Power to the Reader

A website can be many things for many people. For me it’s a way to explain myself; to help my patients and their families; and to share with a broader readership things that are creative, new, or inspiring. There is a quote thought to be from the 12th century physician, Moses Maimonides, which has animated me for some time. He is said to have seen all of the forces of good in the world in perfect balance with all of the forces of evil, and that each day brings us a chance to shift the balance. I have never met anyone who claimed to do this every day. But the person who doesn’t want to try is suffering from what Maimonides called the evil against the self. In the 20th century we called this evil mental illness. But if we have learned anything, it’s that illness is not only something we bring on ourselves, but something our environment and genes bring on us willy-nilly. No one wishes for cancer, but millions of people have fallen into the environmental trap of smoking, for example, and died nonetheless. More...

Is High School Football Safe?

January 20th, 2015 No comments

Henry David Abraham, M.D.

I was recovering from orthopedic surgery chatting with my hospital mate, Scott. I was in for skiing. He was in for football. Scott was the biggest person I had ever seen- a football lineman from a Div 1 school. His coach loved him. He came every night to boost his spirits. “Coach,” said Scott one time. “Do you think I could take up skiing?” “No, Scott,” said the coach solemnly. “Your winter sport is tobogganing.” “Huh?” said the student-athlete. “Yes, Scott. You go up a hill with six of your friends, and Scott, you’re the toboggan.”

No doubt that Scott would have made a great toboggan. He was already a great lineman. Seeing him in bed reminded me that playing football can hurt you, even though the commonest injuries are not lethal. Most are orthopedic, like knee sprains, hamstring injuries and contusions. But there are more worrisome ones. They involve the head. And of all the high school sports football has the greatest number. The chart below tells the story. Of 1219 kids with mild head injuries, football players had the most.

Mild traumatic brain injury (MTBI) is a newer way of saying concussion- head trauma that causes a change in mental status and/or unconsciousness. MTBI is always serious. In the course of a football season the chance of suffering one is about 5%. The risk is four times greater during a game than a practice. Astroturf raises the risk. Taking a hit to the top of the helmet doubles a kid’s chances for losing consciousness, but more concussions occur with front of the head impacts. High school running backs and line backers are more likely to be injured. Needless to say, the injury rates are higher in the NCAA, and still greater in the NFL.

The most disturbing observations come from studies of the brains of deceased NFL players. In selected cases the brain shows an Alzheimer’s-like condition correlating with the player’s previous mental decline. In the emerging alphabet soup of head injury, this new finding is chronic traumatic encephalopathy or CTE. But its existence is controversial because it’s extremely difficult to do controlled studies on this problem. The tragic suicide of Junior Seau, for example, does not prove that his years of football led to his death. Sadly, other people who never played football have committed suicide, too. The simple question is whether football players suicide more. They may not.

But not so fast, football fans. If you count how many times a player’s head gets hit during a season, you find the more hits, the more changes in the brain’s white matter. And after six months, the changes don’t go away. This is what a small controlled study of 15 players found. Would studying more players give the same result? We don’t know. But the average high school player in a season has between 175 and 1410 repeated head impacts. That can’t be good for you. But in this study, none of the 15 suffered an actual concussion. And even if they did, the overwhelming majority of kids who suffer MTBI have a complete recovery of mental function.

How can a parent calculate the risks and benefits to their child athletes? Some numbers can help. But apply common sense. The risks of playing in the NFL aren’t the same as those for high school kids. Take CTE, for example. The rate of high school students who appear to have developed this illness is less than seven in a million. What about other potentially lethal brain injuries? In the U.S. in 2013 there were 243 football related deaths in high school and college. Three were from brain injury. More were from heart disease. Let it be noted that the risks of death or brain injury from riding a bicycle, walking on the street, riding in a car, or swimming are greater.

There is little debate that a major head injury signals an end to playing for the year, and maybe for one’s career. One of my patients wisely called it quits after he tried out for the New England Patriots. On the first play suffered a helmet to helmet blow that knocked him out and caused a convulsion.

More difficult to answer is when and if a kid who suffered a mild concussion should be permitted to get back into the game. One expert in this field is Robert Cantu, a neurosurgeon who has also consulted with the NFL. Because recovery is the rule, so is returning to the season. The mildest cases of head trauma can return to the same game after a period of sideline examinations, once all signs and symptoms are gone at rest and during exertion. One concern is that once a kid suffers one concussion, the chances he or she will suffer a second one go up three to six times. This is a replicated finding. We don’t know why. Perhaps it reflects the child’s style of play, or a brain sensitized by prior trauma.

Numbers asides, the chance to play a sport in high school is unique. For every kid it’s a chance to pursue a dream of strength, grace, courage, and skill. Why else take the risk of skiing, skating, shooting hoops, or swinging perilously over a horizontal bar? Playing a sport is a dream of perfection. What’s so bad about that?

Categories: Opinion Editorials

Outwitting the Woolly Mammoth

June 27th, 2013 No comments

My mother was welcomed onto her bowling team with open arms. She won trophies, and wore her red satin bowling shirt with pride. On its back in gold stitching was the name of her team, the Philadelphia Armenians. My mother-in-law in the suburbs of New Jersey played bridge every month with the same seven friends for 25 years. They supported each other through births, marriages, careers and deaths. What do bowling and card playing have in common? In his landmark work, Bowling Alone, sociologist Robert Putnam calls them examples of “social capital,” the glue that holds us together as a community. Social capital is how the first hunters banded together to outwit the woolly mammoth. In the last half century we’ve had lots of examples of social glue. Watch It’s a Wonderful Life or Saving Private Ryan and you’ll be treated to large doses. But Putnam shows that many of the real ways we’ve bonded with one another are in decline. This is where you can make a difference in the lives of your kids, now and tomorrow.

When I took my kids bowling for the first time, the Big Lebowskis were gone, and by 2002 so were our lanes. Bowling isn’t the only social bond that has faltered. People are also losing interest in churches, scouting, fraternal organizations, and even playing cards with one other. Tom Kissell, membership director of the VFW, sadly noted, “Kids today just aren’t joiners.” Choirmaster Ian Watson bemoans, “People just don’t sing anymore.” Political life is suffering, too. In the recent US Senate race in Massachusetts only 27% of registered voters took the time to go to the polls. Putnam’s work bears out these observations. In one survey 77% of Americans surveyed said the nation was worse off because of “less involvement in community activities.” In 1992 three fourths of Americans felt that the “breakdown of community” was a serious problem. In Washington a paralyzed Congress is more than the result of one party trying to get advantage over another. It reflects a loss of our common vision as Americans.

In a number of ways this shift to a credo of “me, not we” is a byproduct of technology. Air conditioning and TV keep us cool and entertained, but off our front porches where we’d be at risk to talking with a neighbor. What about the Internet? The best of the Internet can energize our communities and spark political involvement. The ‘net can help build bonds between people who like the same stuff but are in distant parts of the world. It can create flash mobs and viral jokes. This is powerful stuff. But can the ‘net build real communities? Join a dating service, and you are connected to scores of potential partners. But if there is “like” at first click, there is no love at first sight, because the ‘net is removed from the world of faces and pheromones. And worse, the ‘net is easily hijacked, with voter manipulation, child abuse, hate mongering, and bomb building the result.

But for parents big changes are possible from many small acts. Every T-ball game you coach, every kids’ concert you attend, creates the long term dividend of human attachment. Churches, scouting, and volunteer fraternal organizations are not dead. If you connect with your community as adults, you create models for your kids to emulate. The Elks value “charity, justice, brotherly love & fidelity.” Got a problem with that? Take a look at the K of C. They’re into “churches, children of special need, and the community at large.” Not your cup of tea? Take a look at Habitat for Humanity, Jimmy Carter’s brainchild building housing for the needy. Pound some nails on a Habitat project. No religion is required, and you can take your teen along to learn a skill or two.

OK, you work 50 hours a week just to pay the mortgage, and the last thing you want to do is give up a day doing volunteer carpentry. So consider this. When I rake leaves I’m like the Invisible Man to anyone walking down the street until I put a Red Sox hat on. Then my neighbors, the oil man, the letter carrier, and dog walking strangers stop to make some baseball small talk. The hat bonds me to “the Red Sox Nation.” Yes, we love the Sox. What’s not to love about Ellsbury stealing third, or Big Papi launching one onto Lansdowne Street? But for town with a team, the team is bigger than baseball. Take your kids to Fenway, and take a look around at the sea of Red Sox hats and jerseys. And in the 8th inning, when people stand and sing Sweet Caroline, sing with them. People are sharing feelings of loyalty we historically have reserved for ethnic groups and nation-states.

After the Boston Marathon bombing, Bruins fans made news at the TD Garden when they rose as one and sang The Star Spangled Banner before the game. Singing is not what hockey fans are known for. But sing they did. In the days that followed, the city blossomed in every corner with people wearing the simple message, “Boston Strong.” We don’t have to wait for another tragedy to teach our kids that we are strong, and that there is value in working, playing, praying and singing together.

Categories: Opinion Editorials

“Energy Drinks”

April 15th, 2013 No comments

The story goes that coffee was discovered when a shepherd noticed his sheep dancing after they ate beans growing on a hillside. Humans have been using that bean ever since for alertness, inspiration, and energy. Caffeine is the world’s most popular drug. The US is the world’s greatest importer of coffee- nine pounds a year for each one of us. At birth caffeine is present in 75% of infants, and thanks to sodas and cocoa, in preschoolers, too. So when caffeinated “energy” drinks appeared in gas stations and supermarkets, consumers yawned, until now.

Today brands like Monster Energy and Red Bull are household names and a $20 billion a year business. One third to one half of teens and young adults will try them. As the use of these drug vehicles has increased, so have reports of problems. Most people are familiar with the common problems of caffeine- jitters, insomnia, and anxiety. Energy drinks kick that list up a notch, to include seizures, strokes, and at least 13 possible deaths. There are now 20,000 emergency department visits a year related to energy drinks. Kids with preexisting medical conditions, especially those of the heart or brain, are particularly vulnerable. Recently, the makers of Monster Energy moved to sidestep the FDA requirement that they report any problems with their products by calling them “beverages.” This moves Monster to a different aisle in the supermarket and lets them sweep bad news under the rug.

“But wait a minute, Dr. Abraham. Aren’t you just being a caffeine cop?  How much caffeine is in an energy drink in the first place?” Answer: about one to three cups of coffee. How bad can that be? This year 18 experts on child nutrition said how bad in a letter to the FDA. They pointed out that a caffeine drink is different from a cup of tea or coffee in a number of important ways.

Caffeine in coffee or tea is in a natural, botanical form, while the caffeine in energy drinks is added by the manufacturer. Another difference is that chemically concocted caffeine drinks contain a wild mix of Frankenchemicals: compounds not often mentioned in polite company that have little or no connection to normal human nutrition. Occasionally these chemicals do things to you. Guarana, one energy additive, for example, has one of the highest concentrations of caffeine in any plant, triple the caffeine in coffee.

A third important difference is a matter of the use of energy drinks by children. There is no minimum legal age to buy them. If a child consumes a drug at a dose intended for an adult, this is an invitation to an overdose. The smaller the child, the greater the trouble. This among other thoughts led a committee of the American Academy of Pediatrics to say, “…caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents.”

That brings me to the cultural differences between coffee, tea and energy drinks. Hot tea or coffee is sipped slowly. People meet for coffee. They serve coffee and tea at the book club. They drink tea together at the Chinese restaurant. The makers of energy drinks live on another planet. An ad for Monster Energy on Amazon says it all. The 16 oz. can of Monster “packs a vicious punch but has a smooth flavor you can really pound down.” Not exactly “meeting a friend for coffee.” This Brave New World of “beverages” may explain a recent study where Australian teens suffered cardiac and neurological toxicity after drinking three to eight bottles of energy drinks at a clip.

From a public health point of view, the greatest harm from an energy drink is when it is mixed with alcohol. Being drunk is bad enough, but being wide-awake drunk is stepping on the accelerator with your eyes closed. Under no circumstance should an energy drink be thought of as a cure for alcohol intoxication. It’s not.

Now before the proprietors of Starbucks and Peet’s take out a contract on me, let the record show that I am not a caffeine cop. Coffee is my favorite drug- er, drink. Of all the drugs I worry about, coffee is not even a warning blip on my radar. Its benefits vastly outweigh the risks. Its psychological and health effects are varied and proven. It reduces the risks of Alzheimer’s disease, certain cancers, heart disease, and type II diabetes.

Should teens drink coffee? It depends. As kids enter the teen years their clocks for sleeping and waking, like daylight savings time, spring ahead an hour or two. That means when adults are getting sleepy, kids are getting ready to rock. That also means that the next morning, as the world awakens, teenagers are zombies. This also means for many teens early morning classes are cruel but usual punishment. Short of starting the school day later, a cup of tea or coffee may work wonders for the early morning zombie. It does for many of us. But it’s not for everyone. Steven Spielberg never drank a cup of coffee in his life. Voltaire drank 30 cups a day. They both turned out all right.

Categories: Opinion Editorials

eBook Just Released! The No Nonsense Guide to Drugs & Alcohol

February 22nd, 2013 No comments

Everyone knows that drugs can kill you. Yet half the kids in America will try some drug before they leave high school. Too often kids don’t believe what they hear because they only get part of the story. They need more. For some kids, drugs are simply fun. For others they’re liquid courage at a party, or a way to take the edge off the blues. This eBook is for the kids who ask “What’s wrong with that, Doc?” Plenty, of course. Few kids die from drugs, but many are hurt, and some are hurt for a life time. This eBook sorts out the risks with the click of a mouse or the touch of a finger.

It’s the first eBook ever that deals with kids sixteen years and older and the drugs they choose. It’s designed to enable the reader to search a topic of interest, and jump to the main points quickly. Whether they have the focus of a genius or the attention span of a gnat, this eBook helps kids make smarter choices about drugs. As an eBook it harnesses the power of the Internet to provide the reader with the latest science for and against many drug claims.  It’s a book, it’s a myth buster, and it’s a doorway to the whole world of drug information. But it’s also a way to save a kid’s life.

  • Clear and compelling graphics.
  • Clinical stories, humor, and pop icons.
  • The hands-down greatest killer, and how Big Tobacco plots to keep it that way.
  • Marijuana as medicine, and marijuana as an assault to the growing brain.
  • The hidden benefits of caffeine.
  • The hidden dangers in the medicine cabinet.
  • The drugs in chemicals, plants, and toads.
  • The surprising winners and losers in our Drug War.
  • And a way to empower young people to change things for the better.

Categories: Home

Prescription Drugs and Teens

November 6th, 2012 No comments

If you haven’t had a cup of coffee yet today, here is an eye-popping curve that will wake you up. The national Centers for Disease Control and Prevention discovered that over the last forty years the death rate from prescribed drugs rose over 400%. The curve below tells the story. It shows the death rate from accidental drug overdoses per 100,000 people. In math class this curve would be called exponential. Of prescription drug deaths, about ¾ are from pain relievers. In 2008, for example, these drugs- opioids- killed 14,800 people. The total drug death rate now is roughly the same as the death rate from car crashes. This figure means that the abuse of prescription drugs is the fastest growing drug problem in America.

A big problem with legal drugs is that they can move from the people who need them to those who don’t. The DEA calls this diversion. Take, for example, the recent story of methadone. This drug has a proven benefit for treating addiction and patients with terminal illness. In recent years doctors began to use it for patients with chronic pain. Although it is prescribed only 2% of the time for this indication, it’s responsible for more than 30 percent of prescription painkiller deaths. Most likely this is in part because of drug diversion.

Kids are world champs when it comes to drug diversion. They find drugs at home, and pass them like candy from friend to friend. Surveys find that they fool with prescription drugs more than they do heroin, cocaine, and methamphetamine combined. Among 12 and 13 year olds, prescription drugs are the drugs of choice. In 2011 8% of high school seniors had tried them. The most common ones are pain medicines (e.g., Vicodin, oxycodone, OxyContin), stimulants (e.g., Ritalin and Adderall), and less often, tranquillizers (e.g., Xanax, Ativan).

Why do they do such stuff? Most of all, because the drugs are available. Open your medicine cabinet and see if you have any mind altering left-overs there. You don’t? Good! Some folks do. Kids can purloin them from purses, or from the medicine cabinets of their grandparents. 54% of high school seniors say that pain drugs like Vicodin are easy to get. Boys tend to abuse stimulants to get high. Girls take them to stay alert.

Kids also mess with them because they think they’re safer than street drugs. Nothing could be less true, which is why you need to go to medical school to learn how to prescribe them safely. They can also get them at the local pharmacy in the form of over-the-counter drugs (e.g., DXM, or dextromethorphan, a component of cough syrup).  Finally, doctors and dentists have made them more available in past years, nearly always for the compassionate relief of pain.

Since this report, the response from government has been both admirable and scary. States have targeted doctors in pain clinics and patients who divert drugs illegally. Computerized patient drug data now flow across state lines to catch those who shop for sympathetic or unethical doctors. The right of privacy is rarely defended against the trampling of regulatory feet. But some ideas are enlightened. One bill in Massachusetts sponsored by Steven Tolman and others would increase the availability of the drug naloxone, which is life-saving in any narcotic overdose.

This mix of bad policy and good in the last few years appears to have helped more than it’s hurt. For example, the number of people who abused prescription drugs fell from 7 million people to 6.1 million in 2011. In 2009, 2.1% of the population abused pain pills. Two years later it was 1.7%. This is the lowest rate since 2002. The drop was particularly encouraging among 18 to 25 year olds. The numbers may seem small, but from a public health perspective these gains are great, especially when you consider the rising tsunami of prescription drug deaths over the last decade.

But the game of preventing prescription abuse starts at home, and parents hold the best cards. You play them by educating your kids about drugs, keeping the meds secure, and getting rid of them once they’ve done their job. Stockpiling drugs is always a no-no. There are those situations when, despite your best efforts, you make no progress in keeping a kid safe from drugs. That’s a time for professional help.

Remember, though, that the drugs in the medicine cabinet were put there for good reason. For the right person and the right dose they reduce suffering and save lives. When they are in the wrong hands and used for the wrong reasons, drugs are trouble. This is especially so when kids free to help themselves to some of the most powerful chemicals in history.  This is not new knowledge. In 1960 the Massachusetts physician Oliver Wendell Holmes said “if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind- and all the worse for the fishes.” Certainly this should apply to your medicine cabinet, when its contents are no longer needed.

Categories: Advice on Parenting