Archive for June, 2008

Prevent Cancer by Healthy Eating

Cancer, the dreaded disease can be prevented to a great extent by adopting a healthy food habit. A good diet can go a long way in reducing the chances of occurrence of cancer, what type of cancer it might be. And the prescribed diet for prevention is the same. Eat a lot of fresh fruits and vegetables, pulses, whole grains and nuts. Maintain a healthy body weight (preferably ideal body weight). Avoid the excessive intake of dairy products, red meat and processed food. These above three rules help to reduce breast cancer, prostrate cancer, stomach cancer, and practically all forms of cancer.

Vitamin A helps to prevent lung cancer, but the best way to avoid it is not smoking and reducing air pollution. There are many myths at play. It is commonly believed that intake of Vitamin C helps prevent cancer, but no such one element can help.

Aflatoxin, is a chemical that is produced by a fungus that grows on peanuts and other nuts when stored improperly, is carcinogenic, but most farmers are now aware of that problem, so the risks have been reduced.

Regional food habits also go a long way in increasing or decreasing the risk of cancer. For example, in Japan, people eat a lot of pickled vegetables. We have seen that the number of people suffering from stomach cancer is very high there. Anything in moderation though, is not a problem. In India, too, people have pickle with their meals. But there, it is just a condiment and not a main dish. So the effect is not so grave.

There is, however, some bad news for Indians. Frequent helpings of kebabs can effectively increase chances of cancer. The blackened meat on the surface, when meat is cooked over an open flame, is carcinogenic (causes cancer). That doesn’t mean you have to stop eating kebabs altogether. You can have it once a week, as long as you are eating healthy the rest of the weak, and giving the DNA the opportunity to repair itself.

There is lack of awareness regarding the link between diet and diseases like cancer. Even in America where so much of research is taking place, the level of awareness among the common people is very low. A lot of information is available on the Internet, but it is not always reliable. International Association of Cancer Research as a possible reference point.

There is confusion regarding wine and cancer. Till now whatever evidence we have had, there is no negative effect of wine. It is good for the heart. But the problem with wine is that it has alcohol. It causes intoxication and addiction. And the good element of wine are available in grapes, cherries etc in non-alcoholic forms. For women, more than one glass of wine a day is not advisable, and for men the limit is two glasses a day. But the above prescribed limit is not easy to follow by maximum of people.

Carbonated drinks are best avoided. They are empty calories. And they decalcify the bones, causing osteoporosis. Even a diet drink, which is claimed to be low on calories, poses the same threat.

When it comes to food, too little is not too good. Surviving on a fruit or vegetable diet is not healthy, because the body is losing key body building nutrients like protein. So even if you are a model and need to be thin, have a helping of whole grains and nuts, to keep the diet balanced.

Treatment of Cocaine & Related Drug Abuse

Cocaine overdose is a medical emergency and should be managed in an intensive care unit. Cocaine toxicity causes hypertension (high blood pressure), tachycardia (high heart rate), tonic clonic seizures, dyspnea (breathlessness), and ventricular arrhythmias (change in rhythm of heart). Intravenous diazepam in doses up to 0.5 mg/kg administered over an 8-h period to control seizure. 0.5–1.0 mg of propranolol intravenously is given to control ventricular arrhythmias.

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Marijuana and Cannabis & Other Related Compounds

Cannabis sativa contains more than 400 compounds in addition to delta-9-tetrahydrocannabinol (THC), Marijuana and Cannabis. Marijuana cigarettes are prepared from the leaves and flowering tops of the plant, and a typical marijuana cigarette contains 0.5–1 g of plant material. Hashish is prepared from concentrated resin of Cannabis sativa and contains a THC concentration of 8 and 12% percent by weight. “Hash oil," a fat soluble plant extract, may contain a THC concentration of 25–60% and may be added to marijuana or hashish to increase potency. Smoking is the most common form of marijuana or hashish use. During smoking more than 150 compounds in addition to THC are released in the smoke.

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Cocaine Abuse: an Introduction

Abuse of cocaine and other psycho stimulants are determined by a complex interaction between the pharmacologic properties and relative availability of each drug. The environmental context, personality and expectations of the user in which the drug is used influence the drug abuse and outcome of the treatment. The concurrent use of several drugs with different pharmacologic effects is increasingly common. Combined use of heroin and cocaine intravenously, are dangerous. Chronic cocaine and psycho stimulant abuse may cause a number of adverse health consequences, like pulmonary disease to reproductive dysfunction. Hypertension and cardiac disease may be exacerbated by drug abuse; combined use of two or more drugs may accentuate medical complications associated with abuse of one of them. Drug abuse increases the risk of exposure to HIV and hepatitis B. Cocaine abuse contribute to the risk for HIV infection in part by suppression of immune function. Concurrent use of cocaine and opiates known as the "speedball" is frequently associated with needle-sharing by IV drug users and contribute to HIV transmission. Intravenous drug abusers continue to represent the largest single group of persons with HIV infection in several major metropolitan areas in the United States.

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Rehabilitation of Opioid (opium) Dependency

The basic strategy of opium rehabilitation is detoxification and the establishment of realistic goals for abstinence and improvement of life functioning. A long term commitment by the patient to maintain a lifestyle without illicit substances is essential for preventing relapse. Patients are educated about their responsibility for improving their lives. Motivation for abstinence is increased by providing information about the medical and psychological problems that can be expected if dependence continues. The dependent person is also advised to establish a drug-free peer group and to participate in self-help groups such as Narcotics Anonymous or Alcoholics Anonymous. Patients and families are encouraged to establish an opioid-free lifestyle by learning to cope with chronic pain and develop realistic vocational planning. An important treatment component is relapse prevention aimed at identifying triggers for a return to drugs and developing appropriate coping strategies. Advice and counseling can be given by the doctor by referring patients to formal drug programs, including methadone maintenance clinics, programs using narcotic antagonists, and therapeutic communities. Long-term follow-up of treated patients indicates that approximately one-third becomes completely drug free, and 60% no longer use drugs.

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Treatment of Opioid (opium) Abuse

Withdrawal symptoms are generally opposite to that of acute drug intoxication like nausea, vomiting, coughing, sweating, salivation, tearing, running nose, twitching of muscles, fever, increase in respiratory rate and increase in blood pressure. There is intense craving for the drug, with sleeplessness and yawning. With shorter acting drugs like morphine and heroin, the withdrawal symptoms generally develop within 8 to 16 hours of taking the last dose. Symptoms become severe in 2 to 3 days and disappear in 5 to 8 days. But some of the symptoms may persist for more than 6 months and probably contribute to relapse.

Treatment of withdrawal symptoms: A thorough physical examination including assessment neurological function is done. Look for systemic or local infection and abscess. Blood should be tested for hepatitis B and HIV. Before starting treatment, proper nutrition should be provided with vitamins and mineral supplementation.

Two modalities can be used to treat opioid dependency. In the first modality, any one of the opioid drugs like methadone 10 to 25 mgs twice a day is given to reduce symptoms. Patient is stabilized at that dose for several days. Than the dose is reduced by 20 % everyday from the original dose till it becomes zero. This way there will be fewer withdrawal symptoms.

In the second modality, symptomatic treatment is given to the patient. Diarrhea is treated with anti diarrheal loperamide, nose block with nasal decongestant, pain with non opioid drugs like ibuprofen etc. During treatment blood pressure must be monitored closely.

A special case of opioid withdrawal is seen among the newborn infants made passively dependent to opioid through mother’s opioid abuse during pregnancy. Withdrawal symptoms of new born consist of crying, tremor, irritability, increased reflexes, diarrhea, increased respiratory rate, sneezing, hiccup, and yawning. Management of these babies is same as that of adults, but the dose has to be adjusted to suit the infant. The dose of methadone is 0.1 to 0.5 mgs per kg per day and in decreasing the dose for 10 to 20 days. Infants of drug dependence also benefit from breast feeding if mother is taking methadone.

Opioid (opium) Abuse and Dependence

The definition of opioid abuse and dependence is given in the Fourth Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association as “repeated use of a drug of opioid class to the point of causing multiple problems”. The definition also requires evidence of three or more in a year, including tolerance, withdrawal, and quantity of use more than required despite consequences. This is dependence of opioid. Abuse can be defined as not having dependence but demonstrate repeated opioid related problems with law, inability to meet obligation and use of opioid despite problems.

The use of opioid for intoxication is about 10% in high school seniors in the US. Male female ratio is almost same.

There is some role of genetics in the development opioid abuse and dependency. In a study involving more than 3000 male twins proved that genetics is involved to some extent. This includes overall vulnerability towards substance abuse and problems.

Three groups of people are more prone to develop opioid abuse, though anyone can develop it. The first group is persons with chronic pain like back pain, joint pain and muscular pain. They misuse their prescribed drugs. If physical dependence develop any drop in opioid level in blood causes severe pain and patient take more opioid and the cycle continues .That is why, doctor should advice the patient that moderate treatment with acceptable pain is the best approach to treatment instead of absence of pain with high dose of opioids, that lead to dependency. Behavior modification techniques like muscle relaxation and meditation should be used when appropriate to help reduce pain and improve function, along with carefully selected exercises.

The second group at high risk is doctors, nurses, pharmacists and other health care professionals, due to easy accessibility. Doctors may start use of opioids to help with sleep or reduce stress or pain and escalate to tolerance and physical dependence. That is why all doctors are advised not to prescribe opioids for themselves and family members.

The third groups of people are those who buy street drugs to get high. Some of them have prior history of some social problems. The typical person begins with occasional opioid use after trying tobacco, marijuana and other substance. This occasional became regular and development of dependency.

Opioid dependent persons are likely to continue their experiments with other drugs. Alcohol, cocaine are some of them. Cocaine is sometimes administered along with opiods intravenously called “speed balls”. This is a deadly combination.

Opioid user’s mortality is very high compare to general population. Mortality is mainly from suicide, homicide, accident, infection like tuberculosis, hepatitis or AIDS. Mortality from those diseases is about 15 times higher in drug abusers. But good news is that, even without any treatment 35 to 40 % of the drug abusers will permanently abstain from using drug after the age of 40 years. As with drug users a favorable prognosis is associated with prior history of marital and employment stability and fewer criminal records. Help from family and friends go a long way to care and reduce substance abuse in susceptible population.

Opium Abuse

Opioid analgesics (pain killers) are essential part of medical practice and have been part of medical practice and health care since 300 B.C. Opioid have disadvantage of overdose and dependency, that may arise from injudicious use. All opioids are capable of producing heroin like toxicity. In US alone there are more than one million opioid dependent individuals.

Morphine and codeine are the main opioid and are derived from milky juice of poppy fruit, papaver somniferous. Semi synthetic opioids includes, diacetylmorphine (heroin), oxycodone etc. Synthetic opioids include tramadol, pentazocine, pentanyl baprenorphine, propoxyphine ete.

Street heroin is 5 to 10% pure and mixed with sugar, powder milk, caffeine, quinine, or strychnine. If there is any increase in purity of street heroine it can lead to unintentional lethal overdose. Smoking or in haling of heroin vapors is call “chasing the dragon”.

If there is no physical dependence opioid effects are rapidly reversible. There is danger of hepatitis B and C and HIV infection if contamination needles are uses.

Opioids causes euphoria and rewarding effects due to stimulation of central nervous system (CNS) other CNS effects are decrease pain perception, nausea, vomiting, and sedation. The adulterants added to street heroin may cause damage to CNS and peripheral nervous system. There is also reduction in sex hormones that is the reason there is reduced sex drive.

High dose of opioids can result in lethal toxicity that can be seen in more than 60% of opioids, depondents, due to high potency of never drugs like fentanyl. Fentanyl is 50 to 100 times more potent than morphine. The symptoms of over dose include slow and shallow respiration, body became cold, high pulse rate, and pupils constrict .Stupor and coma. If prompt treatment is not given, these can cause respiratory and cardiac arrest and death.

The first and most important step in management of opoid overdose and toxicity is to support vital sings in ICU (intensive care unit). Definitive treatment is to give antidote to opioids like naloxone at the dose of 0.4mg to 2mgs intravenously or more muscularly. Response is seen by improvement in vital signs. Dose of the antidote should be titrated to suit individual patient and it should not cause severe respiratory depression and severe withdrawal symptoms. Withdrawal symptoms cannot be treated unless overdose related vital signs are relatively stable. Effects of naloxone reduce after 2 to3 hours, which is why patient has to be monitored for 24 hours for heroin and 72 hours for longer acting opioids like methadone. If there is no response with the antidote, it may be due to overdose of benzodiazepines and it should also be treated.

Some time “allergic like” reaction occurs after intravenous heroine that is due to adulterants. Treatment of this requires continuous respiratory support with oxygen and positive pressure breathing, intravenous fluids, gastric lavage to remove remaining drug and pressor agents to maintain blood pressure.

Rehabilitation of Alcoholics

After proper treatment more than 60% of the alcoholics maintain abstinence for more than one year. Many of them maintain lifetime abstinence. Since there is no proof of superiority of one treatment schedule than the other it is best to keep management of alcoholics as simple as possible.

The first step in rehabilitation of alcoholics is the attempt to help alcoholics to maintain a high level of motivation for abstinence. This includes education about alcoholism, instructing family and friends not to protect the alcoholic from problems caused by alcohol.

The second step is to help the alcoholic to readjust t life without alcohol & establish a functional lifestyle. For this counseling, vocational rehabilitation and self help groups like Alcoholics Anonymous (US) are available for help.

The third step is to prevent relapse of alcoholism. This is done by educating the alcoholic to identify the situation which may cause return of drinking. Physician should formulate ways of managing these risks and develop strategy to cope with the situation. For that reason after stopping drinking, an alcoholic should be followed up monthly as very important in main tenancy of abstinence.

There is no convincing widened to proof that hospitalization is better than out patient management .However, sometime times hospitalization is required for the following reasons (1)The patient has medical problem that is difficult to manage outside hospital (2)If patient is in depression confusion or have other psychiatric problems.(3)The patient liver for from treatment centre(4)Out patient treatment has failed.(5)If there is severe medical problem that makes out patient treatment impracticable.

After treatment of alcoholism out patient contact should be maintained for one year.Counselling should emphasize upon day to day living, improved functioning in absence of alcohol helping the patient to manage free time without alcohol. Patient should be advised to maintain a non drinking peer group, and they should be taught how to handle stags on the job.

The alcoholics should be given vocational training if they do not already have. They should be helped in finding decent jibs with les stressful condition, so that alcoholism does not return.

The main stay of alcoholic rehabilitation involves counseling, education, and cognitive approach medication also might be helpful. For this episode antagonist naltrexone 50 to 150 mgs daily in divided doses. This drug has shown to reduce chances of relapse of drinking. But more studies are required to confirm effectiveness of the medication. Another drug composite 2gm per day has shown similar result as that of naltrexone in a Europe in a study.

Additional support for alcoholics and their relatives and friends is available from self help groups like Alcoholics Anonymous (AA).Typically these groups consists of recovering alcoholics & recovered persons, who can provide very good motivation to the patient. Patient can share his problems & discuss with same peer group. They have personal for crisis management for alcoholics. These can help patients optimize their chance of recovery & freedom from alcohol.

Treatment of Alcoholism

Acute Alcohol Intoxication: The first priority of acute alcohol intoxication is to be certain that vital signs are stable and there is no evidence of respiratory depression and change in blood pressure. The possibility of intoxication with other substances should be considered. For that blood and urine samples are taken and sent for investigation.

Patients who are stable should be asked to lie down on there side in order to minimize the risk of aspiration. If there is likely to be violent behavior from the patient, than the show of force with a team is advisable. The patient should be firmly and politely reminded that the aim of the treatment is to avoid problems and for the betterment of the patient. Still if the patient can not be controlled, CNS depressant should be used. But it should be kept in mind that, CNS depressant like lorazepam does not destabilize the patient.

Alcohol Withdrawal: The first step is a thorough physical examination of the patient, if the patient is planning to stop drinking. Liver failure, cardiac problems, gastrointestinal bleeding and electrolyte imbalance should be ruled out.

The next step is adequate nutrition and rest. Patient should be given vitamin B complex 2 to 3 tablets for about a week prior to stopping of drinking. Generally all the medicines can be given orally.

The third step is to recognize the withdrawal symptoms and treat them promptly. If the patient is treated with CNS depressant benzodiazepines like lorazepam, it should be gradually decreased in 3 to 5 days. But nowadays, longer acting drugs like diazepam is preferred by many doctors. Sudden withdrawal of longer acting CNS depressant has fewer side effects than shorter acting lorazepam. Shorter acting drugs can cause seizure if there is preexisting liver disease or if there is wide fluctuation of blood levels.

Treatment of severe alcoholism delirium tremens (DT) is very difficult. Symptoms of DT continue for 3 to 5 days even if appropriate therapy is instituted. So, aim of the treatment is to prevent injury. If electrolyte imbalance or dehydration is present, they should be corrected. Treat the symptoms as they appear. Some doctors prefer high dose of benzodiazepines (like chlordiazepoxide 800 mgs per day) to reduce agitation. Others prefer anti psychotics, which are not used in treatment of mild withdrawal symptoms.

Now days to reduce cost of hospitalization alcoholic patients are treated as outdoor basis as for as possible. In large number of mild to moderate alcoholics out door basis of treatments hospitalization is a must.

Rehabilitation:-At least 60% of alcoholics can maintain abstinence for more than a year and many can do it foe life ling. Patient should be motivated through counseling from time to time and follow up should be done. Relapse prevention is done by trying to identify satiations which causes relapse and managing these situation as for as possible.