Is Marijuana Use Bad For Your Health?

Over the last few weeks I have had several young patients (and some older patients too) admit freely to smoking marijuana regularly.  When asked if they have considered stopping, they answer “No, why would I stop?”

Ohio has recently legalized medical use of marijuana, and this morning I had some education on the controversy and realities of marijuana use for medical purposes.  It was easier for us doctors when it was illegal, LOL!

Does marijuana have good effects?  Yes, there are therapeutic reasons to use marijuana, which is the basis for legalizing the medical use.  However, it’s important to realize that the medical marijuana law does NOT allow smoking pot.  Legal forms include vaping, edibles, tinctures, oils and patches.

Marijuana helps patients with seizures, anxiety, post-traumatic stress disorder, chronic pain, nausea and vomiting from cancer therapy, fibromyalgia, inflammatory bowel disease, multiple sclerosis, and a host of other medical problems.  Ohio’s medical marijuana program should be deployed later this year (there have been logistical problems).

Doctors have to undergo education before they can be certified to recommend medical marijuana.  Marijuana can NOT be prescribed – it is a schedule I narcotic and if doctors prescribe it they will lose their DEA certification.  Doctors who are certified to recommend medical marijuana use can sponsor patients to get a card which will allow them to buy marijuana at a dispensary.

We have been informed that our medical malpractice insurance carrier will not cover us if we recommend marijuana.  All three large health systems in Cleveland and most (if not all) of the health systems in Ohio are in the same situation.  There are almost 300 physicians in Ohio (as of today) who do have certificates to recommend.  You can find the up-to-date list at this link.

What are the health risks if you do choose to use marijuana?  Smoking a joint increases the heart rate and slows coordination, interferes with thinking and remembering and increases appetite.  States with legal recreational marijuana use have recorded an increase in car accidents attributable to people driving while stoned.  I’ve seen a number of young women who smoke marijuana regularly and complain about weight gain.  (Go figure!)

Marijuana IS addictive.  It is the most commonly used drug of abuse in the United States.  Research has shown that 9% adult habitual users of marijuana  and 17% of teenage users will become addicted.  Signs of addiction include inability to stop using marijuana, continued use in spite of negative social and health consequences and difficulty maintaining relationships with others that don’t smoke pot.

Marijuana causes changes in the brain, specifically in areas related to learning and memory.  It’s worse when teenagers smoke pot, because their brains are still developing.  Pregnant women who use marijuana have children with higher rates of attention, learning and behavior problems.  Secondhand marijuana smoke also contains THC so parents who smoke pot around their children are exposing them to an addictive substance that affects their growth and development.

While it’s not proven that marijuana use causes lung cancer, it definitely causes problems with the lungs, including cough and phlegm production and an increased risk of bronchitis.  Also, most people who use marijuana also smoke tobacco, with all the risks tobacco smoking brings.

Even though use of small amounts of marijuana (the equivalent of one or two “hits” on a marijuana cigarette) can alleviate anxiety, using more actually can worsen anxiety.  Marijuana users are also much more likely to develop mental disorders like schizophrenia.  Teens in particular are more likely to have depression, anxiety and suicidal thoughts if they smoke pot.  It’s not clear whether this is a causative relationship (i.e. do they smoke pot because they’re depressed and anxious, or the other way around).

There is also a risk of poisoning with edible marijuana products.  Absorption through the GI tract is unpredictable and it can take 30 minutes to 2 hours to take effect.  It is easy to over-indulge if it takes that long for the drug to make itself felt.  Also, children can easily overdose if they get into marijuana edibles.  In states where marijuana is legal, ER visits for accidental overdoses in children have gone up significantly.

Marijuana use is on the rise.  Both adults and teens are using marijuana and have the mistaken impression that because it has been legalized for recreational and medicinal use that means it is safe.  Marijuana use is NOT safe, it has real and significant health and social consequences.

QUESTION: Do you think marijuana use should be legal?  Why or why not?

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Statins And Diabetes Risk

I’m an integrative physician.  I get a LOT of people coming to see me thinking that I will tell them they don’t need to take meds for this or that problem.  One of the most common is statins.  Recently more and more people have been concerned about the link between statins and diabetes risk.

Statins are drugs that are prescribed to lower cholesterol and prevent heart attacks and strokes.  It is very clear that they are effective in reducing the risk of a second heart attacks in people who have already had one.  However, many doctors prescribe them regularly for those who have no evidence of an increased heart disease risk.

Statins are generally very safe, but more recently there has been a growing awareness that they are linked to an increased risk of type 2 diabetes.  They also seem to make blood sugar control a little bit worse in some people who already have diabetes.

So what is the actual risk?  Before people flatly refuse to discuss them (or doctors blindly prescribe them) we should know the risks we are talking about.  I have been using an evidence-based medicine website called thennt.com to review treatments.  NNT refers to Number Needed to Treat.  How many people do we have to treat to benefit one patient?  Conversely NNH is Number Needed to Harm.  How many people do we have to treat to HURT one patient?

Low Cardiovascular Risk

Patients who have less than a 20% risk of a heart attack over the next 10 years did not seem to benefit from taking a statin.  It did not prevent overall deaths, and the NNT for preventing nonfatal heart attacks was 217 (313 for nonfatal stroke)

On the other hand, one in 204 patients treated with statins in the low-risk group developed diabetes, and one in 21 developed muscle pain bad enough they had to stop or switch medications.

High Cardiovascular Risk

Patients who already have had a heart attack or who have documented coronary heart disease are another story altogether.  These patients are usually treated with higher doses of statins (the highest available or highest tolerable dose, typically).

Over 5 years, one in 83 high-risk patients avoided a fatal cardiovascular event due to taking statin drugs.  One in 39 avoided a nonfatal heart attack, and one in 125 avoided a nonfatal stroke.  For those who have had a heart attack or stroke or have known heart disease, statins are lifesaving drugs.

On the other hand, because of the higher doses involved, they also have more risks.  One in 10 had significant muscle pain.  One in 50 developed diabetes (that they wouldn’t have developed if they hadn’t taken the drug).

So one in 50 developed diabetes, but one in 83 DIDN’T DIE from a cardiovascular death, due to taking a statin.  Having diabetes is NOT a fate worse than death.

Other options?

What else can we do for preventing heart attacks, instead of taking statins?  As I tell everyone, CHANGE YOUR DIET!  In fact, diet is MORE effective than statin drugs for preventing some cardiovascular events.

The Mediterranean diet (about which there are gazillions of websites, books, cookbooks, how-to’s, etc.) is effective for preventing death and cardiovascular events.  One in 61 patients avoided death or a nonfatal heart attack or stroke by following the Mediterranean diet.

In short, statins are effective in those who are at high risk of cardiovascular events, but not in those who are at lower risk.  There is a link between treatment with statins and diabetes risk.  However, in high risk patients the benefit (reducing death and nonfatal cardiovascular events) seems to outweigh the risk (diabetes and muscle pain).  In all patients, diet and lifestyle change is an integral part of cardiovascular risk reduction.

QUESTION: Do you take a statin?  Does this information make you more or less anxious about it?

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Plantar Fasciitis – Oh My Aching Heel!

I have been in pain for weeks.  Possibly for months.  I don’t recall when the pain started, it’s been so long.  The pain in the bottom of my left heel has ranged from a twinge to severe enough to make me limp badly.  I have plantar fasciitis.

Credit: drmoy.com

What is plantar fasciitis?

Plantar fasciitis is a mechanical problem that happens where the plantar fascia attaches to the front of the heel bone.  The plantar fascia is a tough band of tissue that supports the arch of the foot and acts as a shock absorber when we walk.  It runs from the ball of the foot to the front of the heel bone.

When the mechanics of the foot don’t work right, that attachment place gets inflamed and painful.  Typically the pain is worst first thing in the morning.  In fact if someone tells me their foot hurts on the bottom and the first step out of bed in the morning is the worst pain they feel all day, I know it’s plantar fasciitis.  Nothing else does that!

What causes plantar fasciitis?

The most common cause of plantar fasciitis is wearing the wrong shoes.  Flip-flops and other shoes with no arch support are the most common cause.  I bought some super cute Converse sneakers some months ago, and I think that’s when the pain started.  Tight calf muscles and Achilles tendons also contribute to the mechanical problems that start and maintain the problem.

What can be done about plantar fasciitis?

The first thing is to start wearing proper footwear.  If you have a high arch (like me) you are especially prone to this problem and should be very careful to wear supportive shoes.  Several people have advised me to never go barefoot, even in the house, especially on wood or tile floors.  I’m working on that!  It’s hard for me to wear shoes in the house, and most house slippers have no arch support.

Aggressive calf stretching is important to keep the calf muscles and Achilles tendons loose and limber.  My personal favorite stretch is to stand on the edge of a stair step on the balls of my feet and let my body weight pull me down into my heels.  Be sure to do calf stretches both with the knee straight and with the knee bent.  There are two big strong muscles in the calf and to stretch them both you need to stretch both ways.

Another measure to help heal the pain is ice.  Ice, ice, ice, and then when you’re done  ice some more.  A frozen water bottle is a good way to both stretch and massage the bottom of the foot while applying cold therapy.

What if it doesn’t work?

If I have a patient that comes in with persistent pain in spite of doing all the above simple things, it is usually time for a cortisone injection.  I haven’t done that yet, because I’m chicken, LOL!  It might be time for it soon, though.

In extremely resistant cases patients usually need to see the podiatrist (foot doctor).  Splinting, injections, massage, physical therapy, and sometimes even surgery may be needed.

Trust me when I tell you, good supportive quality shoes are definitely worth the expense!  It’s an investment in good pain-free foot health!

QUESTION: Have you ever had plantar fasciitis?  What did it take to get rid of it?

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Wound Healing And Nutrition

One of the most devastating complications of diabetes is chronic nonhealing foot wounds.  I’ve had many patients in the hospital for chronic wounds that become infected.  Unfortunately many of them are unable to heal their wounds and wind up with partial or complete amputations of their foot and lower leg.

Diabetics and other chronically ill older patients often have diets that aren’t healthy.  They don’t get enough healthy fats, protein and micronutrients from the food they eat.  These problems contribute to ill health and complications like poor wound healing.

Vitamin deficiencies are more common in older adults, especially those who don’t have a varied, healthy diet.  Inadequate intake, decreased absorption and use of medications  are among the causes of nutrient deficiencies.  Protein, vitamin D, folic acid, vitamin B12 and water are examples of nutrients that older adults may not get in adequate amounts.

In the case of diabetics, elevated levels of blood sugar over time result in the formation of advanced glycation end products (AGEs) which damage proteins and increase levels of inflammation in the cells and tissues.  This is one of the main ways diabetes contributes to end organ damage in just about every organ in the body.  AGEs are thought to contribute to a number of diseases, from Alzheimer’s disease to end stage kidney failure to cataracts to atherosclerotic cardiovascular disease.

If someone develops a chronic wound, what nutrients are needed to help in healing?  Protein, carbohydrate, fat, vitamins and minerals are all needed.  The best sources of these nutrients come from a healthy balanced diet of course.  However, studies have shown that 95% of Americans are not getting enough of one or more vitamins or minerals in their diet.  Especially if someone is trying to heal a wound, getting enough nutrients is critical and the patient likely will benefit from a supplement.

Protein

People who are sick or have a wound to heal need extra protein.  Estimates are that such people need about 1.5 grams per kilogram of body weight.  So a woman who weighs 70 kg (155 pounds) would need about 105 grams of protein per day.  One ounce of animal flesh (beef, poultry, pork or fish), one cup of dairy milk or one ounce of cheese contains about 8 grams protein.  One egg contains 6 grams, 8 ounces of Greek yogurt contains 23 grams, one cup of navy beans contains 20 grams and 4 ounces of tofu contain 16 grams of protein.

Fat

Getting extra fat in the diet helps provide energy and calories for healing and also provides building blocks for making new cells.  Omega 3 fats help mute inflammation and encourage healing, and omega 6 fats balance things out.  Fish oil has been shown to be helpful in patients with pressure ulcers in the ICU setting.

Carbohydrates

Complex carbohydrates provide fiber which feeds the healthy bacteria in the gut, as well as calories for energy.  Our gut bacteria help support a healthy immune system.  Healing wounds and getting well is hard work!  Depends on how malnourished someone is (and how sick they are) a patient may need up to 40 calories per kilogram of body weight.  That 70-kilogram woman above would need up to 2800 calories per day, plus more if she is doing more than just lying in bed.

It’s important that these carbohydrates should be whole-food complex carbohydrates like fresh fruits and vegetables, beans and whole grains like oatmeal.  Refined carbohydrates like white bread, bagels, bakery and the like are NOT helpful and increase the production of AGEs.

Vitamins and Minerals

Vitamin A, vitamin C, vitamin D, zinc, selenium and antioxidants have been investigated as being helpful in wound healing.  While supplementation with high doses of single nutrients has not been shown to help, using a good quality well-balanced multivitamin is smart.  After all, if only 5% of Americans get all the nutrients they need from their diet, who doesn’t need a multivitamin?  And if deficiencies slow down wound healing, those with slow-healing wounds would benefit even more!

Unfortunately many Americans are badly malnourished.  Those with very low or very high body mass index (BMI) are most at risk of significant malnutrition.

How do you know if someone is malnourished?  They may or may not lose a lot of weight, especially if they were obese to start with.  Low blood albumin levels are a clue, as is swelling (edema).  The edema may be mostly in the legs, but the arms and abdomen may be puffy and swollen too.  They are weak, and there may be a big change in their strength and ability to take care of themselves.

People who are malnourished will have loss of muscle and fat tissue.  A good place to look is at the temples.  If the temples look bony and it’s easy to feel the skull bones and see the bones of the eye sockets, it is suggestive of malnutrition.

If you know anyone with a chronic wound, especially if they are diabetic, encourage them to see their doctor and work hard to get their blood sugar under control.  Good blood sugar control slows the production of AGEs and decreases inflammation.

Also, make sure they are getting plenty of protein and taking a high-quality multivitamin.  Antioxidants and fish oil may be helpful as well.  If your doctor isn’t able to make recommendations about specific supplements, you’re welcome to reach out to me or get a quick assessment at jenniferwurstmd.com/healthprint.

Chronic wounds are tough to heal.  In addition to careful wound care and avoiding pressure on the wound, attention to a healthy diet and smart supplementation are practical steps you can take to speed up the healing process.

QUESTION: Have you known anyone with a chronic wound?  What did it take to heal it?

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What Is Pneumonia Anyway?

Angela is an older woman who unfortunately several years ago was diagnosed with multiple sclerosis.  She suddenly became weaker and was having trouble walking, shortly after developing some cold symptoms and a cough.  When she went to the ER, she was found on Xray to have evidence of pneumonia.

I’ve had two patients in the office this week with pneumonia and found myself having to explain exactly what that meant.  We’ve got tons of folks right now with cough and respiratory congestion, and the majority don’t have pneumonia.  What IS pneumonia, anyway?

Parts Of The Lung

To help you understand what pneumonia is and why it is so dangerous, we have to start with knowing the different parts of the lung and how they work.  When you take a deep breath, the air goes into your nose or mouth, down your throat, between the vocal folds (or vocal cords) and into the trachea.  This is an enormous airway that you can feel below the Adam’s apple in the front of your neck just below the skin.  It’s got ridges because of rings of cartilage that make sure the trachea stays wide open.

From the trachea, the airway divides into left and right main stem bronchi, the main airways leading to the left and right lungs.  The bronchi divide into smaller and smaller airways like the branches of a tree until they reach the alveoli.  Here is a really excellent diagram I found on WebMD (they own the copyright, so kudos to them!) that you can use to visualize these different parts.

Credit: WebMD.com

Where’s The Infection?

Different lower respiratory infections affect different parts of the lung.  (Lung infections are called lower respiratory infections, as opposed to colds, sinus infections, ear infections and strep throat which are upper respiratory infections.)

Croup, or tracheobronchitis, affects the largest airways, the trachea and mainstem bronchi.  It causes a very hoarse voice, horrible sore throat, dry painful “barking” cough and fever.  In children with small airways it can cause a high-pitched noise called stridor when they breathe.  Usually the symptoms are worst at night, especially in children.  Croup is so scary!  My son had it twice when he was small, and we were in the ER both times.  I’m a doctor, I KNEW what it was, and it was still scary!

Bronchitis is very common, and is usually caused by a cold virus.  This affects the bronchi inside the lungs themselves and causes a “rumbling” sound called rhonchi when breathing, a (usually) moist productive cough and can have associated cold symptoms like runny nose and congestion.

Bronchiolitis is a specific form of bronchitis that attacks the very smallest airways right before the alveoli.  Its most common cause is a virus called respiratory syncytial virus (RSV) that can be very dangerous for small babies.  For older children and adults it causes a cold or bronchitis, but small babies can get very sick and need hospitalization with wheezing and trouble breathing with this illness.

Pneumonia is an infection in the alveoli.  The alveoli are the sacs where carbon dioxide is released and oxygen is absorbed by the blood.  The are extremely delicate and can be badly damaged and scarred by infection.  We can often see evidence of pneumonia on Xray because larger areas of the lung can be infected.

Credit: www.med-ed.virginia.edu

What Is Pneumonia?

Symptoms of pneumonia include cough, chest pain with breathing, fever, shortness of breath and generally feeling unwell.

If the part of the lung that exchanges carbon dioxide and oxygen is full of pus and not functioning, the body can have trouble getting enough oxygen.  This can be very dangerous, especially in people who don’t have good lung function to start with (like asthmatics and people with COPD), those whose immune systems aren’t normal (like Angela with her MS, or like my diabetic patients) and those who are very young or very old.

Pneumonia is the number-8 leading cause of death in the US (with influenza).  Preventing pneumonia starts with good handwashing and includes staying generally as healthy as one possibly can.  Getting plenty of rest, eating healthy and taking a good quality multivitamin, exercising and managing your stress are integral to maintaining a strong immune system.  Vaccination against influenza and Streptococcus pneumoniae (the cause of the most dangerous form of pneumonia) decrease your risk as well.

We haven’t even started in to cold and flu season and I’m already seeing cases of pneumonia.  With the Farmer’s Almanac forecasting a long, cold, snowy winter we’d better start now to reduce our risk of pneumonia this season.

QUESTION: Have you had pneumonia?

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