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When many of us get a headache, a fever, or just suffer the aches and pains of physical exertion we don’t think twice about reaching for an over-the-counter pain reliever. Acetaminophen, which is the medicine in the well-known brand Tylenol, has long been considered the safest pain medication. Non-steroidal anti-inflammatory medications (NSAIDs) can cause stomach irritation and ulcers and can decrease kidney function. Opiates (morphine and its relatives) can cause drowsiness, constipation and addiction. Acetaminophen has none of these side effects and remains the first choice of many physicians when safety (not efficacy) is paramount.
But yesterday an FDA working group released a report reminding us that even acetaminophen has risks. Specifically, acetaminophen in high doses can cause serious, even fatal, liver injury. Liver injury can happen at even lower doses in people who drink alcohol regularly or who have other liver diseases. Every year some people die of liver failure due to acetaminophen overdose. Some of these overdoses are intentional, and some are due to misunderstanding medications with multiple ingredients. For example, some prescription medicines like Vicodin and Percocet contain an opiate pain medicine and also acetaminophen. Patients who don’t know this and take Tylenol in addition may inadvertently take a dangerously high dose of acetaminophen.
The FDA working group recommended limiting the maximum adult daily dose of acetaminophen to no more than 3,250 mg. (It’s currently 4,000 mg.) The maximum dose should be even lower for patients drinking 3 or more alcoholic drinks daily. The group also recommended eliminating the “extra strength” tablet dose of 500 mg and limiting tablets to 325 mg and single adult doses to a maximum of 650 mg.
I still think acetaminophen is the safest available pain reliever. We all need to be more careful about keeping track of the ingredients in the over-the-counter and prescription medicines we take, and in the case of acetaminophen, we need to keep a close eye on our total daily dose.
Learn more:
ABC News article: FDA Group Issues Cautions on Acetaminophen Overdose
FDA report: Recommendations for FDA Interventions to Decrease the Occurrence of Acetaminophen Hepatotoxicity (The report is 286 pages long. I recommend reading the executive summary on the fifth page.)
For the last few years the future of primary care has been looking bleak. Fewer and fewer medical students are choosing primary care careers, just as baby-boomers retire and will need more care. Primary care physicians meanwhile are retiring early or cutting back their practices at record numbers, worsening the coming shortage.
The current issue of the Annals of Internal Medicine publishes a perspective article by Dr. David Norenberg that heaps on the gloom. Describing himself as closer to the end of his career than the beginning, he mourns the end of the golden age of primary care. While he was attracted to the close and prolonged relationship with patients that only primary care can provide, he sees young students turned off by the recent trends in medicine – insurance companies dictating care, reimbursement set by arcane algorithms, and a focus on quantity, not quality.
A recent Medical Economics article (link below) lends credence to Dr. Norenberg’s pessimism. It details the filling of next year’s residency positions by medical school graduates. Yet again, primary care positions have declined as students stampede into subspecialties.
Dr. Norenberg’s observations are right on the mark. Then he proceeds to offer a solution that is sure to fail: a single-payer medical system based on Medicare that pays primary care doctors more. Versions of this general scheme – giving everyone Medicare either as a sole insurer or as a “public option” to private insurance – are being considered as possible overhauls to our healthcare system. Meanwhile, just this month the General Accounting Office announced that Medicare will run out of money by 2017.
The hull of the ship is leaking. Time to board more passengers.
Demanding that insurers (either private or government) pay primary care doctors more will only lead to an internecine fight with specialists over who gets a bigger slice of the pie. We miss the bigger picture that the whole pie will be gone in a decade. We’re fighting over crumbs.
The case that primary care is valuable must be made to patients, not policy makers. Patients will vote with their own dollars and decide for themselves the kind of healthcare they prefer. The insurance model in which we all pay for each other’s care is failing catastrophically, but because of entrenched interests we will stay on that sinking ship until the water is up to our necks.
Eventually, out of the wreckage, patients will build a new system in which they each largely pay for their own care, using insurance only for unforeseen disasters. How long that takes depends on when we notice the water rising. Some of us are already heading for the lifeboats.
Learn more:
Annals of Internal Medicine article: The Demise of Primary Care: A Diatribe From the Trenches
Medical Economics article: “Match Day” delivers another blow to primary care
Financial Times article: Medicare forecast to run out of money in 2017
Previous related posts:
Cancer, Diet, New Study, Prevention
Folic acid, a vitamin found naturally in green leafy vegetables and legumes, is essential for making the building blocks of DNA. And since copying DNA is an important part of what cells do before they divide, it’s critical for cell division. Developing fetuses have very rapidly dividing cells, so it’s not surprising that folic acid deficiency has been linked to birth defects, specifically brain and spinal cord abnormalities.
To prevent these birth defects, physicians for many years have recommended folic acid supplements to pregnant women and women planning pregnancy. The problem is that folic acid deficiency harms babies in the first weeks of pregnancy, before many women know they’re pregnant and before they seek prenatal care. In an effort to end folic acid deficiency more comprehensively, the U.S. began requiring that flour and other grains be fortified with folic acid in 1998. The incidence of brain and spinal cord birth defects subsequently declined.
So if folic acid is good for pregnant women, might it have benefits for everyone else?
Well, unfortunately, no other major benefits have been found to taking folic acid supplements. Folic acid deficiency can cause anemia, but that’s rare and is easily treated (with folic acid!) when diagnosed. Back in the 1940s it was noted that leukemia patients tended to have low folic acid levels. It was hypothesized that folic acid deficiency played a role in leukemia and a trial was done in which leukemia patients were given folic acid. Surprisingly, they died sooner than the patients getting placebo. Their folic acid levels were low because it was being used up in the rapidly dividing leukemia cells; giving them more folic acid helped the leukemia cells divide faster.
Since then folic acid supplementation has been linked with other cancers. Though the findings were not definitive, given the absence of proven benefits (in those of us who are not women in child-bearing age) there is no compelling reason to recommend folic acid for everyone.
This Monday’s LA Times had two very helpful articles which summarized the controversy.
The U.S. Preventive Services Task Force (USPSTF) reviewed the evidence on folic acid and reissued their recommendations this month. The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 micrograms) of folic acid. There is no recommendation for men or for women not in their child-bearing years.
The rest of us should probably just eat our veggies. If you do take a folic acid supplement (and I don’t) make sure it doesn’t contain more than 1 mg (1,000 micrograms) of folic acid.
Thanks to Ron T. for pointing me to the LA Times articles.
Tangential miscellany:
On Memorial Day my partner, Dr. Dorothy Lowe, and some of our staff and I will be riding in the Acura LA Bike Tour. Register to ride with us, or come out to cheer and watch the spectacle of thousands of riders taking to the streets. You don’t have other plans for 5 a.m., do you?
Learn more:
LA Times articles: Folic acid might be losing its sheen and Folic acid is important, but take care not to overdo it
Infectious Diseases, New Study, Prevention
Vaccines have become a victim of their own success. In 1809 Massachusetts became the first state to pass a law requiring a vaccination – of smallpox – ushering a series of public health victories over a number of serious diseases. In the past 200 years smallpox has been eradicated, and measles, polio, rubella and tetanus have become so rare that they have disappeared from public consciousness.
The number of children who contract vaccine-preventable diseases today is tiny compared to the number before the era of vaccines. Before measles vaccination there were 500,000 reported cases of measles annually in the US. In the last few years the average has been 62 per year.
Perhaps because of this spectacular success, parents are now much less aware of the terrible consequences of vaccine-preventable diseases, and some parents are increasingly concerned about the risks of vaccines. Despite the fact that the risks associated with vaccines are extremely small, unfounded rumors and beliefs about these risks continue to circulate. In the last few years increasing numbers of parents are refusing vaccination for their children.
An important article in this week’s New England Journal of Medicine summarized the trends in vaccine refusal, the reasons parents cite for refusal, and the risks of vaccine refusal. The article supports what we already thought we knew. Obviously, unvaccinated children are more likely to contract vaccine-preventable diseases. But more importantly, clusters of unvaccinated children put at risk other children around them. For example, children who cannot be vaccinated because of medical problems depend on the general immunity in their surrounding community to keep them healthy. Children whose parents refuse vaccination put those children who cannot be vaccinated at risk.
Southern California is known for its wonderful heterogeneity of ideas and lifestyles. We think ourselves cool because we drink free range coffee and eat nothing but organic tofu and weave our sandals from post-consumer hemp. But some ideas, besides being false, are also profoundly harmful. While public health officials struggle with crafting policies to make vaccination more ubiquitous, you and I have to make it clear that refusing to vaccinate your kids is just not cool.
Tangential miscellany:
I received many positive responses (and some new readers) from last week’s post about the virus previously known as swine flu. I hope the new readers aren’t bored when I get back to writing about diabetes and cancer screening. Most health topics aren’t as funny as the potential worldwide spread of a new virus!
There is much less buzz (thank goodness) about H1N1 (swine) flu this week, but I thought a brief update would be useful.
Learn more:
New England Journal of Medicine article: Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases
A year ago I wrote about a measles outbreak in unvaccinated kids: U.S. Measles Cases at Highest Numbers Since 2001
My post last week on the virus previously known as swine flu: Swine Flu: Unlikely to End the World