Daily Archives: 7 May 06

Not All See Video Mockery of Zarqawi as Good Strategy

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“An effort by the American military to discredit the terrorist leader Abu Musab al-Zarqawi by showing video outtakes of him fumbling with a machine gun — suggesting that he lacks real fighting skill — was questioned yesterday by retired and active American military officers.

…The weapon in question is complicated to master, and American soldiers and marines undergo many days of training to achieve the most basic competence with it. Moreover, the weapon in Mr. Zarqawi’s hands was an older variant, which makes its malfunctioning unsurprising. The veterans said Mr. Zarqawi, who had spent his years as a terrorist surrounded by simpler weapons of Soviet design, could hardly have been expected to know how to handle it.” (New York Times )

In a Dentist Shortage, British (Ouch) Do It Themselves

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“Britain’s state-financed dental service, …stretched beyond its limit, no longer serves everyone and no longer even pretends to try.” (New York Times )

And neither, for that matter, does the United States’! None of my MassHealth (the version of Medicaid here) patients have any dental benefits, and it is getting more and more difficult to find even emergency services for them. From time to time, the underlying reason why someone presents to me with a mental health problem such as despondency or suicidality, alcohol or drug abuse (which MassHealth still pays for) is agonizing dental disease. When I can arrange to treat the ‘root cause’ [pun intended], it is only because I have begged and pleaded, calling in a favor from a dentist or dental surgeon colleague. More often, regrettably, the patient leaves the psychiatric service in as much mouth pain as when they came in, my efforts to go beyond merely patching them up to no avail. But I guess that is no different from many of the insoluble socioeconomic problems that are the real foundations of some of the mental illnesses I try to treat.

Addendum: Walker pointed me toward a particularly apt quote from Malcolm Gladwell’s <a href=”http://www.gladwell.com/2005/2005_08_29_a_hazard.html
” title=””>”The Moral Hazard Myth”:

“… People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of “poor parenting, low educational achievement and slow or faulty intellectual development.” They are an outward marker of caste. “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.’ “

The U. S. health-care system, according to “Uninsured in America,” has created a group of people who increasingly look different from others and suffer in ways that others do not…”

10 Reasons Why A Community of Democracies Can’t Be Our Big Foreign Policy Idea

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Suzanne Nossel in The Huffington Post: “This past week I joined a couple of progressive brainstorming sessions discussing the new foreign policy ideas that can help us out of the hole. Oftentimes the question of creating a “Community of Democracies” as a caucus at the UN and a forum for building international consensus is raised. (I’m now on a flight to Asia hoping to post when I arrive and to be asleep before I can put in all the links, but google “community of democracies” and you’ll get the background you need.
Democracy Arsenal’s Mort Halperin and former Secretary of State Madeleine Albright have been championing this idea for a decade or more. Ivo Daalder and others at http://www.tpmcafe.com’s America Abroad have talked about it more recently). While the proposal has merit, it won’t work either politically or policywise as the centerpiece of new progressive thinking, and here’s why…”

Between Addiction and Abstinence

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“Once akin to exorcists, committed to casting out the demons altogether, those who work with addictive behavior of all kinds are now trying less dogmatic approaches — ones that allow for moderate use as a bridge to abstinence.

A government-financed study of alcoholism released last week, the largest to date, suggests how deeply this ‘moderate use’ idea has taken hold. The study found that the treatment produced ‘good clinical outcomes’ in about three-quarters of the almost 1,400 heavy, chronic drinkers in the study. Some quit altogether; most, however, had moderated their drinking — to 14 drinks a week or fewer for men, 11 or fewer for women.

‘The fact is that these moderate measures are becoming more and more accepted in judging treatments,’ said Dr. Edward Nunes, a professor of clinical psychiatry at Columbia University.

Millions of recovering addicts and their families as well as counselors working in the trenches consider this approach to be foolhardy and immoral. Addicts are by definition unable to control or manage their addictions, they say, and leaving an opening for moderate use only encourages the experimentation that can lead to ruin or death.

Cases like that of Mr. Kennedy dramatically illustrate how close to breakdown many addicts live, they say. ‘Implying you can simply cut down does a tremendous disservice to those who have this addiction,’ said Stanley L., a recovering alcoholic in Pennsylvania who still attends group counseling sessions.” (New York Times )

I can’t help thinking that part of the impetus to accept moderation instead of abstinence comes from the growing prominence of pharmacological approaches to addiction which either moderate the desire or reward; or substitute a ‘more benign’ addiction for a more destructive one.

Comfortably Numb?

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Why Do Some Patients Under General Anaesthetic Remain Aware Of What’s Happening? “Around one in 500 people who undergo a general anaesthetic are aware of what’s happening during their operation. On Friday 12 May leading anaesthetists and scientists studying consciousness will meet for the very first time to try to find out why this happens and, crucially, how to prevent it. Recent advances in our understanding of consciousness may help prevent this problem from occurring in the future. ” (Medical News Today)

While the article does not detail what those advances in the understanding of consciousness are, my guess is that they relate to functional brain imaging of conscious mental activity. Nevertheless, I doubt that we will see surgeons obtaining PET scans or fMRIs of patients under general anaesthesia on the operating room gurney anytime soon. Consciousness researchers and surgeons couldn’t be further apart in the medical realm, methinks…

Some procedures are done under ‘conscious sedation,’ either because they are painfree or because they can be done with regional anaesthesia such as a nerve block. In some neurosurgical procedures, it is necessary that the patient be able to carry out actions on command to make sure that the surgeons are not messing about with the wrong parts of the brain.

But to be immobilized, conscious and feeling the pain of the surgical incisions would be the ultimate torture, to my mind. I have never seen or heard an interview with a patient who has been through that, but thinking about it inspires the kind of visceral horror that I imagine motivated those who fought for the abolition of vivisection.

Revia (naltrexone) For Alcoholism

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New study endorses medication’s efficacy. In a complex design in which it was compared with behavioral treatment/counseling and acamprosate, another medication marketed for relapse prevention in alcoholism, the opiate blocker Revia (naltrexone) gets the nod as helpful. I use this medication for this purpose but have always puzzled about various aspects of how it works if it does.

First of all, as an endogenous opiate blocker, it supposedly blocks some of the activity of the internal reward system and thus diminishes the satisfaction connected with alcohol abuse. But why does it not block most satisfaction in the person’s life if that is the case? There is nothing specific about the effects of alcohol on the endogenous reward system; it responds generically to rewards.

Secondly, addictive behaviors pretty quickly pass beyond the stage of being rewarding; most people persist in abusing addictive drugs because they would be sick or in distress if they stopped. How would a reward blocker matter in such a case? I know I am speaking pretty schematically here, but I need to have some conviction I understand how a medication is supposed to work on a neurochemical basis before I will recommend it to my patients. That is partly because I believe that any medication works less well, or not at all, if the user does not have a belief in its effectiveness. In psychiatric treatment, where most classes of medications were discovered serendipitously and explanations derived after the fact, that is a particular problem.

The effects of naltrexone are modest at best; several studies have found that, while as in this study it was better than acamprosate, the combination of the two is far better than either alone in reducing the frequency and severity of alcoholic relapses. And the benefits usually are more robust in more severe alcoholism.