Should I be eating more fiber?

High-grade cancer that’s still confined to the prostate is generally treated surgically. But a third of the men who have their cancerous prostates removed will experience a rise in blood levels of prostate-specific antigen (PSA). This is called PSA recurrence. And since detectable PSA could signal the cancer’s return, doctors will often treat it by irradiating the prostate bed, or the area where the gland used to be.

In February, Dr. William U. Shipley and his colleagues at Massachusetts General Hospital reported that radiation is a more effective treatment for PSA recurrence when given in combination with androgen-deprivation therapy (ADT). ADT interferes with the body’s ability to make or use testosterone, which is the hormone (or androgen) that makes prostate tumors grow more aggressively. It targets rogue cancer cells in the body that escape radiation.
Here’s what the study found

The newly published study randomly assigned 760 men with detectable PSA after surgery to one of two groups. One group got radiation plus ADT and the other group got radiation plus a daily placebo tablet. The study recruited patients between 1998 and 2003, and after an average follow-up of 12 years, 5.8% of men in the combined treatment group had died of prostate cancer, compared to 13.4% in the radiation-only group. Rates of metastatic prostate cancer were also lower among men treated with ADT: 14.5% compared to 23% among the placebo-treated controls.

“The take-home message is that ADT has a major and beneficial impact on the risk of death from prostate cancer when added to radiation for PSA recurrence,” said Ian Thompson, M.D., a professor of oncology at the UT School of Medicine, in San Antonio, Texas, and the author of an editorial accompanying the newly published findings.

Men in this study received a high dose of the ADT drug bicalutamide, which doctors use less frequently for PSA recurrence today, instead favoring other testosterone-suppressing medications that have since been shown to be more effective. Therefore this is an instance of a long-term study reporting results after treatment standards — in this case the selection of a specific ADT regime — have changed.
A new treatment standard

Still, some men have difficulty tolerating ADT, and not all of them should get it, particularly if they’re older and more likely to die of something other than prostate cancer. “I’d reserve ADT for younger men with a long life expectancy ahead of them who were diagnosed initially with high-grade or late-stage disease,” Thompson said.

“This important study confirms that combined therapy is superior to radiation alone and should be viewed as the standard treatment for PSA relapse,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “High dose bicalutamide has been associated with cardiovascular side effects, but ongoing and future research is clarifying how best to use ADT in this particular setting.” The prescription retinoid that my dermatologist suggested sounded like a great idea. It was a topical vitamin A-based cream, which has been shown to help reduce fine lines and wrinkles. Now that I’m a middle ager, I thought I’d give it a try. Then I got to the drugstore, and found that the little tube had a huge price: $371! I didn’t want to shell out that much for a mere face cream, so I didn’t fill the prescription.

But my case was only skin-deep. What about people who can’t — or don’t want to — pay for prescription medications to treat chronic or serious illness? “It’s a real problem. Medications only work if people take them, and you can’t take them if you can’t afford them,” says Dr. Joshua Gagne, a pharmacist and epidemiologist with Harvard-affiliated Brigham and Women’s Hospital.

According to a National Center for Health Statistics survey, about 8% of adults in the United States don’t take prescribed medications because they can’t afford them.

Even if cost is not affecting your medication regimen, the following ideas may save you some money.

    Try generics. Generic drugs have the same active ingredients as brand-name medications, but generics are substantially less expensive. For example, the cholesterol-lowering drug Lipitor retails for about $390 for a 30-day supply. The generic version, atorvastatin, is about $10 for a 30-day supply. Always ask your doctor if a generic is available. “If a generic isn’t available, ask if there’s a similar drug with a generic version,” suggests Dr. Gagne.
    Go to a big-box store. Many pharmacies in grocery stores and big-box chains offer hundreds of generic medications for just $4 (for a 30-day supply) or $10 (for a 90-day supply). Ask for the list when you’re at the pharmacy or look it up on the Internet, and bring a copy to your doctor. Don’t be discouraged if your medication isn’t on the list; check a different store. “Different chains have different lists,” says Dr. Gagne.
    Get a bigger dose. Some prescription medications can be divided with a pill splitter. Ask your doctor if that’s the case with your medication, and if it’s possible to get a double dose. For example, you might get 10-milligram (mg) pills that can be split into 5-mg pills. Some medications cannot be split, such as capsules or tablets that are enteric-coated, or those that release medicine over time. “As a general rule, extended-release or slow-release medications should not be split,” says Dr. Gagne. These include drugs like metformin ER (Glucophage XR) for diabetes and pantoprazole (Protonix) for heartburn.
    Get a larger supply. Instead of getting a prescription that lasts for 30 days, and making an insurance copay each time, ask for a 90-day supply so you can make just one copay every three months. This works for medications you take long-term.
    Apply for assistance. There are many kinds of prescription assistance programs, offered by state and local governments, Medicare, nonprofit groups, and even drug makers. The programs typically have income requirements. Nonprofit organizations include: Needy Meds and Partnership for Prescription Assistance. Other resources include state assistance programs and Medicare Extra Help. Another option is to call the manufacturer of your medication directly. You can look up your medication on this Medicare website.
    If you’re on Medicare, consider updating your plan. Medicare plans can change from year to year, including the medications they cover, and the copays and deductible amounts. You have an opportunity to switch Medicare plans during the annual enrollment period from October 15 to December 7. Review the options using Medicare’s personalized plan search on its website.
    Shop around. Medication retail prices vary. Some pharmacies buy directly from drug makers; others use a middleman, which can drive up prices. Call pharmacies in your area to compare prices, or use a computer or smartphone app to do the work for you, such as WeRx or GoodRx. The attorney general’s office in your state may also have a website that provides similar information.

This last strategy is the one that worked for me. My dermatologist directed me to a pharmacy that sold the retinoid cream for less (because of a deal with the drug maker). It wasn’t free by any means, but the price was enough to get me to fill the prescription. Do I look younger yet? Not quite. But thanks to the discount, my wallet is looking a little better. Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn’t happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn’t really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is “of course not!”

Now, let’s shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.
Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, “Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?”

However, I was wrong — dead wrong.
Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can’t inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person’s risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it’s still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: “Vancouver’s safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts.” Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it’s time to change our biases and old ways of thinking — people’s lives depend on it.

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