [continues 1014 words]
The ouster of the New England Journal of Medicine's longtime editor was the culmination of a yearlong battle over whether to use the journal's venerable brand name to sell new products and reach a wider audience. Jerome P. Kassirer, whose departure was announced late Sunday night, had fought to keep the magazine out of a number of money-making ventures. Dr. Kassirer, the magazine's editor since 1991, recently helped rebuff a revenue-sharing deal with an Internet bookseller and opposed the journal branching out into a mainstream medical magazine, arguing that it would tarnish the journal's reputation as one of the world's leading medical magazines. [continues 811 words]
Edited by Seymour Fisher and Roger P. Greenberg. 404 pp. New York, John Wiley, 1997. $49.95. ISBN 0-471-14848-2 This book, written entirely by academic psychologists, is a dose of strong medicine. A critical review of the psychoactive-drug literature, it asserts essentially that there is inadequate scientific information to conclude that psychoactive drugs are substantially more effective than placebos. The editors remind us that the interpretation of any research data is likely to reflect the researcher's bias: in this case, a bias toward biologic treatment, the pharmaceutical industry's financial motives, or both. They say, "We feel it is important to balance this bias by adopting a counterattitude based on a determined skepticism." Their intellectual, scholarly review is difficult to dismiss; yet the reader may feel their conclusions are immoderate. [continues 633 words]
To the Editor: Botulism causes skeletal-muscle weakness resulting from bacterial exotoxins that irreversibly block the release of acetylcholine from presynaptic motor neurons. We report three cases of botulism in members of the Native American Church who consumed peyote, a cactus with hallucinogenic properties that has been legalized for sacramental use in traditional American Indian religious ceremonies. Thirteen church members ingested peyote from a communal jar during a ceremony. Two to four days afterward, three men (40, 42, and 72 years old) noted the onset of bilaterally symmetric, moderate, flaccid weakness in all extremities. Two had nasal speech, dysphagia, and diplopia. Two of the patients consented to undergo electromyographic studies, the results of which were notable for markedly diminished amplitudes of all compound muscle action potentials, which increased greatly (40 to 82 percent) after exercise. This magnitude of increase has been observed in 85 percent of patients with botulism and indicates a presynaptic defect of the neuromuscular junction, thus supporting the clinical diagnosis of botulism. [continues 349 words]
To the Editor: A disturbingly large percentage of dying patients experience unrelieved pain. (1) This percentage is far higher than it should be, given the availability of pain medications and the knowledge of how to use them. Many physicians believe that they could risk disciplinary action if they use high doses of narcotics or other controlled substances to manage pain at the end of life. (2) They also believe that if they undertreat pain, they risk no professional consequenc es. Dying patients clearly have the right to adequate pain medication; this was recently recognized by the Supreme Court. (3,4) [continues 317 words]
By Jerome J. Platt. 458 pp. Cambridge, Mass., Harvard University Press, 1997. $49.95. ISBN 0-674-13632-2 Over a century ago, the active ingredient in the coca leaf was purified, and the first cases of cocaine dependence were described in North America and Western Europe. Overlooked for many years, cocaine resurfaced as a public health problem in the 1980s. Today, among the major addictions, cocaine dependence remains the most elusive. Alcohol, opiates, and nicotine all produce characteristic withdrawal syndromes, which respond to treatment with pharmacologic agonists or sympatholytic agents. For cocaine, the withdrawal syndrome is more evanescent, and its treatment implications remain unclear. For alcohol, opiate, and nicotine dependence, a growing list of medications is available to help induce remission or prevent relapse, including the aversive agent disulfiram, the long-acting opiate agonist methadone, the long-acting opiate antagonist naltrexone, and nicotine-replacement therapies with patch and gum delivery systems. Recent advances include naltrexone for alcoholism, the long-acting agonist levomethadyl acetate hydrochloride for opiate dependence, and the antidepressant bupropion for smoking cessation. Cocaine has yet to yield to agonist, antagonist, or antidepressant strategies, although intensive work is ongoing, and there have been hints. Several psychotherapeutic and behavioral strategies have shown promise. This progress and the development of effective medications for the other addictions reinforce the importance of the research effort in this area and inspire confidence that it will continue to bear fruit. [continues 368 words]
Reefer Madness The Federal Response to California's MedicalMarijuana Law George J. Annas Introduction Marijuana is unique among illegal drugs in its political symbolism, its safety, and its wide use. More than 65 million Americans have tried marijuana, the use of which is not associated with increased mortality. (1) Since the federal government first tried to tax it out of existence in 1937, at least partly in response to the 1936 film Reefer Madness, marijuana has remained at the center of controversy. Now physicians are becoming more actively involved. Most recently, the federal drug policy against any use of marijuana has been challenged by California's attempt to legalize its use by certain patients on the recommendation of their physicians. The federal government responded by threatening California physicians who recommend marijuana to their sick patients with investigation and the loss of their prescription privileges under Drug Enforcement Administration (DEA) regulations. (2) [continues 3893 words]
