What Matters

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Mild TD is defined as passage of one or two unformed stools in 24 hours without nausea, vomiting, abdominal pain, fever, or blood in stools. What is the evidence for the effectiveness of antibiotics, compared with other interventions such as loperamide, for mild TD?

Tinja Lääveri, MD, of the University of Helsinki, and colleagues conducted a systematic review on the efficacy and safety of loperamide for TD (Travel Med Infect Dis. 2016 Jul-Aug;14[4]:299-312). Fifteen articles were retrieved.

Loperamide was observed to be noninferior to antibiotics for the treatment of TD. In one study, loperamide was observed to be superior to bismuth, which is commonly recommended to prevent TD. Adverse events with loperamide occurred predominantly among patients with bloody diarrhea.

The authors remind us that loperamide is different from antimotility agents such as diphenoxylate with atropine, as loperamide has an antisecretory effect at lower doses and decreases motility only at higher doses.

If you subscribe to the idea that diarrhea helps rid the body of toxins, be reminded that secretory diarrhea is exploited by the organism to spread the infestation to as many humans as possible.

The recommended regimen for loperamide is a 4-mg loading dose, followed by 2 mg after every episode of diarrhea. Tell your patients not to use loperamide if they are having fever or bloody diarrhea, or if you suspect they could have C. difficile colitis (that is, recent antibiotics or other risk factors).

Happy travels.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

The Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain released in March 2016 suggests that if “patients are found to be receiving high total daily dosages of opioids, clinicians should discuss their safety concerns with the patient [and] consider tapering to a safer dosage...”

All of us who prescribe opioids have had these discussions with patients. They are frequently fraught with hand-wringing and, all-too-often, a “steeling” for battle. We may have a general sense for what these discussions are like from the provider perspective, but what are they like for patients?

Joseph W. Frank, MD, MPH, and his colleagues conducted in-person, semi-structured interviews of 24 adult primary care patients to assess patient perspectives on opioid tapering (Pain Med. 2016 Oct;17(10):1838-47). Patients were selected if they were: 1) currently on opioid medications without tapering; 2) currently tapering chronic opioid therapy (6 months or greater); and 3) discontinued chronic opioids therapy within the past 3 years.

Interestingly, patients had an overall low self-perceived risk of opioid overdose. Patients attributed reports of overdose to intent or risky behaviors. Patients rated the importance of treatment of current pain higher than the future potential risk of opioid use and had little faith in nonopioid pain management strategies. Patients reported fear of opioid withdrawal. They also reported the importance of social support and a healthy, trusting relationship with their provider for the facilitation of tapering. None of the patients reported switching providers who had recommended tapering. Patients who had tapered off opioids reported improved quality of life and a level of pain that was largely unchanged.

This work provides critical insight into the fears and reservations of patients facing the prospect of life on lower doses of opioids or life without them altogether. Addressing these fears directly may facilitate the discussions with patients when discussing the tapering of opioids.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

The Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain released in March 2016 suggests that if “patients are found to be receiving high total daily dosages of opioids, clinicians should discuss their safety concerns with the patient [and] consider tapering to a safer dosage...”

All of us who prescribe opioids have had these discussions with patients. They are frequently fraught with hand-wringing and, all-too-often, a “steeling” for battle. We may have a general sense for what these discussions are like from the provider perspective, but what are they like for patients?

Joseph W. Frank, MD, MPH, and his colleagues conducted in-person, semi-structured interviews of 24 adult primary care patients to assess patient perspectives on opioid tapering (Pain Med. 2016 Oct;17(10):1838-47). Patients were selected if they were: 1) currently on opioid medications without tapering; 2) currently tapering chronic opioid therapy (6 months or greater); and 3) discontinued chronic opioids therapy within the past 3 years.

Interestingly, patients had an overall low self-perceived risk of opioid overdose. Patients attributed reports of overdose to intent or risky behaviors. Patients rated the importance of treatment of current pain higher than the future potential risk of opioid use and had little faith in nonopioid pain management strategies. Patients reported fear of opioid withdrawal. They also reported the importance of social support and a healthy, trusting relationship with their provider for the facilitation of tapering. None of the patients reported switching providers who had recommended tapering. Patients who had tapered off opioids reported improved quality of life and a level of pain that was largely unchanged.

This work provides critical insight into the fears and reservations of patients facing the prospect of life on lower doses of opioids or life without them altogether. Addressing these fears directly may facilitate the discussions with patients when discussing the tapering of opioids.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

The Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain released in March 2016 suggests that if “patients are found to be receiving high total daily dosages of opioids, clinicians should discuss their safety concerns with the patient [and] consider tapering to a safer dosage...”

All of us who prescribe opioids have had these discussions with patients. They are frequently fraught with hand-wringing and, all-too-often, a “steeling” for battle. We may have a general sense for what these discussions are like from the provider perspective, but what are they like for patients?

Joseph W. Frank, MD, MPH, and his colleagues conducted in-person, semi-structured interviews of 24 adult primary care patients to assess patient perspectives on opioid tapering (Pain Med. 2016 Oct;17(10):1838-47). Patients were selected if they were: 1) currently on opioid medications without tapering; 2) currently tapering chronic opioid therapy (6 months or greater); and 3) discontinued chronic opioids therapy within the past 3 years.

Interestingly, patients had an overall low self-perceived risk of opioid overdose. Patients attributed reports of overdose to intent or risky behaviors. Patients rated the importance of treatment of current pain higher than the future potential risk of opioid use and had little faith in nonopioid pain management strategies. Patients reported fear of opioid withdrawal. They also reported the importance of social support and a healthy, trusting relationship with their provider for the facilitation of tapering. None of the patients reported switching providers who had recommended tapering. Patients who had tapered off opioids reported improved quality of life and a level of pain that was largely unchanged.

This work provides critical insight into the fears and reservations of patients facing the prospect of life on lower doses of opioids or life without them altogether. Addressing these fears directly may facilitate the discussions with patients when discussing the tapering of opioids.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.

Dysmenorrhea can be partially explained by increased prostaglandin production resulting in increased uterine contractions and cramping pain. While NSAIDs are believed to exert their therapeutic benefit by reducing prostaglandin production through Cyclooxygenase-2 inhibition, some of my patients either prefer not to or cannot take standard therapies (NSAIDs or hormonal therapy) and still struggle with symptoms.

The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.

James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).

It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.

Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).

I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.

For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.

Dysmenorrhea can be partially explained by increased prostaglandin production resulting in increased uterine contractions and cramping pain. While NSAIDs are believed to exert their therapeutic benefit by reducing prostaglandin production through Cyclooxygenase-2 inhibition, some of my patients either prefer not to or cannot take standard therapies (NSAIDs or hormonal therapy) and still struggle with symptoms.

The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.

James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).

It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.

Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).

I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.

For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

Up to 90% of reproductive women around the world describe experiencing painful menstrual periods (dysmenorrhea) at some point. Younger women struggle more than older women. Dysmenorrhea can lead to absenteeism and presenteeism to the tune of about $2 billion annually.

Dysmenorrhea can be partially explained by increased prostaglandin production resulting in increased uterine contractions and cramping pain. While NSAIDs are believed to exert their therapeutic benefit by reducing prostaglandin production through Cyclooxygenase-2 inhibition, some of my patients either prefer not to or cannot take standard therapies (NSAIDs or hormonal therapy) and still struggle with symptoms.

The next step was to find an alternate treatment method. Ginger root is used throughout the world as a seasoning, spice, and medicine. Ginger has been shown to inhibit COX-2 and has been studied for its potential role in reducing pain and inflammation. As a result, ginger may have a role in the treatment of dysmenorrhea.

James W. Daily, PhD, conducted a systematic review of the literature on the efficacy of ginger for treating primary dysmenorrhea (Pain Med. 2015 Dec;16[12]:2243-55).

It included all randomized trials investigating the effect of ginger powder on younger women. Included studies evaluated ginger efficacy on individuals aged 13-30 years. Most included studies excluded women with irregular menstrual cycles and individuals using hormonal medications, oral or intrauterine contraceptives, or a pregnancy history. Dosing was 750-2,000 mg ginger powder capsules per day for the first 3 days of the menstrual cycle.

Four studies were included in the meta-analysis, which suggested that ginger powder given during the first 3-4 days of the menstrual cycle was associated with significant reduction in the pain visual analog scale (risk ratio, –1.85; 95% confidence interval: –2.87 to –0.84; P = .0003).

I am not a consistent proponent of alternative therapies but mostly because it is difficult for me to keep up on the evidence for these treatment options. In this case, my bias is that individuals in this age group are much more willing to engage with alternative therapies and offering them may build trust.

For these patients, offering ginger powder may engage patients in self-help and help them appreciate you as a clinician willing to embrace alternative therapies. The hard part is recommending a brand that you know and trust, complicated by the lack of oversight and quality control for over-the-counter, nontraditional therapies.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn. and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.

But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.

So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?

Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).

Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.

Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.

Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.

But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.

So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?

Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).

Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.

Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.

Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.

But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.

So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?

Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).

Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.

Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.

Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
 

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.

Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.

So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?

Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.

Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.

In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.

For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.

Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.

So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?

Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.

Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.

In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.

For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Acne is the most common skin condition, affecting up to 50 million individuals annually. Self-esteem is affected, and scarring can result if left untreated or inadequately treated. Although still somewhat controversial in some circles, available data have linked acne to dairy products, refined sugar ingestion, and high glycemic loads.

Acne has been linked to insulin levels and insulin-like growth factor (IGF-1). Glycemic loads are associated with both insulin and IGF-1. Metformin reduces glucose release from the liver while increasing glucose uptake in muscles and adipocytes.

So, can interventions that reduce glycemic load, such as diet and metformin, decrease the incidence of acne in patients among whom other standard interventions have been tried?

Gabriella Fabbrocini, MD, of the University of Naples, Italy, and her colleagues tested this hypothesis by conducting a randomized, clinical trial evaluating the impact of a low glycemic diet and metformin on acne (Clin Exp Dermatol. 2016 Jan;41[1]:38-42). Twenty males aged 17-24 years with acne for at least 1 year were randomized to either metformin 500 mg twice daily with a 1,500- to 2,000-kcal diet rich in fruits, vegetables, fish, and low carbohydrates with standard therapy; or standard therapy alone. Standard therapy consisted of a bland skin detergent and a sebostatic cream. Acne severity was rated by four observers.

Patients in the metformin group demonstrated a statistically significant improvement in acne severity, compared with patients in the standard care only group. No side effects were reported with metformin.

In this study, only patients with an “altered metabolic profile” were enrolled and randomized. An “altered metabolic profile” was defined as impaired fasting glucose, high total cholesterol or LDL, reduced HDL, and elevated waist circumference and body mass index. Results should be generalizable only to patients with these characteristics. The sample size in this study was small, but the included picture of acne resolution on one subject was indeed impressive.

For patients among whom traditional acne treatment approaches have not been effective, and knowing the tolerability and affordability of metformin, this may be a reasonable intervention.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

This is why the idea of intermittent energy restriction (IER) seems so appealing. IER is defined by periods of fasting alternating with periods of no or minimal dietary intervention. In other words, no calorie counting during the nonfasting times.

But is it effective for weight loss?

C.S. Davis of Monash University, Melbourne, and colleagues conducted a systematic review of IER for weight loss (Eur J Clin Nutr. 2016 Mar;70[3]:292-9). The authors searched for articles evaluating the IER for weight loss among overweight and obese adults aged 18 years or older. IER was defined as periods of low energy intake (fast) alternating with periods of normal food intake (feed).

Eight studies were included in this review. Included studies defined low energy intake as 25%-50% of daily energy, or 400-1,400 kcal/day. The feed period was defined as either eating ad libitum or no less than 1,400 kcal/day. Studies varied in their approach and ranged from 2-4 consecutive fast days per week, followed by consecutive feed days, to three cycles of 5 weeks of fasting, followed by 5 weeks of ad lib eating.

IER was associated with 0.2-0.8 kg of weight loss per week. IER was associated with weight loss comparable to daily energy restriction (DER; that is, a typical diet). IER was comparable to typical daily energy restriction diets for fat mass, free-fat mass, and waist circumference.

The authors state that the amount of weight loss achieved with IER for a 100-kg individual would be associated with a 5% reduction in weight over a 5-week to 6-month time period. A 5% reduction is associated with a clinically significant reduction in health risk.

However, the authors found that fewer study participants planned to stick with IER beyond 6 months, compared with DER. Perhaps despite the difficulty that may exist in counting calories every day, the habit of doing the counting every day may be easier than doing it on an intermittent basis.

Regardless, IER is an option that may be beneficial to some patients. If other things haven’t worked for your patients, it is definitely worth a try.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

This is why the idea of intermittent energy restriction (IER) seems so appealing. IER is defined by periods of fasting alternating with periods of no or minimal dietary intervention. In other words, no calorie counting during the nonfasting times.

But is it effective for weight loss?

C.S. Davis of Monash University, Melbourne, and colleagues conducted a systematic review of IER for weight loss (Eur J Clin Nutr. 2016 Mar;70[3]:292-9). The authors searched for articles evaluating the IER for weight loss among overweight and obese adults aged 18 years or older. IER was defined as periods of low energy intake (fast) alternating with periods of normal food intake (feed).

Eight studies were included in this review. Included studies defined low energy intake as 25%-50% of daily energy, or 400-1,400 kcal/day. The feed period was defined as either eating ad libitum or no less than 1,400 kcal/day. Studies varied in their approach and ranged from 2-4 consecutive fast days per week, followed by consecutive feed days, to three cycles of 5 weeks of fasting, followed by 5 weeks of ad lib eating.

IER was associated with 0.2-0.8 kg of weight loss per week. IER was associated with weight loss comparable to daily energy restriction (DER; that is, a typical diet). IER was comparable to typical daily energy restriction diets for fat mass, free-fat mass, and waist circumference.

The authors state that the amount of weight loss achieved with IER for a 100-kg individual would be associated with a 5% reduction in weight over a 5-week to 6-month time period. A 5% reduction is associated with a clinically significant reduction in health risk.

However, the authors found that fewer study participants planned to stick with IER beyond 6 months, compared with DER. Perhaps despite the difficulty that may exist in counting calories every day, the habit of doing the counting every day may be easier than doing it on an intermittent basis.

Regardless, IER is an option that may be beneficial to some patients. If other things haven’t worked for your patients, it is definitely worth a try.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

My patients find it extremely difficult to determine the number of calories they consume on a daily basis. This activity can be laborious and time consuming, even when you have the right “app.”

So, when I tell my overweight and obese patients to restrict their caloric consumption to lose weight, the discussion usually begins with, “I know this might be difficult, but …” And it usually ends with me feeling a little less than anemic optimism.

This is why the idea of intermittent energy restriction (IER) seems so appealing. IER is defined by periods of fasting alternating with periods of no or minimal dietary intervention. In other words, no calorie counting during the nonfasting times.

But is it effective for weight loss?

C.S. Davis of Monash University, Melbourne, and colleagues conducted a systematic review of IER for weight loss (Eur J Clin Nutr. 2016 Mar;70[3]:292-9). The authors searched for articles evaluating the IER for weight loss among overweight and obese adults aged 18 years or older. IER was defined as periods of low energy intake (fast) alternating with periods of normal food intake (feed).

Eight studies were included in this review. Included studies defined low energy intake as 25%-50% of daily energy, or 400-1,400 kcal/day. The feed period was defined as either eating ad libitum or no less than 1,400 kcal/day. Studies varied in their approach and ranged from 2-4 consecutive fast days per week, followed by consecutive feed days, to three cycles of 5 weeks of fasting, followed by 5 weeks of ad lib eating.

IER was associated with 0.2-0.8 kg of weight loss per week. IER was associated with weight loss comparable to daily energy restriction (DER; that is, a typical diet). IER was comparable to typical daily energy restriction diets for fat mass, free-fat mass, and waist circumference.

The authors state that the amount of weight loss achieved with IER for a 100-kg individual would be associated with a 5% reduction in weight over a 5-week to 6-month time period. A 5% reduction is associated with a clinically significant reduction in health risk.

However, the authors found that fewer study participants planned to stick with IER beyond 6 months, compared with DER. Perhaps despite the difficulty that may exist in counting calories every day, the habit of doing the counting every day may be easier than doing it on an intermittent basis.

Regardless, IER is an option that may be beneficial to some patients. If other things haven’t worked for your patients, it is definitely worth a try.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

About three-quarters of current cigarette smokers want to quit, 40% will attempt to quit annually, and 90% of self-initiated attempts will be unsuccessful. Mean weight gain after smoking cessation may be as much as 13 pounds at 1 year, and 21 pounds over 5 years.

Population data suggest that more than one-half of women and one-third of men with a previous attempt to quit smoking report that weight gain was one of the primary reasons for relapse back to smoking.

Developing effective approaches to the prevention of post-cessation weight gain (PCWG) may increase the likelihood of sustained smoking abstinence and may engage “weight-concerned smokers” in the quitting process. Bupropion SR has the greatest effect for preventing PCWG, but nicotine replacement therapies may have an effect as well while they are being used. Varenicline has no effect on PCWG.

Lorcaserin is a 5-HT_2c (serotonin) receptor agonist FDA-approved for weight loss. Varenicline is the most effective monotherapy for smoking cessation and targets the alpha-4 beta-2 nicotinic acetylcholine receptor.

Ryan Hurt, MD, and his colleagues recently completed a pilot clinical trial evaluating the potential efficacy of combining varenicline and lorcaserin for the prevention of PCWG in obese and overweight smokers (Nicotine Tob Res. 2016 Nov 16. doi: 10.1093/ntr/ntw304).

In this study, 20 smokers with a body mass index of 27-40 kg/m² received varenicline and lorcaserin for 12 weeks.

Fifty percent of subjects were abstinent from smoking at 12 weeks, among whom weight gain was only +1.1 ± 3.9 kg (90% confidence interval, –0.9 to +3.1). The most-common side effect of the combination was sleep disturbance, reported by five patients.

The study was limited by the small sample size and the absence of a control group or placebo.

As clinicians, we frequently employ combination therapy in chronic diseases such as diabetes and hypertension when single-agent therapy is ineffective. By combining drugs with different therapeutic targets, we can achieve our treatment goals.

In tobacco dependence treatment, we use combination pharmacotherapy for heavier smokers or for those who have tried and failed to quit previously. Interestingly, lorcaserin has been demonstrated in another pilot study to increase smoking cessation rates by itself.

The combination of lorcaserin and varenicline holds promise for the treatment of tobacco dependence by attacking tobacco dependence through two different mechanisms and preventing PCWG, which may prevent relapse back to smoking.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

About three-quarters of current cigarette smokers want to quit, 40% will attempt to quit annually, and 90% of self-initiated attempts will be unsuccessful. Mean weight gain after smoking cessation may be as much as 13 pounds at 1 year, and 21 pounds over 5 years.

Population data suggest that more than one-half of women and one-third of men with a previous attempt to quit smoking report that weight gain was one of the primary reasons for relapse back to smoking.

Developing effective approaches to the prevention of post-cessation weight gain (PCWG) may increase the likelihood of sustained smoking abstinence and may engage “weight-concerned smokers” in the quitting process. Bupropion SR has the greatest effect for preventing PCWG, but nicotine replacement therapies may have an effect as well while they are being used. Varenicline has no effect on PCWG.

Lorcaserin is a 5-HT_2c (serotonin) receptor agonist FDA-approved for weight loss. Varenicline is the most effective monotherapy for smoking cessation and targets the alpha-4 beta-2 nicotinic acetylcholine receptor.

Ryan Hurt, MD, and his colleagues recently completed a pilot clinical trial evaluating the potential efficacy of combining varenicline and lorcaserin for the prevention of PCWG in obese and overweight smokers (Nicotine Tob Res. 2016 Nov 16. doi: 10.1093/ntr/ntw304).

In this study, 20 smokers with a body mass index of 27-40 kg/m² received varenicline and lorcaserin for 12 weeks.

Fifty percent of subjects were abstinent from smoking at 12 weeks, among whom weight gain was only +1.1 ± 3.9 kg (90% confidence interval, –0.9 to +3.1). The most-common side effect of the combination was sleep disturbance, reported by five patients.

The study was limited by the small sample size and the absence of a control group or placebo.

As clinicians, we frequently employ combination therapy in chronic diseases such as diabetes and hypertension when single-agent therapy is ineffective. By combining drugs with different therapeutic targets, we can achieve our treatment goals.

In tobacco dependence treatment, we use combination pharmacotherapy for heavier smokers or for those who have tried and failed to quit previously. Interestingly, lorcaserin has been demonstrated in another pilot study to increase smoking cessation rates by itself.

The combination of lorcaserin and varenicline holds promise for the treatment of tobacco dependence by attacking tobacco dependence through two different mechanisms and preventing PCWG, which may prevent relapse back to smoking.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

 

About three-quarters of current cigarette smokers want to quit, 40% will attempt to quit annually, and 90% of self-initiated attempts will be unsuccessful. Mean weight gain after smoking cessation may be as much as 13 pounds at 1 year, and 21 pounds over 5 years.

Population data suggest that more than one-half of women and one-third of men with a previous attempt to quit smoking report that weight gain was one of the primary reasons for relapse back to smoking.

Developing effective approaches to the prevention of post-cessation weight gain (PCWG) may increase the likelihood of sustained smoking abstinence and may engage “weight-concerned smokers” in the quitting process. Bupropion SR has the greatest effect for preventing PCWG, but nicotine replacement therapies may have an effect as well while they are being used. Varenicline has no effect on PCWG.

Lorcaserin is a 5-HT_2c (serotonin) receptor agonist FDA-approved for weight loss. Varenicline is the most effective monotherapy for smoking cessation and targets the alpha-4 beta-2 nicotinic acetylcholine receptor.

Ryan Hurt, MD, and his colleagues recently completed a pilot clinical trial evaluating the potential efficacy of combining varenicline and lorcaserin for the prevention of PCWG in obese and overweight smokers (Nicotine Tob Res. 2016 Nov 16. doi: 10.1093/ntr/ntw304).

In this study, 20 smokers with a body mass index of 27-40 kg/m² received varenicline and lorcaserin for 12 weeks.

Fifty percent of subjects were abstinent from smoking at 12 weeks, among whom weight gain was only +1.1 ± 3.9 kg (90% confidence interval, –0.9 to +3.1). The most-common side effect of the combination was sleep disturbance, reported by five patients.

The study was limited by the small sample size and the absence of a control group or placebo.

As clinicians, we frequently employ combination therapy in chronic diseases such as diabetes and hypertension when single-agent therapy is ineffective. By combining drugs with different therapeutic targets, we can achieve our treatment goals.

In tobacco dependence treatment, we use combination pharmacotherapy for heavier smokers or for those who have tried and failed to quit previously. Interestingly, lorcaserin has been demonstrated in another pilot study to increase smoking cessation rates by itself.

The combination of lorcaserin and varenicline holds promise for the treatment of tobacco dependence by attacking tobacco dependence through two different mechanisms and preventing PCWG, which may prevent relapse back to smoking.
 

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

Perhaps it’s the northern climate. Perhaps it’s that people at my office work a lot in the absence of office windows. But there are a lot of seasonal affective disorder lamps around me.

The one in my office turns on automatically (frequently in my absence), and the eerie blue light from my office floods the cubicles outside my door.

At a social gathering the other day, I related the story of my “moody blues office,” and somebody asked if the blue light for seasonal affective disorder was better than the white light. I did not know, so I did some reading.

It turns out that there is a retinal photoreceptor in the ganglion cells with a maximum sensitivity of 470-490 nm to blue light. These non-image–forming photoreceptors play a role in regulating the biological clock. Experiments have been conducted evaluating the impact of different wavelengths of light on symptoms of SAD.

In a study of people with subsyndromal SAD, investigators randomized 48 participants to bright white fluorescent light or narrow-band blue light (peak LED wavelength, 470 nm). Patients were exposed to the light for 20 minutes on 5 consecutive days. Standard scales measuring mood and fatigue were administered (BMC Psychiatry. 2016 Feb 18;16:27).

Investigators did not detect differences between the groups, and the authors concluded they had comparable efficacy.

Although the sample size is small, the data suggest that blue light is comparable to white light. I will start needing to pay attention if the folks in the cubicles outside my office are less depressed.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert has no relevant financial disclosures about this article.

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

I have learned a few things in my almost half-century of hurtling through space with all of you on this fragile blue-green rock. My most recent enlightenment is that the universe has a way of flipping our certitude on its head. Mental acrobatics requires flexibility, requiring us to bend so we don’t break.

On July 1, Minnesota began allowing clinicians to certify patients for “intractable pain” as a qualifying condition for the Minnesota Medical Cannabis Program. Recall that medical marijuana is a Schedule I drug, and we cannot prescribe it. These programs are set up in such a way that the only role a clinician plays is to certify patients with qualifying conditions. This allows a patient to pay a registration fee and visit a cannabis patient center, where a pharmacist will recommend cannabis dose and type.

Months before this, I was waxing professorial about our lack of certainty about dosing and efficacy of medical marijuana. Then I met a 30-year-old with chronic back pain.

She had been evaluated by every subspecialist. This patient was taking and failing supertherapeutic doses of NSAIDs, acetaminophen, and gabapentin. No more surgical options existed. She had been removed from opioid contracts for aberrant behavior. She had had a hysterectomy for severe bleeding. She was in pain and asking for help.

She relates to you that street marijuana has helped with the pain, but she is worried about being arrested and losing her job. Do we put her on another opioid contract? Do we throw up our hands in defeat, apologize, and show her the door?

Serendipitously, I ran across a study evaluating the relationship between cannabis use over a 20-year period and health conditions. The study by Madeline Meier, Ph.D., and her colleagues evaluated 1,037 New Zealanders followed into their late 30s. Laboratory measures were available, and tobacco use was determined (JAMA Psychiatry. 2016 Jul 1;73[7]:731-40).

Cannabis was associated with poorer periodontal health, but with no other health conditions in early midlife. In contrast, tobacco use was associated with significant adverse health consequences in multiple domains.

This study looked at smoked cannabis. In contrast, the cannabis that my patient would take is an oil, negating any potential respiratory health issues from by-products of burning. Furthermore, products with higher concentrations of or consisting exclusively of cannabidiol can be selected. Cannabidiol is proposed to possess health benefits and is not psychoactive.

As the opioid crisis rages, solutions are not readily presenting themselves. Will we be on the wrong side of medical history by providing patients with chronic pain access to medical marijuana? Perhaps we can avoid, at least for a short time, the all-too inevitable outcome of chronic pain patients in their 30s: ever-increasing opioid doses with the same amount of pain, frequent emergency department visits, a fractured patient-physician relationship, and drug overdose.

For our patients’ sake, I hope we can bend before we break.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.