A history of opioid abuse. . . and other storiesBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5036 (Published 06 December 2018) Cite this as: BMJ 2018;363:k5036
Writing in the New York Review of Books, a former editor of the New England Journal of Medicine traces the history of the opioid abuse epidemic in the United States. It’s estimated that 72 000 Americans died from drug overdoses in 2017, compared with 64 000 the previous year and 52 000 the year before that (https://www.nybooks.com/articles/2018/12/06/opioid-nation). Most of these deaths involved opioids. Blame for the epidemic is often laid on a single drug, OxyContin, which was marketed as non-addictive but turned out to be addictive. However, the full story is more complicated, and most opioid deaths now involve fentanyl, heroin, and cocaine.
Doctors often find it hard to help patients with medically unexplained symptoms. Cognitive behavioural therapy has some benefits according to a systematic review, most noticeably for somatic symptoms themselves and for accompanying problems of anxiety and depression (J Affect Disord doi:10.1016/j.jad.2018.10.114). However, the quality of the trials wasn’t high and the improvement in symptoms wasn’t reflected in a reduction in the number of visits to doctors.
The rule of halves
Applied to chronic disease, the rule of halves states that only half of people with a particular condition have been diagnosed, of whom only a half are on treatment, of whom only a half are getting effective doses. A survey of the population of Copenhagen finds that the rule is too pessimistic as far as diabetes is concerned (BMJ Open doi:10.1136/bmjopen-2018-023211). The investigators estimated that three quarters of people with diabetes had been diagnosed and that 90% of them were receiving treatment. Even so, there’s still some way to go to provide optimal HbA1c levels. Around half (40%-60%) of people on treatment had achieved target levels of HbA1c and lipids.
The Rotterdam study, a longitudinal investigation of more than 7000 older adults in the Netherlands, explored whether some forms of physical activity were more effective in promoting health than others. The answer seems to be no. Walking, cycling, gardening, sports, and domestic work were all associated with a lower mortality for cardiovascular disease, chronic lung disease, infection, and for all causes combined (Int J Epidemiol doi:10.1093/ije/dyy058). However, physical activity had no protective effect on mortality from cancer or dementia.
Probiotics and gut flora
Probiotics are preparations of live bacteria such as bifidobacteria and lactobacilli. People buy and consume them in the belief that they promote health and wellbeing. An experimental study in which paid volunteers had samples taken from multiple sites in the gastrointestinal tract after ingesting probiotics suggests that any effect is likely to be short lived (Cell doi:10.1016/j.cell.2018.08.041). Although probiotic bacteria remain viable during their passage through the gastrointestinal tract and can readily be detected in stool, this didn’t mean that the gut had been colonised or that there were any persistent effects on the intestinal microbiome.