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Patient tells how social media helped her overcome the “shame” of her eating disorder

Patient tells how social media helped her overcome the "shame" of her eating disorder

3375657138_d025fc4092_bMany of us turn to our friends and families for encouragement when times are tough. So it’s no wonder that social media sites have also become important sources of emotional support for people with illnesses.

Recently, a story over on MindBodyGreen highlighted how one woman used Facebook as a tool to help her overcome the shame and deception that hampered her recovery from her eating disorder. As Lindsey Hall explains:

Two months into rehab, I was still struggling with letting go of the games of my eating disorder. Transitioning from in-patient to out, I’d been rapidly finding myself falling backwards instead of forwards.

Here I was, 24 years old, still living some days bagel by bagel, still opening the door to deception, and guilt and shame. I knew on some level that admitting to my eating disorder on social media would be a way for me to stop the show. I knew I needed to own this struggle in order to own all of myself, and to continue on my journey learning the art of self-acceptance.

As Hall describes in the story, her decision to make her eating disorder public on Facebook was a leap of faith with no guarantee that it was the right thing to do:

I’ll never really know what drove me to write that Facebook status, but I posted it anyway to the open arms of nearly 2,500 “friends” and family, to people that had met me once at a bar or sat next to on a plane. Having lived so long behind a smoke screen, I was ready to expose myself. I needed to feel bare, even while broken, in order to be able to clean my slate, and start from scratch in reconstructing my life.

The feedback Hall received from her gutsy post on Facebook and the subsequent blog posts and stories about her eating disorder haven’t always been positive, but as Hall explains, that wasn’t that point. Hall’s eating disorder is public information now, and this new level of accountability has helped her keep her eating habits on track.

Previously: Incorporating the family in helping teens overcome eating disordersA growing consensus for revamping anorexia nervosa treatmentPossible predictors of longer-term recovery from eating disordersGrieving on Facebook: A personal story and How patients use social media to foster support systems, connect with physicians
Photo by .craig

Addiction, FDA, Health Policy, Pediatrics, Public Health

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

cigarette packToday, the Institute of Medicine released a new report evaluating the public health effects of reducing teenagers’ access to cigarettes and other tobacco products. Right now, in most places in the United States, you must be 18 years old to buy cigarettes and other tobacco products. But a few states and cities have higher minimums, and in 2013, the IOM convened a committee, at the request of the U.S. Food and Drug Administration, to examine the potential effects of a higher minimum legal age for tobacco access across the country.

The committee, which was led by Richard Bonnie of the University of Virginia and included Stanford adolescent medicine expert Bonnie Halpern-Felsher, PhD, reviewed the existing scientific literature on tobacco use in teens. They also devised mathematical models to predict what would happen if the federal minimum legal age were 19, 21 or 25.

The report brief (.pdf) says, in part:

Based on its review of the literature, the committee concludes that overall, increasing the MLA [minimum legal age] for tobacco products will likely prevent or delay  initiation of tobacco use by adolescents and young adults. The age group most impacted will be those age 15 to 17 years. The committee also concludes that the impact of raising the MLA to 21 will likely be substantially higher than raising it to 19. However, the added effect of raising the MLA from 21  to 25 will likely be considerably less.

The parts of the brain most responsible for decision making, impulse control, sensation seeking, and susceptibility to peer pressure  continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine. In  addition, the majority of underage users rely on social sources—like family and friends—to get tobacco. Raising the MLA to 19 will therefore not have much of an effect on reducing the social sources of those in high school. Raising the MLA to 21 will mean that those who can legally obtain tobacco are less likely to be in the same social networks as high school students.

Although it can take time to fully realize the benefits of reduced smoking, since heart disease, lung cancer and other diseases linked to smoking take decades to develop, the payoff would ultimately be significant, the report adds:

…if the MLA were raised now to 21 nationwide, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung  cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Previously: How e-cigarettes are sparking a new wave of tobacco marketing, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and UN’s top health official: Anti-tobacco efforts can lead to better health “in every corner of the world”
Photo by Thomas Lieser

Addiction, FDA, Health Policy, Medicine and Society, Public Health, Public Safety

To keep edibles away from kids, marijuana policies must be “fully baked”

To keep edibles away from kids, marijuana policies must be "fully baked"

sanfran031606_fig1_highresDepending on your position, legal marijuana might raise images of stoners on every street corner or of users enjoying a private puff in their backyards. However you probably don’t picture a child munching on a pot-laden brownie she found in her kitchen cupboard.

But as Stanford legal experts Robert MacCoun, PhD, and Michelle Mello, JD, PhD, point out in a commentary published today in the New England Journal of Medicine, the loose state regulation of marijuana edibles creates some unnecessarily and potentially serious public health risks that should concern everyone.

Packaged in brightly colored wrappers, edibles often mimic popular sweets, but they contain a powerful dollop of tetrahydrocannabinol (THC), the chemical responsible for marijuana’s psychoactive effects. Some edibles contain multiple “servings” of THC per package.

Both Colorado and Washington — the two states with legal recreational marijuana — require “child-resistant” packaging and a warning to “keep out of the reach of children.” But edibles remain quite attractive to children, who may confuse them with regular candies and snacks, and potentially deceptive to adults, who may assume one bar is a just one serving. “I look at these packages and I get hungry just looking at them,” MacCoun said.

The edibles are not regulated as either a food or a drug by the U.S. Food and Drug Administration, because the federal government considers marijuana illegal. Legalizing states have been slow to fill the gap, and have done so incompletely, Mello said. “This is sort of a weird space that’s betwixt and between federal and state oversight,” she said.

It’s time for the medical community to get involved, MacCoun said. “Most people don’t understand the brain metabolizes chemicals ingested by mouth differently than those smoked.”

Ingested marijuana offers a delayed high, so people keep eating thinking they are fine. The intoxication lasts longer and is associated with more hallucinations and perceptual distortions, he said. “It’s almost like a different drug.”

For now, the issue is most pressing in Colorado and Washington, but many other states are considering legalizing recreational marijuana, including California, MacCoun said.

“We’re not taking some strong position these products should be banned. Sensible and fairly modest regulations would reduce the risk without greatly restricting people’s freedom to consume these products,” MacCoun said.

Previously: Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and Medical marijuana not safe for kids, Packard Children’s doc says
Photo by DEA

Addiction, Behavioral Science, Ethics, Events, In the News, Media

At Stanford visit, Glenn Beck addresses compassion, change and humility

At Stanford visit, Glenn Beck addresses compassion, change and humility

glennUntil this week, I wouldn’t have associated radio personality Glenn Beck with compassion. And when Jim Doty, MD, director of Stanford Medicine’s  Center for Compassion and Altruism Research and Education invited Beck to the Stanford campus, he realized the right-of-center author and provocateur might be a tough sell to his audience accustomed to guests such as the Dalai Lama and Sri Sri Ravi Shankar.

“Please trust me,” Doty tweeted last week.

Yet fireworks were absent from the nearly two-hour conversation, which ranged from Beck’s struggle with addiction to his Mormon faith and his passion for radio.

Beck came across as human, a man who had endured struggles, made mistakes and is striving to learn from them. He is a father and husband, who organizes charity efforts and volunteers in his church. He said he’s gone from a person for whom the audience size was just a measure of his success to a man who cares deeply about people and his audience members. He prays for humility and said he is not trying to be divisive.

“I spend a lot of time, at the end of my day, saying, ‘Okay, am I that guy? What could I have done better,'” Beck said. “You self-examine all the time and with that self-examination you grow. It’s good. I know who I am because I’m pushed up against the wall all the time.”

Americans share a certain set of principles in common, Beck said. The rift begins when people replace their principles with specific interests and policies.

“For example, if I said to you, ‘Do we torture?’,” Beck said. Nearly everyone would say no. But once threats from terrorists are introduced, the conversation becomes more divided.

“The left and the right have principles in common. We may disagree on interests, but we have to start anchoring ourselves in the principles.”

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Addiction, Obesity, Science, Videos

Discussing how obesity and addiction share common neurochemistry

Discussing how obesity and addiction share common neurochemistry

In a TEDMED talk published last week, renowned neuroscientist Nora Volkow, MD, discusses using insights from her research on drug addiction and brain chemistry to better understand the obesity epidemic.

Volkow, who directs the National Institute on Drug Abuse at the NIH, thought compulsive drug-taking behavior seemed remarkably similar to not being able to control what one eats. And indeed, with the help of PET scans that image living human brains, she found that the brain chemistry behind these two stigmatized problems is very similar.

The problem has to do with fewer dopamine D2 receptors; in her words, that’s “the biochemical signature of a brain where the capacity to control strong urges has been compromised.” She goes on to talk about such things as pleasurable stimuli versus conditioned stimuli, deprivation states, and how modern society could engineer environments that encourage health.

Volkow ends on a sociological note, challenging the moralizing idea that addiction and obesity indicate a failure to self-regulate:

Dismissal of addiction and obesity as just problems of self-control ignores the fact that for us to be able to exert self-control would require the proper function of the areas in our brains that regulate our behaviors… It’s like driving a car without brakes. No matter how much you want to stop, you will not be able to do it.

Previously: How eating motivated by pleasure affects the brain’s reward system and my fuel obesity; The brain’s control tower for pleasure; New tools from NIDA help diagnose and treat drug abuse

Addiction, Health Policy, Parenting, Pediatrics, Podcasts, Public Health

Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization

Discussing the American Academy of Pediatrics' call to put the brakes on marijuana legalization

A wave of changes in state laws on the use of marijuana for medicinal and recreational purposes has stirred the American Academy of Pediatrics. It’s taken 10 years for the AAP to update its policy on the legalization of marijuana, and they released its new one on Monday.

74381759_e5a563cf3d_zThe organization still opposes legalization but it has opened the door to reform in several ways. First, recognizing that minority kids bear the brunt of criminal penalties for pot use, they call for decriminalization. Second, they call for the U.S. Drug Enforcement Agency to reclassify marijuana from a Schedule 1 listing for controlled substances to a Schedule 2. This action would effectively allow more research to be conducted and in turn scientifically determine where marijuana is most effective as a treatment. A review by the federal government is currently underway.

I asked Stanford pediatrician Seth Ammerman, MD, the lead author of the statement, what the AAP was trying to achieve with its policy redo and why such a restrictive stance on legalization since the train for legalization – recreational and medicinal –  seems to have already left the “coffee house.”

In this 1:2:1 podcast, Ammerman cites major two concerns. First, if legalized and commercialized, marijuana will become a big business, and the same marketing efforts by tobacco companies that encouraged teens to take up cigarettes will lasso them to pot smoking. “Well, aren’t kids smoking pot already?” I asked. Ammerman fully realizes that any teen who wants pot can readily buy it – legalization, to the AAP, is an imprimatur. Secondly, Ammerman cited, as does the new policy statement, the compelling and growing scientific evidence that the brain in formation continues to gel through the teen years and into the 20s. Marijuana, just like alcohol and any other drug, is likely to play a lot of bad tricks as the prefrontal cortex solidifies.

As described in the policy paper:

New research has also demonstrated that the adolescent brain, particularly the prefrontal cortex areas controlling judgment and decision-making, is not fully developed until the mid-20s, raising questions about how any substance use may affect the developing brain. Research has shown that the younger an adolescent begins using drugs, including marijuana, the more likely it is that drug dependence or addiction will develop in adulthood.

Ammerman says that the AAP will follow closely what happens in states where marijuana has been legalized both for health and recreation, and it will look carefully at what future evidence suggests. Clearly, there’s still a lot of smoke around this issue.

Previously: To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics
Photo by Paul-Henri S

Addiction, Health Policy, In the News, Pediatrics

To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics

To protect teens' health, marijuana should not be legalized, says American Academy of Pediatrics

teen smoking Today, the country’s most prominent group of pediatricians issued a policy statement that opposes marijuana legalization and advocates for policies to help minimize the drug’s harmful effects on children and adolescents. The new statement, from the American Academy of Pediatrics, was written in response to recent research on adolescent brain development and the biology of addiction, as well as a changing national climate on marijuana laws.

I spoke with Stanford’s Seth Ammerman, MD, an adolescent medicine specialist and the lead author of the new statement and accompanying technical report. Ammerman studies substance-use issues in youth and also has extensive experience working with at-risk young people, in part through his role as medical director of the Adolescent Health Van run by Lucile Packard Children’s Hospital Stanford.

“The national trend is definitely toward more medical marijuana, and also toward legalization for adults,” he said. “This trend can definitely affect kids, so it was really important for the Academy to have a voice, to be working on a national conversation about this.”

During our conversation, Ammerman explained some of the latest research that has motivated the AAP’s stance against marijuana legalization:

In the past decade, we’ve learned that brain development doesn’t finish until one’s early to mid-20s, and substance use can alter the developing brain. There are a few ways we know this: One, there’s clear evidence that the younger you start using drugs regularly, the more likely you are to become addicted. This is true for alcohol, tobacco, and marijuana, among others. For those who put off substance use until their late teens or early 20s, addiction rates are significantly lower.

We also know that the developing brain is very vulnerable to substance use. One in 10 adolescents who use marijuana become addicted. That means that 90 percent won’t — which is the good news — but the problem is we can’t predict which 10 percent will develop addiction.

We also have a lot of research about the adverse effects of marijuana use. Heavy users fare worse in many ways: their cognitive levels fall, they are less likely to finish high school or attend college, and they tend to suffer more from depression. Most users are not heavy users, but again, we can’t predict who will fall into this category.

The AAP is also in favor of decriminalizing marijuana, replacing current criminal penalties with lesser criminal or civil penalties and drug treatment. This is an especially important step to reduce the long-term damage to educational and job opportunities that currently comes with marijuana arrests, Ammerman said, adding: “There is a significant problem of racial inequity associated with marijuana arrests: minorities are way over-arrested and their lives are messed up because of marijuana arrests. It’s a very important step to say we need to help kids, not punish them.”

Previously: Medical marijuana not safe for kids, Packard Children’s doc says, Pediatrics group calls for stricter limits on tobacco advertising and To reduce use, educate teens on the risks of marijuana and prescription drugs

Photo by mexico rosel

Addiction, Pain, Public Health, Research

Medical marijuana and the risk of painkiller overdose

Medical marijuana and the risk of painkiller overdose

medical marijuanaAfter a study published this fall showed that that opioid overdoses (e.g., with painkillers such as Oxycontin) occur at lower rates in states with legalized medical marijuana, many people interpreted the results as proof that using medical marijuana lowers an individual’s risk of overdose. For example, some speculated that marijuana allows people in pain to forgo using opioids or at least use them in lower doses. Other suggested that medical marijuana reduces users’ consumption of alcohol and anti-anxiety medications, both of which make opioid use more likely to lead to overdose. Still others hypothesized that medical marijuana improves mental health, reducing the risk of intentional opioid overdose (i.e., suicide attempts),

However, all of this speculation was premature. Many things that are associated when geographic areas are compared are not associated in the lives of the individuals who reside in those areas. For example, geographic areas with higher rates of cigarette smoking and higher radon exposure have lower cancer rates, even though individuals who smoke and/or get exposed to radon have higher rather than lower risk of cancer.

The only way to understand the influence of medical marijuana on individuals’ risk of opioid overdose is to actually research individuals, and that is what an Australian team has done. In a recently published study of more than 1,500 people who were on prescribed opioids for pain, they examined experiences with medical marijuana.

Seeking pain relief from medical marijuana was common in the sample, with 1 in 6 participants doing so and 1 in 4 saying they would do so if they had ready access to it. The results did not support the idea that medical marijuana users are at relatively low risk of opioid overdose. Indeed, on every dimension they appeared to be at higher risk than those individuals who did not use medical marijuana for pain.

Specifically, relative to individuals who only used opioids for pain, the medical marijuana users were on higher doses of opioids, were more likely to take opioids in ways not recommended by their doctor, were over twice as likely to have an alcohol use disorder and four times as likely to have a heroin use disorder. Medical marijuana users were also over 50 percent more likely to be taking anti-anxiety medications (benzodiazepines), which when combined with opioids are particularly likely to cause an overdose.

Neither did the medical marijuana users have better mental health. Almost two-thirds were depressed and about 30 percent had an anxiety disorder.   These rates were half again as high as those for non-medical marijuana users.

Medical marijuana thus appears to be commonly sought for pain relief among people who are taking prescribed opioids for pain. But in this population, it’s a marker for much higher rather than lower risk for opioid overdose.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He has served in the past as a senior advisor in the Office of National Drug Control Policy in Washington, DC. He can be followed on Twitter at @KeithNHumphreys.

Previously: Assessing the opioid overdose epidemicTo reduce use, educate teens on the risks of marijuana and prescription drugs and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by David Trawin

Addiction, Behavioral Science, In the News, Mental Health, Research, Stanford News

Veterans helping veterans: The buddy system

Veterans helping veterans: The buddy system

image.img.320.highI interviewed Army specialist Jayson Early by phone over the summer, shortly after he completed an in-patient program for PTSD at the Veterans Affairs hospital in Menlo Park. This was for a Stanford Medicine magazine story I was researching about a pilot project to help get much needed mental-health services to the recently returned waves of Afghanistan and Iraqi vets. What struck me most after talking with Early was just how clueless he had been, first as a teenaged-recruit, then as a young veteran, about the fact that going to war could cause mental wounds.

As the mother of a 17-year-old boy, though, I completely understood: Early just wanted to serve his country. He requested to be sent to war. In 2008, he got his wish and was deployed to Iraq just a year after exchanging his high-school baseball uniform for military fatigues. His first field assignment, an innocuous-sounding public affairs errand to photograph a burned out truck at an Iraqi police station, would be the first of many that left him with permanent scars:

“There were body parts, coagulated blood, hair all over,” [Early] says, pausing. “I just wasn’t expecting it.” An Iraqi family had been executed in the vehicle, presumably by insurgents. Early had gone through intense military training to prepare for moments like these. He blocked any emotions. He followed orders, clicked the camera and moved on. It wasn’t until years later that he realized just how permanently those images, and many more like them, had burned into his brain.

Stanford psychiatrist Shaili Jain, MD, interviewed in a podcast about her work with PTSD and veterans, had told me about a new pilot project that connects veterans with other veterans as a unique way to bridge what she called a “treatment gap” – the difficulty of getting mental-health services to the veterans that need them. My article – which is a timely read, given that today is Veterans Day – tells the story of Early’s connection with one of the veteran’s hired through this project, Erik Ontiveros, who went through treatment for addictions and PTSD himself, and just why it’s so hard to get treatment to veterans. As one well-known expert on PTSD explains in the story:

“It’s wicked difficult to treat anyone with moral injuries from combat in the traditional medical model,” says psychiatrist Jonathan Shay, MD, an expert on PTSD known for his books on the difficulties soldiers face returning home from war. “It destroys the capacity for trust. What it leaves is despair, an expectation of harm, humiliation or exploitation, and that is a horrible state of being. The traditional medical model – in an office with the door closed – is the last thing they want. I’m convinced that’s where peers come in. Peers are indispensable.”

Early told me many of his horror stories from war – stories that he rarely talks about. The time he was called to another execution area where there were enough body parts for 12 people who had all been gagged, bound, shot and burned. But, he said, they could only put together eight people. “We were trying to find a way to identify them,” he said. “Whenever I grabbed a hand, it would just crumble to dust.”

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Addiction, Emergency Medicine, Health Policy, Research, Stanford News

Assessing the opioid overdose epidemic

Assessing the opioid overdose epidemic

Vicodin bottle Flickr Sharyn MorrowIn recent years, doctors and policy-makers have become aware of the dangers of prescription opioid medications like methadone, oxycodone and hydrocodone (which is sold as OxyContin or Vicodin). In a study published in this month’s JAMA Internal Medicine, Stanford medical student Michael Yokell and Stanford surgeon Nancy Wang, MD, took a new approach to quantifying those dangers.

Many previous studies of the toll of opioids looked at death certificate data and examined trends among deaths due to opioid overdoses, including street drugs like heroin and prescription painkillers. The new study looked at emergency department admissions and found that more than two thirds of ER visits due to overdoses were related to prescription opioids, while heroin overdoses accounted for 16 percent. Moreover, only about 2 percent of cases that made it to the ER died, but more than half the patients needed further hospitalization.

The study also found that those admitted to the emergency room because of opioid overdoses are more likely to have conditions such as chronic breathing problems, heart problems or mental health issues. Yokell explained that it’s important for doctors to be aware of the possibility of overdose and consider prescribing alternatives or discuss the risk of overdose with patients.

Beyond providing better access to emergency medical care and treatments for patients, an important next step to resolving the problem of opioid misuse is to establish or improve statewide prescription monitoring programs. For example, California has a prescription drug-monitoring database called CURES, but not all doctors actively use the program. “We can do a better job of making that database more widely used by physicians in the state.  We need more doctors to sign up and use it. It’s a valuable resource,” said Yokell.

Additionally, many people get access to prescription opioids via fraudulent prescriptions or from dealers that have illegally obtained the drugs – sometimes from breaking into and raiding pharmacies. “It’s important to keep in mind that good prescribing practices are one component of an effective strategy. There are many other ways for people to get their hands on [prescription opioids] and use them inappropriately.”

Although fixing things on the prescription side is important for managing the opioid overdose epidemic, Yokell notes that it’s not enough. Cases that make it to the ER are likely to survive, but Yokell noted that the fear of criminal charges often results in people avoiding medical care for overdoses caused by opioids and that getting this group better access to emergency services and treatment could improve outcomes. Paramedics and doctors have access to the drug naxolone, marketed as Narcan, which is safe and effective treatment for opioid overdose. But “people don’t call 911, so they are dying,” Yokell told me.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Increasing access to an anti-overdose drug and A focus on addiction, the country’s leading cause of accidental death
Photo by Sharyn Morrow

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