A Country Doctor Writes:

An article in The New York Times sent me once again on a journal reading journey. Opioids Feel Like Love. That’s Why They’re Deadly in Tough Times is behind a paywall, but there are many other articles on the topic of the brain opioid theory of social attachment (BOTSA).

Falling in love involves a euphoria at least partly mediated by brain opioids. The opiate mu receptor also interacts with oxytocin, known to build emotional bonds, and dopamine, involved in reward mechanisms as well as serotonin, involved in feelings of well being. These substances build and strengthen our bonds to loved ones.

But, as with opioid use or abuse, the euphoria doesn’t last forever. It is eventually replaced with a comfortable new sense of normal. If we are then suddenly cut off from those we have bonded with, a chemical withdrawal sets in. And it is in fact partly an opiate withdrawal, albeit not usually as violent as withdrawing from heroin.

“Social pain” and “physical pain” are both mediated, at least in part, via the mu receptor. Opiates have been shown to reduce separation anxiety in puppies and opiate antagonists increase vocalization in separated puppies. Adult rodents chose to self administer opiates more if they were socially isolated.

In humans, addicts on methadone maintenance therapy indicated less anxiety about losing relationships than addicts who were sober without the help of methadone.

When we think of opiates in this context, it clarifies both the history of opiate smoking in ancient times and the rise in opiate addiction in modern times.

I can’t imagine there was a chronic pain epidemic 300 years ago, more significant than the general hardships of life in those times. And, similarly, we now know that individuals who fall victim to opiate addiction are more likely to have childhood trauma and psychiatric symptoms prior to their opiate addiction.

So, even though the term “perfect storm” is hackneyed, our current epidemic of opiate use and abuse certainly were the result of such a constellation of factors. Chronic Pain Syndrome, the presumed physical condition we thought we were treating, is not just one thing. It is a hodgepodge of suffering. And the more we learn about it, the less useful it is to try to sort out what is physical and what is psychological. The lines are not only blurred, they are probably not real at all. And the now discredited belief that pain was a vital sign and opiates would eliminate it was only a pipe dream – incidentally, a term that was coined in the era of opium dens, when people smoked the mother substance in those long, fancy pipes!

I read in the news media that my native Sweden is not restricting personal freedoms the way other countries are. I just recently happened to subscribe to Svenska Dagbladet, one of the big Stockholm newspapers. Here is what they quote historian Lars Trägårdh saying about why:

“First, there is a deeper trust in public institutions in Sweden than in other countries. It is not blind injunctions that make us obedient citizens but faith in expert authorities who in turn trust their citizens. It is a matter of mutual trust.

Therefore, Swedish authorities believe that it is enough to make recommendations such as staying inside if you feel ill and avoid large crowds. “Use your brains“…. Classic Swedish freedom and responsibility in other words. May also be called common knowledge, common sense or sense of duty.

Secondly, the Swedish exception can be explained by the ban on ministerial rule. This is a deeply rooted rule that goes back to the 17th century when the foundation was laid for the Swedish state apparatus. This means that Sweden is governed by expert authorities and not the government. Politicians who want to show muscles in tough times should keep their paws away from apolitical institutions whose decisions are based on skill and expertise.

This is very deeply rooted in Sweden. Elsewhere in the world where they don’t have this strict rule, many politicians now take the opportunity to prove themselves as strong leaders and impose harsh prohibitions especially if it is an election year. “

https://www.svd.se/historiker-coronafester-ger-inga-pluspoang-har

If Covid-19 were a vicious STD spread via toilet seats, you wouldn’t tell everyone to stay away from public places including their worksites for months while the economy contracts and evaporates until there were no more cases. You would just do CLEANING, WIDESPREAD TESTING and TRACE CONTACTS. That’s what South Korea did, AND IT WORKED —— @ACDocWrites on Twitter

As I watch the Covid-19 doomsday scenarios play out in the media, it becomes very clear that our strategy of shutting down life as we know it to stop this communicable disease makes relatively little sense if it is not done alongside aggressive standard epidemiologic practices.

To put it more bluntly: Mere isolation is just plain Medieval.

We know how to do this: We test asymptomatic people for HIV, hepatitis, gonorrhea, syphilis, tuberculosis and many other communicable diseases and in most cases we also deploy public health staff to trace contacts that need testing and followup.

So, why were we in this country so paralyzed, why did we resort to economy-halting measures that will likely wipe out retirement savings, cause widespread layoffs and permanent unemployment, bankruptcies and evictions and general despair like that of the Great Depression?

Now, I’m just a Country Doctor, and I’m not particularly interested in the science of epidemiology, but reading in The New York Times about what South Korea did I am baffled: Why did we not try harder to get more people tested early on?

Every once in a while something in the business literature catches my attention. Last week I found an article in the Harvard Business Review daily newsletter about Job Crafting. I had never heard the term, and I had not paid any attention to the possibility that how we view and approach our career can affect our personality and our morality instead of the other way around.

Business professors Smith and Kouchaki write:

“As originally presented by scholars Amy Wrzesniewski (Yale University) and Jane Dutton (University of Michigan), people can craft their jobs by first altering the way they think about their work (cognitive crafting), second, changing the scope and type of tasks they engage in (task crafting) and, third, changing the nature of their relationships and interactions with others at work (relational crafting). To date, most scholars and practitioners have explored job crafting as a means to make work more meaningful and satisfying, and potentially increase individual performance. But we suggest that you can also engage in job crafting to become your best moral self.”

I don’t often see articles about morality and business, and not often about health care and morality either, for that matter. But last week’s reading gave me reason to think about how our work can elevate us to a higher plane if we view it the right way. We often think that we bring some of our own selves into our work, but we don’t talk nearly enough about how our work shapes us and how we make daily choices in exactly how and in what direction we allow that to happen.

“Whether you view your job as merely a paycheck, as a step up the career ladder, or even as a calling, we encourage you to also approach your job as an avenue for becoming a better person — as a laboratory for refining your character. Doing so will not only help you become virtuous, but it can help others as well. Psychology research on elevation (the moral emotion experienced upon witnessing the virtuous acts of others that leads to a desire to become a better person yourself) suggests that morality can be contagious. Crafting your job in a way that leads to exemplary behaviors might just result in a moral contagion that benefits others in your organization as well. Like a tiny pebble tossed into a vast pond, your simple job crafting efforts might ripple throughout your entire workplace. Try job crafting to make the world a better place — one life at a time, starting with your own.”

I guess we and the journals that cater to us need to claim some of our attention and reading time to consider not just drugs and diseases, patients and third parties but us, the healers, the physicians and other clinicians who are at constant risk of burning out if we don’t see the moral value in and resonate with the moral implications of how we do our work, of our behavior and of our attitudes.

Using a treatment without having any understanding of how it works is often thought of as unscientific and suggesting that a placebo can help a sick patient has until now been viewed as unethical.

The New England Journal of Medicine just published an article about placebo (making you feel better) and nocebo (making you feel worse) effects, two of the most intriguing aspects of the supposedly scientific practice of medicine. These phenomena have long been seen as complicating pharmaceutical research. But today we have a deeper understanding of how placebo and nocebo effects come about, down to the neural pathways. The fact that we understand the mechanisms better has made their use start to gain more legitimacy.

According to the article, placebo effects have been shown to be associated with the release of substances such as endogenous opioids, endocannabinoids, dopamine, oxytocin and vasopressin. We even have some understanding of which substances mediate which type of response. For example, placebo treatment of Parkinson’s disease raise dopamine levels and “increased pain perception through verbal suggestion, a nocebo effect, has been shown to be mediated by the neuropeptide cholecystokinin”.

In my own clinical experience (40 years last summer) and writing, the understanding of the impact of exactly how a treatment option is presented is a recurring observation and theme. See for example “Negative Expectations”, “Patients are the Real Healers”, “Patient Centered and Evidenced Based Medicine – Can We Really Have Both?” and “Getting it Right”.

As the NEJM article points out, many double blind clinical trials of medications for pain and psychiatric disorders show similar effectiveness of placebo and active substance. Another interesting statistic is that up to 19% of adults and 26% of elderly patients report side effects from placebos. The article, in linking placebo and nocebo effects to patients’ relationship with and trust in their physician suggests that a patient who stops a medication may not or not only be doing this because of perceived side effects but perhaps deep down due to mistrust in their physician.

Similarly, “patients with common colds who perceive their clinicians as empathetic report symptoms that are less severe and of shorter duration than those of patients who do not perceive their clinicians as empathetic; patients who perceive their clinicians as empathetic also have reduced levels of objective measures of inflammation such as interleukin-8 and neutrophil counts”.

As we present patients with treatment options, we need to give more thought to the risk-benefit of the traditionally all-important notion of informed consent.

I, for instance, have tended to present statistics in a counterproductive way. Instead of saying 5% of people get a particular side effect, the article hints that maybe we should say that 95% don’t get it while at the same time explaining the potential benefit of the treatment.

The article also suggests describing the severe or significant side effects a medication can cause and then mentioning that other, milder side effects can occur, but because of the nocebo effect, the mere mention of these has been shown to increase the statistical probability that patients may have them. Giving the option of hearing all the non-critical reported side effects has been called “contextualized informed consent” and “authorized concealment”.

I can’t help reflecting on how focused we are in medicine on the subject matter and how little we speak about the delivery of subject information. The business world seems to talk more about how to sell something than how to produce it. I think as physicians or scientists we look down on that, thinking that a cup of coffee is a cup of coffee, so why are all these people devoting their lives to how to sell that cup of coffee?

So we need to get off our high horses and take a look at how we present information about what we “sell”, because what we try and hope to sell may have greater impact on our “customers” future health than which brand of coffee they choose to drink.