Thursday, January 3, 2019

Healthy, wholesome easy lunches

Most of these claims are considered unproven, based on preliminary evidence such as animal research, or human studies involving a very small number of people. The only approved use of CBD is for certain childhood seizure disorders (called Lennox-Gastaut syndrome and Dravet syndrome); the FDA approved the first-ever medication containing CBD for these conditions in June of 2018, and then in September the FDA reclassified CBD from Schedule I (“drugs with no currently accepted medical use and a high potential for abuse,” such as heroin) to Schedule V (drugs with a low potential for abuse)

Side effects of CBD are generally minor and include diarrhea, fatigue, and anxiety. It can also interact with medications you take, so it’s important for your doctor to know if you’re taking it.
Is pot going mainstream?

The news about the Coca-Cola Company follows recent announcements by Coors and Constellation Brands (makers of Corona beer) about developing marijuana-containing products. And a few CBD-containing beverages are already on the market.

So, it seems like this is only the beginning. In fact, the time could soon come when CBD (and, perhaps, marijuana) make it into widely available foods and beverages, including those sold in supermarkets. With the legalization of marijuana spreading like a weed (sorry, couldn’t resist!), it may be just a matter of time before it’s viewed a bit like alcohol. And that means it could soon be in the food supply. I just hope that by the time that happens, we have a better understanding of its risks and benefits.

As for CBD, you can expect claims of health benefits to multiply as it morphs from a component of an illicit drug to a financial opportunity in the growing “wellness” food and beverage industry. But I’ll still be looking for more studies confirming its safety and health benefits before I’ll buy anything containing CBD. Today is National Depression Screening Day. If you are experiencing symptoms of depression, you should know that there are effective treatments and help is available.

When you are depressed, your self-esteem wanes and you may start to dislike yourself. People with depression often think of themselves as “worthless, incapable of any achievement, and morally despicable.” Why do people who are depressed have this negative self-appraisal? And what could be happening in their brains?

The study: In 2017, researcher and psychiatrist Christopher Davey and his colleagues compared the brain blood flow of 86 unmedicated depressed patients with that of 95 healthy control participants using a type of magnetic resonance imaging (MRI) called functional MRI. Depressed patients were in the early stages of their illness, but, as is often the case, two-thirds of them had an anxiety disorder as well.

The tasks: The researchers asked participants to lie in an MRI machine, and then gave them several tasks to complete while they imaged their brain blood flow. The first task involved self-appraisal. During this task, participants had to indicate whether a certain descriptor fit them or not by pressing a left or right button that corresponded with “yes” or “no.”

Then, they were asked whether words had four or more vowels (a task to test external attention). As you can imagine, this does not require internal attention like the self-reflection task did. The answers are in the words themselves.

As they answered these questions, the researchers documented whether the connections between different brain regions were affected.
What did we learn about people who are depressed?

There were no differences in reaction times to the self-descriptors in the depressed and control groups, and they were similarly accurate about the vowel test too. However, depressed participants said that the negative adjectives described them far more often than the control subjects, and more often than not, the adjectives indicated that they did not like themselves.

Choosing a self-descriptor means that you have to match the word with an impression that you already have of yourself. This matching process involves brain regions at the front and back of the brain. Like a well-coordinated rowing team, these different regions in the brain must be flexible and coordinated so that this matching can occur. In the case of self-appraisal, activation at the front of the brain (the medial prefrontal cortex) often moderates activation at the back of the brain (posterior cingulate cortex.)

As researchers had expected, when depressed patients reflected on themselves, the brain’s front and back rowing teams were not coordinated. When the brain region at the back of the brain was activated by a self-descriptor, the front region overreacted when trying to control it. The greater the overreaction, the worse depressed people felt about themselves compared to control subjects.

But that was not all. The assessment itself was also less stable. As a result, the brain had to work harder to establish some order too. (No wonder depressed people are often fatigued!) Although it was not entirely clear what specific aspect of depression was associated with this brain overreaction, the researchers found that it was highly likely that difficulty concentrating, and a sense of inner tension, were both affected in concert with these brain changes.
What can you do?

If you’re depressed, know that the unstable connection between the front and back regions of your brain is making you dislike yourself and disturbing your emotional control. Your brain has lost its flexibility and accuracy.

That’s why a relatively new treatment called self-system therapy (SST) has been shown to be so effective for depression. With this therapy, people who are depressed can achieve better control of their emotions. They learn to counteract their negative self-impressions. Unlike cognitive therapy, which focuses on reframing these negative ideas, SST doesn’t focus on these negative ideas at all. Instead, it helps patients feel better by teaching them to focus on making good things happen by pursuing “promotion” goals that involve advancement, growth, and achievement. In fact, it is far more effective than cognitive therapy.

So, being aware that your brain distorts your self-impression in the first step in this therapy. Once you understand this, you can learn how to switch your attention to positive goals so that you can feel better about yourself again. There has been lots of attention on concussions in youth, especially from sports, over the past few years. It’s good that we are paying more attention to concussions. As the stories of prior National Football League players show us, concussions can lead to lifelong problems.

The problem for doctors, parents, and coaches has been that while we want to do the right thing when a child gets a concussion, we haven’t known what that right thing is. So it’s great news that the Centers for Disease Control and Prevention (CDC) has reviewed all the research and made recommendations to help guide us as we care for children with concussions.

The recommendations reflect the fact that every child who has a concussion is different. Every injury is different, obviously, but it’s more than that. Some children are more likely to have trouble, such as those who have had prior concussions or have learning problems, mental health problems, or neurological problems. Interestingly, children whose families are stressed for reasons such as poverty can take a longer time to recover from concussions. And there is a bit of a wild card factor too: sometimes children unexpectedly take a long time to recover — or, conversely, recover very quickly.
Overview of new concussion care recommendations

    Most children with concussions don’t need CT or MRI scans. If there was a severe injury or the child is having severe or unusual symptoms, then it’s worth doing to be sure there isn’t internal bleeding, a fracture, or some other injury. Most of the time with concussions, there is nothing to see — and it’s not worth the risk or expense involved in these studies.
    Use the right tool to make the diagnosis. There are some symptoms we associate with concussion, like bad headache, dizziness, loss of memory of the accident. But because it isn’t always clear, it’s helpful to use a checklist or questionnaire that is “validated,” meaning that it’s been shown to accurately pick out those with a concussion from those who simply have a bad clunk to the head and not a concussion. The CDC lists some tools that are recommended.
    When a child has a concussion, assess for risk factors for a prolonged recovery. As I said above, some children take longer to get better — and while we can never predict for sure, it’s important to think about that at the time of the injury. This can help doctors…
    Provide education for parents and caregivers about concussions and what to expect. Most people with concussions get completely better within one to three months. It’s important that patients, families, and coaches know what all the symptoms are after a concussion — and know not only what’s normal, but also what is a sign of a problem. For example, trouble sleeping, dizziness, and moodiness can be normal, but if any of those symptoms are getting worse, it’s important to call the doctor.
    Help children return gradually to normal activities after a concussion. Rest — of not just the body but the mind too — is important for the first two to three days after a concussion, but after that it’s important to start getting back to normal. When people rest completely for longer than that, it actually takes them longer to get better!

Getting back to normal after a concussion

Gradual is the key word for returning to exercise and school — and this is where families, doctors, schools, and coaches need to work together. The basic idea is to start slow and see how the child does. If they do okay, they can do a bit more schoolwork or exercise. If they don’t do okay, meaning they have more symptoms, that’s where the education comes in — they should do less and go more slowly. The process of getting back to normal life can take a few days, or a few months. It has to be tailored to each child and each situation, which is why collaboration is so important. It’s also really important not to rush the process, especially when it comes to returning to a sport where concussions are common, such as football, hockey, or soccer. If a child gets another concussion while they are still recovering, it will take them much longer to get better and put them at risk of permanent disabilities. I am now 11 years into recovery from my battle with opiate addiction, and I have always been fascinated with two related questions: is there truly such a thing as an “addictive personality,” and do people substitute addictions?
The myth of the addictive personality

The recently deceased writer and television personality Anthony Bourdain was criticized by some for recreationally using alcohol and cannabis, in what was seemingly a very controlled and responsible manner, decades after he quit heroin and cocaine. Was this a valid criticism? Can a person who was addicted to drugs or alcohol in their teens safely have a glass of wine with dinner in their middle age?

It depends on which model of addiction and recovery you subscribe to. If you are a traditionalist who believes that addictions last a lifetime, that people readily substitute addictions, and that people have ingrained “addictive personalities,” the answer is: absolutely not. This would be playing with fire.

During my 90 days in rehab, it was forcefully impressed upon me that addictions are routinely substituted, and that if one is ever addicted to any substance, then lifelong abstinence from all potentially addictive substances is one’s only hope of salvation. This seemed to make sense, as a person would have the same lifelong predispositions to an addiction: genetic makeup, childhood traumas, diagnoses of anxiety or depression — all of which could plausibly set them up to become addicted to, say, alcohol, once they have put in the hard work to get their heroin addiction under control. In medical terms, the concern is that different addictions can have a common final pathway in the mesolimbic dopamine system (the reward system of our brain), so it is logical that the body might try to find a second pathway to satisfy these hungry neurotransmitters if the first one is blocked, a “cross-addiction.”

I learned early in my own recovery how critical it is to apply logic and evidence to the field of addiction, and that just because things make sense, and because we have thought about them in a certain way for an extended period of time, that doesn’t mean that they are necessarily true. While in rehab, I was actually told a lot of other things that turned out to have no basis in scientific evidence. For example, I was told on a daily basis that “a drug is a drug is a drug.” This mentality doesn’t allow for there being a difference between, for example, the powerful opiate fentanyl, which kills thousands of people every year, and buprenorphene (Suboxone) which is a widely-accepted treatment for opioid use disorder.

I have come to believe that an uncompromising “abstinence-only” model is a holdover from the very beginnings of the recovery movement, almost 100 years ago, and our understanding has greatly evolved since then. The concepts of addiction and recovery that made sense in 1935, when Alcoholics Anonymous was founded, and which have been carried on by tradition, might not still hold true in the modern age of neurochemistry and functional MRIs. That said, mutual help groups today do have a place in some people’s recovery and they can encourage the work of changing and maintaining change.
Recovery may improve resiliency to new addictions

It seems as if no one definitively knows the answer about whether people substitute addictions. According to the National Institute on Drug Abuse in response to a request for comment from the website Tonic: “A previous substance use disorder is a risk factor for future development of substance use disorder (SUD),” but “It is also possible that someone who once had an SUD but doesn’t currently have one has a balance of risk and protective genetic and environmental factors that could allow for alcohol consumption without developing an AUD [alcohol use disorder].”

One study published in JAMA in 2014 showed that, “As compared with those who do not recover from an SUD, people who recover have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution, but rather is associated with a lower risk of new SUD onset.”

The authors of this study suggest that factors such as “coping strategies, skills, and motivation of individuals who recover from an SUD may protect them from the onset of a new SUD.” In other words, by making the life-affirming transition from addicted to recovered, we gain a recovery “toolbox” that helps us navigate life’s challenges and stresses in a much healthier way. We learn to connect with people, push our egos aside, and to ask for help if we need it. Thus, when faced with stressful situations that formerly would trigger us to drink or drug, we might respond by exercising or calling a friend, rather than using a substance. As such, we substitute addictions with healthier activities that perform the function that the drink or drug used to, albeit in a much more fulfilling way.

This issue is also, partly, a question of semantics, and of how narrowly or widely we define addictions. Many hold that an addiction can be to either a substance or a process: gambling, eating, video game playing, Internet use, sex, work, religion, exercise, or compulsive spending. Lots of people gain weight when they quit smoking. Is that a case of substituting an addiction? I like to joke that, in my observations, the only reliable outcome from a stay at rehab was a nicotine addiction, because many people, in an attempt to cope with the trauma and dislocation of being sent away to rehab, pick up cigarettes.
People grow and change

Personally, I am skeptical that many people substitute addictions. In my experience, people who are addicted tend to have a particular affinity for a particular class of drug, not for all drugs and alcohol. This is probably based on some combination of their neurochemistry and their psychological makeup. I was addicted to opiates, but didn’t have difficulties with substances in other classes. I have seen this to mostly be the case with thousands of my brothers and sisters in recovery who I have had the honor to interact with. People continue to add to their coping skills toolbox throughout life, so the unhappy 18-year-old who is struggling is not the well-adjusted 50-year-old who has worked through many of their problems, or who has improved their life circumstances. Vulnerabilities can improve over time. People aren’t static, which is what reminds us to never give up hope when dealing with an addicted loved one, no matter how dire the circumstances appear to be.

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