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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Back pain: Will treatment for the mind, body—or both—help?

Imaging scan of a man's bones, trunk, and head viewed from the side on a dark background; orangey-red color on lower spine suggests low back pain

If you’ve ever struggled with low back pain, you know that it can be surprisingly debilitating, even if the discomfort is short-term. You may find it difficult to grocery shop, do housework, play sports, or even tie your shoelaces. When back pain is chronic, lasting 12 weeks or longer, it can impair quality of life and physical function, and contribute to or worsen stress, anxiety, and depression.

While people dealing with chronic back pain are often directed to physical therapy, research shows that psychological approaches that teach strategies to manage your experience of pain can help. So, would combining these approaches do more to ease the pain? A recent systematic review of multiple studies suggests that it might.

How big is this problem, and what did this study find?

Worldwide, low back pain is a leading cause of disability and affects more than 560 million people. In the US, four in 10 people surveyed in 2019 had experienced low back pain within the past three months, according to the Centers for Disease Control and Prevention.

Published in TheBMJ, the review drew on 97 studies of adults experiencing chronic, nonspecific low back pain, with or without leg pain. Using statistical modeling, the researchers compared the effectiveness of therapies aimed at improving

  • physical function, such as standing, climbing stairs, and managing personal care
  • fear avoidance, because fear of pain can lead people to avoid movement, which contributes to the cycle of muscle weakening and further pain
  • pain intensity, measured by pain scores from validated rating scales.

The review revealed that physical therapy plus psychological approaches, such as pain education and cognitive behavioral therapy, more effectively improved chronic low back pain than physical therapy alone. More specifically:

  • For improving physical function and fear avoidance, pain education programs in conjunction with physical therapy offered the most sustained effects.
  • For improving pain intensity, behavioral therapy combined with physical therapy offered the longest-lasting benefits.

The study shows the advantages of an interdisciplinary approach to chronic low back pain. Integrating behavioral therapy and physical therapy helped people achieve better function, reduce the cycle of avoidant behavior, and reduce the intensity of their pain. In their daily lives, this may lead to more productive workdays and better sleep, as well as enabling people to participate in more social activities, which boosts overall well-being.

What else should you know about this study?

The authors define chronic, nonspecific low back pain as pain between the bottom of the rib cage and buttocks crease, without an identified structural cause like spinal stenosis, cancer, or fracture.

However, “nonspecific” is a controversial term. Many experts on back pain believe that further evaluation might determine specific, multiple factors that contribute to pain.

A physiatrist, also known as a physical medicine and rehabilitation physician, can diagnose a range of pain conditions and help people navigate therapies to manage back pain.

In addition, the authors noted that the reporting of socioeconomic and demographic information was poor and inconsistent across the included studies. This means that the findings of the study may not apply to everyone.

How do psychological therapies help with pain?

Psychological therapies can help people reframe negative thoughts and change pain perception, attitudes, and behaviors. Examples of approaches that aim to reduce pain-related distress are cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), biofeedback, and pain reprocessing therapy (PRT). A recent study evaluating PRT showed that psychological treatment focused on changing beliefs about the causes and consequences of chronic low back pain may provide substantial, long-lasting pain relief.

Neuroscience has demonstrated that the brain and body are always connected, and pain is a combination of medical, cognitive, emotional, and environmental issues. Strategies to manage pain effectively must address your body and brain by integrating physical and psychological therapies, such as with functional restoration programs and working with a pain psychologist. Gaining a better understanding of pain, and treating all factors contributing to your chronic pain, can be empowering and healing.

Follow me on Twitter @DanielleSarnoMD

About the Author

photo of Danielle L. Sarno, MD

Danielle L. Sarno, MD, Contributor

Dr. Danielle Sarno is the director of interventional pain management in the department of neurosurgery at Brigham and Women’s Hospital, and an instructor of physical medicine and rehabilitation at Harvard Medical School. She is the founding … See Full Bio View all posts by Danielle L. Sarno, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Gun violence: A long-lasting toll on children and teens

A classroom with several rows of empty desks and chairs in front of large-multipaned windows

In the aftermath of the killing of 19 children and two adults in an elementary school in Uvalde, Texas, there is a lot of discussion — and argument — about what we should do to prevent shootings like this from happening.

In the midst of all the back and forth between banning guns and arming teachers, there is an important question that cannot be lost: what does it do to a generation of children to grow up knowing that there is nowhere they are safe?

There is increasing research that growing up amidst violence, poverty, abuse, chronic stress, or even chronic unpredictability affects the brains and bodies of children in ways that can be permanent. These adverse childhood experiences put the body on high alert, engaging the flight-or-fight responses of the body in an ongoing way. This increases the risk of depression, anxiety, and substance abuse, but it does so much more: the stress on the body increases the risk of cancer, heart disease, chronic disease, chronic pain, and even shortens the lifespan. The stress on the brain can literally change how it is formed and wired.

Long-term effects on a generation

Think for a moment about what this could mean: an entire generation could be forever damaged in ways we cannot change. The ramifications, not just for their well-being but for future generations and our work force and health care system, are staggering: stress like this can be passed on, and affects parenting.

As we talk about arming teachers and increasing armed police at schools, it is important to remember that research shows that the more guns, the higher the risk of homicide. It’s also important to remember that many children die every year from unintentional shootings in the home. In fact, guns have overtaken motor vehicle accidents as the leading cause of death in children. The idea of “arming the good guys” is an understandable response to horrible events like Uvalde, Parkland, and Sandy Hook, but the data would suggest that it may not be the most successful one. Violence begets violence, and guns aren’t reliably used the way we want them to be.

It’s not just guns, of course. There are other stressors, like poverty, community violence, child abuse, racism and all the other forms of intolerance, and lack of access to health care and mental health care. The pandemic has likely forever altered this generation in ways we cannot change, too.

The communities our children are growing up in and the world they are growing up in are increasingly becoming scary places. If we care about our children, if we care about our future, we need to stop fighting among ourselves and come together to create solutions that support the health and well-being of children, families, and communities. We need to nurture our children, not terrify them.

About the Author

photo of Claire McCarthy, MD

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Period equity: What it is and why it matters

Photo of tampons, pads, and menstrual hygiene products on floor

It’s happened to so many people who menstruate: you’re going about your life until you realize that you just got your period. The ungainly scramble to find a restroom and the fervent prayer that you packed a menstrual product leaves you feeling anxious, vulnerable, and exposed. This is compounded by the fact that our society stigmatizes menstruation — or really, anything to do with a uterus — and a taboo hangs over these discussions.

This scenario is far worse if you are one of the nearly 22 million women living in poverty in the US who cannot afford menstrual hygiene products, a problem known as period poverty. One study in Obstetrics & Gynecology demonstrated that 64% of women reported ever having difficulty affording menstrual products, such as pads, tampons, or reusable products like menstrual cups. And 21% reported that they were unable to afford these products every month. People who are homeless or incarcerated are at particularly high risk of not having access to adequate menstrual hygiene products.

Why are period products a luxury?

Menstruating is a basic fact of human existence. Menstrual hygiene products are necessities, not luxuries, and should be treated as such. Unfortunately, food stamps and subsidies under the WIC (women, infants, and children) program that help with groceries do not cover menstrual products.

I have had patients tell me that they use toilet paper or paper towels instead of pads or tampons because they cannot afford menstrual products. People with heavy periods requiring frequent changes of these products particularly face financial challenges, as they must buy even more pads or tampons than the average menstruating person. If they try to extend the life of products by using them for multiple hours at a time, they can wind up with vulvar irritation and vaginal discomfort. They may also be at greater risk for toxic shock syndrome, a life-threatening infection.

Why is it important to talk about stigma around periods?

We need to address stigma around menstruation in order to understand and fix the challenges people face around access to menstrual hygiene products. Period poverty is real. Period equity should be real, too. Embarrassment or taboos may prevent people from advocating for themselves, but if that stigma is removed — or even eased by talking through these issues — we as a society can move forward to address the needs of half of our population. There is no equity when half the population bears the financial and physical distress as a consequence of the reproductive cycle needed to ensure human survival.

How can we address period poverty?

There are simple solutions to period poverty. The first is to eliminate the tax on menstrual products. Think about it: just as food, a necessity for all of us, is not taxed, menstrual products should not be taxed. Products that are reusable, such as menstrual cups or underwear, should be subsidized, and their use encouraged, to eliminate excess waste from individually wrapped pads and tampons. If these products are publicized, promoted, and affordable, more women may opt for them. Pads and tampons should be available free of charge in schools and federal buildings (note: automatic download).

Finally, you can take action: write to or call your legislators! There is a fantastic bill, Menstrual Equity For All Act of 2019, sponsored by Representative Grace Meng, that was introduced on March 26, 2019, but never received a vote. There is no good reason why this bill, which would allow homeless people, incarcerated people, students, and federal employees free access to menstrual hygiene products, was never even brought forward for a vote. We live in one of the world’s wealthiest countries, and lack of menstrual hygiene products should never impact someone’s ability to work or go to school. It’s time to stop treating people with a uterus as second-class citizens.

About the Author

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Huma Farid, MD, Contributor

Dr. Huma Farid is an obstetrician/gynecologist at Beth Israel Deaconess Medical Center, and an instructor in obstetrics and gynecology at Harvard Medical School. She directs the resident colposcopy clinic and is the associate program director for the obstetrics and … See Full Bio View all posts by Huma Farid, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Colon cancer screening decisions: What’s the best option and when?

illustration of intestines flanked by two figures in medical scrubs, the one on the left is holding a clipboard and the one on the right is holding a magnifying glass and holding it over the colon

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States, and rates are rising, particularly in adults ages 20 to 49. Unfortunately, approximately 30% of eligible people in the US still have not been screened for CRC.

Colon cancer may be prevented with screening tests that look for cancer or precancerous growths called colon polyps.

When should you start screening?

The United States Preventative Services Task Force recommends starting screening for CRC at age 45 for average-risk patients. These guidelines reflect the most up-to-date research on when risk for colon cancer begins to increase.

Average-risk patients are those with no personal or family history of colon cancer or a genetic condition that increases the risk of developing CRC. For this reason, it is important for patients to share their family history, including all cancer diagnoses in blood relatives, with their primary care doctor, who can help decide the right time to begin colon cancer screening.

High-risk patients are advised to begin screening before age 45. A primary care physician can help determine when and how a patient who is concerned about their risk level should be screened for CRC. Patients who have a history of CRC or polyps; a first-degree family member with CRC or advanced polyps (those that would have gone on to become CRC if they had not been removed); a family history of certain genetic syndromes; or a history of inflammatory bowel disease (like Crohn’s disease or ulcerative colitis) are some examples of high-risk factors.

What are the options for CRC screening?

Colonoscopy: Colonoscopy is the gold standard of screening tests, and identifies approximately 95% of CRC. It is also the only method that allows a gastroenterologist to both detect and remove potentially precancerous colon polyps. Colonoscopies are considered low-risk procedures, but they do have a small risk of bleeding and perforation that increases in older age groups.

Patients need to clean out their colon prior to the procedure by drinking a colonoscopy prep, which washes stool out of the colon so that it can be properly assessed during the procedure. The prescription instructions for the prep are provided by the gastroenterologist’s office.

In most cases, the procedure will be performed under sedation to ensure the patient is as comfortable as possible. It is important to note that patients are not placed under general anesthesia, but most remain sleepy and comfortable throughout their colonoscopy.

During the colonoscopy, a gastroenterologist will insert a flexible tube with a camera at the end, called a colonoscope, into the rectum. The entire colon is then carefully examined. If no polyps are detected and the preparation (cleanout) of the colon is adequate, a repeat a colonoscopy is suggested in 10 years. If polyps are detected, or the patient’s risk level or symptoms change, this interval will be shorter.

FIT testing: The fecal immunochemical test (FIT) is a lab test that looks for hidden blood in the stool. Patients use a kit to collect their stool and then use a probe to scrape the stool, which is then placed into a tube and mailed to the lab. FIT testing is repeated every year. A drawback of FIT testing is that it has a false positive rate of approximately 5%. It can effectively rule out CRC with 79% accuracy. FIT testing is noninvasive, convenient, and cost-effective, making it an acceptable alternative to a colonoscopy for many people. If a stool test is positive, a colonoscopy is needed to evaluate the reason for the positive test.

Flexible sigmoidoscopy: A flexible tube with a camera is used to look at the rectum and the lower part of the colon. The advantages of this procedure are that it is faster than a colonoscopy (only 5 to 15 minutes) and requires less aggressive laxative medications. Typically, patients receive a flexible sigmoidoscopy every five years if no polyps are detected. As this test does not examine the whole colon, it cannot detect cancers or polyps in the unexamined portion. At best, it can detect 70% of cancers and polyps. If an abnormality is detected, a follow-up colonoscopy is needed to look at the entire colon.

CT colonography: A CT scan is used to visualize your rectum and entire colon. Just like with a colonoscopy, patients need to take laxative medications the night before to empty the colon. A small tube is placed in the rectum to expand the colon to get clear pictures. This test may be useful for patients who cannot tolerate anesthesia or have other medical conditions that prevent them from having a colonoscopy. A drawback of CT colonography is radiation exposure, and finding unrelated abnormalities outside the colon that can lead to unnecessary tests. While CT colonography is about 88.7% accurate at finding certain polyps, it is less accurate than colonoscopy overall. If the CT colonography result is abnormal, a colonoscopy is required for full evaluation of the colon.

Cologuard: This is a test where patients collect their stool, scrape it with a probe, insert it into a container with preservative, and mail it to the lab. This test looks for atypical DNA, or traces of blood in the collected stool that may be suggestive of precancerous polyps or CRC. Typically, patients repeat the test every three years. If the Cologuard test is positive, a colonoscopy is necessary for further evaluation. However, Cologuard’s accuracy is still limited; 13% of the time the test indicates the patient may have cancer when they do not. In 2019, a study showed that annual FIT testing or colonoscopy may be more effective and less costly than Cologuard. Further research is ongoing to evaluate how accurate (and thus how useful) this test is at detecting CRC.

Which screening option should you choose?

The most important part of colon cancer screening is to have a screening test performed. For most patients, colonoscopy or FIT testing are the most common ways to screen for colon cancer. However, there are other options to consider if you are unable to undergo or are uncomfortable with colonoscopy or FIT testing. Ultimately, this is an important and personalized decision, and a discussion for a patient to have with their healthcare provider, so that the right test can be done at the right time.

About the Authors

photo of Nisa Desai, MD

Nisa Desai, MD, Contributor

Dr. Nisa Desai is a practicing hospitalist physician at Beth Israel Deaconess Medical Center, and an instructor in medicine at Harvard Medical School. She completed undergraduate education at Northwestern University, followed by medical school at the … See Full Bio View all posts by Nisa Desai, MD photo of Loren Rabinowitz, MD

Loren Rabinowitz, MD, Contributor

Dr. Loren Rabinowitz is an instructor in medicine Beth Israel Deaconess Medical Center and Harvard Medical School, and an attending physician in the Inflammatory Bowel Disease Center at BIDMC. Her clinical research is focused on the … See Full Bio View all posts by Loren Rabinowitz, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Misgendering: What it is and why it matters

illustration resembling a chalk drawing of a line of figures on a black background with a variety of gender identity symbols in different colors for heads

As a cisgender woman with long hair and a closet full of dresses, I can count on one hand the number of times I’ve been misgendered by being called “he” or “sir.” Cisgender means I was assigned female at birth and identify as a woman. For people who are transgender and/or nonbinary (TNB), with a different gender identity than their assigned sex at birth, being misgendered may be a daily occurrence.

Why does misgendering matter?

Imagine a scenario in which you are called the wrong pronoun or honorific — for example Mr., Ms., or Mrs. — multiple times a day. It might happen in person, over the phone, or via email. Each time it happens, you must decide whether it is worth it to correct that person or easier to let it go. Imagine that you are repeatedly confronted with this experience and the decision of whether or not to correct it throughout the day — every day. As we know from research, and as I’ve also heard from the TNB people I know, this is both exhausting and demoralizing. When people are misgendered, they feel invalidated and unseen. When this happens daily, it becomes a burden that can negatively impact their mental health and their ability to function in the world.

If you are a cisgender person, you can lighten this burden for TNB people by using the right names, pronouns, and honorifics to refer to them, apologizing when you misgender someone, and correcting other people when they misgender someone.

How do you use the correct name, pronouns, and honorifics?

It’s simple: follow the person’s lead, or ask them. The name, pronouns, and honorifics that a person chooses to use for themselves communicate to others how they want to be seen and acknowledged. Using the correct terms for someone is a sign of respect and recognition that you see them as they see themselves.

If you knew someone previously as one gender and now they use a different name, pronouns, or honorifics, it can be hard to remember to use the right terms, especially if the person is gender-fluid and changes their pronouns more often. It can also be challenging to adjust to using gender-neutral pronouns like they and them, neopronouns like ze and zir, and unfamiliar honorifics, such as Mx (pronounced “mix”). But using the right terms is critically important for supporting and respecting TNB people.

A few tips and tools

  • Try not to make assumptions about a person’s name, pronouns, or honorifics based on how they look. The only way to know for sure what terms a person uses is to ask them in private (“What pronouns do you use?”). Asking someone in front of other people may unintentionally put them on the spot to disclose their identity to new people. You can ask anyone — cisgender or TNB — their name, pronouns, or honorifics.
  • Once you know what terms a person uses, the best way to make sure that you use the correct ones is to practice (this tool can help). Practice when they are in the room and when they are not in the room. Practice before you know you will see someone. Practice with others in your life: your cisgender friends, your spouse, your pet, your child. In our household, my wife and I try to use gender-neutral pronouns to refer to our preschooler’s toys and dolls so that we can practice using them ourselves. We even change the pronouns of characters in books that we read as another way to practice.
  • Another tip for remembering to use the correct name, pronouns, and honorifics is to pause before you speak. When we are stressed or busy, we are more likely to misgender people. Try to pause for a beat before you speak to make sure you are using the right terms to refer to someone. Similarly, reread emails before you send them to make sure you are not misgendering someone.
  • Be patient as you learn to use new terms and pronouns. It gets easier with practice and may become second nature over time.

How to apologize for misgendering someone

Misgendering will happen. What’s most important is how you handle it when it does. The best way to handle misgendering someone who is present is to apologize and try harder next time (“I’m sorry, I meant [correct name/pronoun/honorific]”). Keep your apology brief so that it doesn’t become about you and your mistake.

If you are corrected by someone else, try not to be defensive. Instead, simply respond with a thank you and a correction (“Oh, thank you — I’ll email [correct name/pronoun] about that”). This is an important step, even if the misgendered person is not present, so you can practice and so others can learn from your example. Any time you misgender someone, practice so you can do better next time.

How to correct misgendering when you hear or see it

As a cisgender colleague and supervisor to numerous TNB people, many of whom are nonbinary and use they/them pronouns, I often find myself in situations where I need to correct misgendering. I might say something like “I noticed you used she to refer to that person. Just to let you know, they use they/them pronouns.” Or I might write a note in a Zoom chat or in an email, “Just a friendly reminder that this person uses they/them pronouns.” Stepping forward this way lessens the burden of correcting misgendering for TNB people. It also models to others that a correction can be done in a friendly way, and is important for respecting and including TNB people.

How to use gender-neutral language and normalize pronouns

One way to avoid misgendering is to use gender neutral language. Here are some examples:

  • Instead of “boys and girls” or “ladies and gentlemen,” say “everyone.”
  • Instead of “fireman” or “policeman,” say “firefighter” or “police officer.”
  • Instead of “hey guys,” say “hey everyone” or “hey all.”

Try to pay attention to your language and find ways to switch to gender-neutral terms.

You can be mindful of your own pronouns and help other people be mindful by normalizing displays of pronouns. Here are some ways that I make my own pronouns (she/her) visible to others:

  • I list my pronouns in my email signature, in my Zoom name, and on the title page of presentations.
  • I wear a pronoun pin at work.
  • I introduce myself with my pronouns.

These actions signal to others that I am thinking about pronouns,  and am aware that people may use different pronouns than might be expected from their appearance.

You may still make mistakes, but it’s important to keep practicing and trying to use the right terms! By using the correct names, pronouns, and honorifics to refer to people, apologizing when you misgender someone, and correcting other people when they misgender, you can support and respect the TNB people around you. This helps create a more inclusive world for everyone.

About the Author

photo of Sabra L. Katz-Wise, PhD

Sabra L. Katz-Wise, PhD, Contributor

Sabra L. Katz-Wise, PhD (she/her) is an assistant professor in adolescent/young adult medicine at Boston Children’s Hospital, in pediatrics at Harvard Medical School, and in social and behavioral sciences at the Harvard T.H. Chan School of … See Full Bio View all posts by Sabra L. Katz-Wise, PhD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Cognitive effects in midlife of long-term cannabis use

photo of a small model of a human brain resting on a cannabis leaf, with a stethoscope behind them

As of June 2022, 37 US states have passed medical cannabis laws and 19 states have legalized recreational cannabis. Cannabis has proven beneficial for a range of conditions such as childhood seizure disorders, nausea, vomiting, and loss of appetite in people with HIV/AIDs.

In the meantime, a new generation of cannabis products has exploded onto the scene, driven by marketing that fuels a multibillion-dollar industry. The average content of THC (tetra-9-tetrahydrocannabinol, the psychoactive and potentially addictive chemical in cannabis) in smoked whole-plant products has risen from 1% to 4% in the 1970s to 15% to 30% from today’s cannabis dispensaries. Edibles and vapes may contain even higher concentrations of THC.

While public perception that cannabis is a harmless substance is growing, the long-term benefits and risks of cannabis use remain unclear. However, one consistent pattern of research has emerged: heavy long-term cannabis use can impact midlife cognition.

New research on cannabis use and cognition in midlife

Recent research published in The American Journal of Psychiatry closely followed nearly 1,000 individuals in New Zealand from age 3 to age 45 to understand the impact of cannabis use on brain function. The research team discovered that individuals who used cannabis long-term (for several years or more) and heavily (at least weekly, though a majority in their study used more than four times a week) exhibited impairments across several domains of cognition.

Long-term cannabis users’ IQs declined by 5.5 points on average from childhood, and there were deficits in learning and processing speed compared to people that did not use cannabis. The more frequently an individual used cannabis, the greater the resulting cognitive impairment, suggesting a potential causative link.

The study also found that people who knew these long-term cannabis users well observed that they had developed memory and attention problems. The above findings persisted even when the study authors controlled for factors such as dependence on other drugs, childhood socioeconomic status, or baseline childhood intelligence.

The impact of cannabis on cognitive impairment was greater than that of alcohol or tobacco use. Long-term cannabis users also had smaller hippocampi (the region of the brain responsible for learning and memory). Interestingly, individuals who used cannabis less than once a week with no history of developing dependence did not have cannabis-related cognitive deficits. This suggests there is a range of recreational use that may not lead to long-term cognitive issues.

More studies are needed on cannabis use and brain health

The new research is just one of several studies suggesting there is a link between long-term heavy cannabis use and cognition. Still, future studies are needed to establish causation and explore how long-term cannabis use might impact the risk of developing dementia, since midlife cognitive impairment is associated with higher rates of dementia.

What should you do if you experience cognitive effects of cannabis?

Some people who consume cannabis long-term may develop brain fog, lowered motivation, difficulty with learning, or difficulty with attention. Symptoms are typically reversible, though using products with higher THC content may increase risk of developing cognitive symptoms.

Consider the following if you are experiencing cannabis-related cognitive symptoms:

  • Try a slow taper. Gradually decrease the potency (THC content) of cannabis you use or how frequently you use it over several weeks, especially if you have a history of cannabis withdrawal.
  • Work with your doctor. Be open with your doctor about your cognitive symptoms, as other medical or psychiatric factors may be at play. Your doctor can also help you navigate a cannabis taper safely, and potentially more comfortably, using other supportive means. Unfortunately, most patients are not comfortable talking with their doctors about cannabis use.
  • Give it time. It may take up to a month before you experience improvements after reducing your dose, as cannabis can remain in the body for two to four weeks.
  • Try objective cognitive tracking. Using an app or objective test such as the mini-mental status exam to track your brain function may be more accurate than self-observation. Your mental health provider may be able to assist with administering intermittent cognitive assessments.
  • Consider alternative strategies. Brain function is not static, like eye color or the number of toes on our feet. Aerobic exercise and engaging in mindfulness, meditation, and psychotherapy may improve long-term cognition.

Cannabis is an exciting yet controversial topic that has drawn both hype and skepticism. It is important for individuals and healthcare professionals to place emphasis on research studies and not on speculation or personal stories. Emerging studies suggesting the connection between long-term heavy use of cannabis and neurocognition should raise concern for policymakers, providers, and patients.

About the Authors

photo of Kevin Hill, MD, MHS

Kevin Hill, MD, MHS, Contributor

Dr. Kevin Hill is director of addiction psychiatry at Beth Israel Deaconess Medical Center, and an associate professor of psychiatry at Harvard Medical School. He earned a master’s in health science at the Robert Wood Johnson … See Full Bio View all posts by Kevin Hill, MD, MHS photo of Michael Hsu, MD

Michael Hsu, MD, Guest Contributor

Dr. Michael Hsu is a resident psychiatrist and is currently the chief resident of outpatient psychiatry at Brigham and Women's Hospital, a teaching hospital of Harvard Medical School. After graduating from the University of Pennsylvania with … See Full Bio View all posts by Michael Hsu, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Ring vaccination might help curtail monkeypox outbreaks

A red figure standing in a white circle connected to a white circle with a black figure, who is connected to circles with two other black figures; the concept of how infection spreads

By now, you’ve probably heard that there is a monkeypox outbreak traveling around the globe. Cases have spread far and wide, including in the US, Canada, Europe, and Australia. It’s the largest outbreak ever recorded outside of western and central Africa, where monkeypox is common.

But controlling this outbreak demands preventive measures, such as avoiding close contact with people who have the illness and vaccination. One method of vaccination, called ring vaccination, has worked well in the past to contain smallpox and Ebola outbreaks. It may be effective for monkeypox as well.

How can monkeypox be contained?

According to the Centers for Disease Control and Prevention (CDC) and the World Health Organization, monkeypox is unlikely to become a pandemic. At this time, the threat to the general public is not high. The focus is on identifying possible cases and containing the outbreak as soon as possible.

Three important steps can help stop this outbreak:

  1. Recognize early symptoms
  • Usually, early symptoms are flulike, including fever, fatigue, headache, and enlarged lymph nodes.
  • A rash appears a few days later, changing over a week or two from small flat spots to tiny blisters similar to chickenpox, then to larger, pus-filled blisters.
  • The rash often starts on the face and then appears on the palms, arms, legs, and other parts of the body. If monkeypox is spread by sexual contact, the rash may show up first on or near the genitals.
  1. Take steps to stop the spread
  • Monkeypox spreads through respiratory droplets or by contact with fluid from skin sores.
  •  Anyone who has been diagnosed with monkeypox, or who suspects they might have it, should avoid close contact with others. Once the sores scab over, the infected person is no longer contagious.
  • Health care workers and other caregivers should wear standard infection control gear, including gloves and a mask.
  • In the current outbreak, many cases began with sores in the genital and rectal areas among men who have sex with men, so doctors suspect sexual contact spread the infection. As a result, experts are encouraging abstinence when monkeypox is suspected or confirmed.
  1. Use vaccination to help break the chain
  • Monkeypox is closely related to smallpox. People who received a smallpox vaccine in the past may have some protection from monkeypox. (The US smallpox vaccination program was discontinued in 1972, and smallpox was declared eradicated worldwide in 1980.)
  • Stockpiled smallpox vaccinations and newer vaccines that can be used for monkeypox or smallpox are also available.

Ring vaccination

Monkeypox differs from the virus that causes COVID-19. People with monkeypox usually have symptoms when they’re contagious, and the number of infected persons is usually limited.

This means it’s possible to vaccinate a “ring” of people around them rather than vaccinating an entire population. This selective approach is called ring vaccination.

Ring vaccination has been used successfully to contain smallpox and Ebola outbreaks. It may come in handy for monkeypox as well. Here’s how it works:

  • As soon as a case of monkeypox is suspected or confirmed, the patient and their close contacts are interviewed to identify possible exposures.
  • Vaccination is offered to all close contacts.
  • Vaccination is also offered to those who had close contact with the infected person’s contacts.

Ideally, people should be vaccinated within four days of exposure.

This approach requires widespread awareness of monkeypox, rapid isolation of suspected cases, and an efficient contact tracing system. And of course, vaccines must be available whenever and wherever new cases arise.

Are the vaccines used for monkeypox effective?

According to the CDC, the smallpox vaccine is 85% effective against monkeypox.

While a newer vaccine (JYNNEOS) directed against monkeypox and smallpox has only been tested for effectiveness in animals, it is also expected to be highly effective in humans.

Of course, vaccinations can only work if people are willing to receive them. We’ll learn more about this as more people are offered the option for vaccination.

Are the vaccines used for monkeypox safe?

As with most vaccines, the most common side effects include

  • sore or itchy arm at the site of the injection
  • mild allergic reactions
  • mild fever or fatigue.

Fortunately, more severe side effects, such as significant allergic reactions, are rare.

The bottom line

In light of the current monkeypox outbreak, you may soon be hearing more about ring vaccination. Then again, if appropriate measures are taken to prevent its spread, this outbreak may soon be over. Either way, this won’t be the last time an unusual virus shows up seemingly out of the blue in unexpected places. Climate change, shrinking animal habitats, rising global animal trade, and increasing international travel mean that it’s only a matter of time before this happens again.

About the Author

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Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

If cannabis becomes a problem: How to manage withdrawal

close-up photo of the hands of a young man rolling a joint

 

Proponents of cannabis generally dismiss the idea that there is a cannabis withdrawal syndrome. One routinely hears statements such as, “I smoked weed every day for 30 years and then just walked away from it without any problems. It’s not addictive.” Some cannabis researchers, on the other hand, describe serious withdrawal symptoms that can include aggression, anger, irritability, anxiety, insomnia, anorexia, depression, restlessness, headaches, vomiting, and abdominal pain. Given this long list of withdrawal symptoms, it’s a wonder that anyone tries to reduce or stop using cannabis. Why is there such a disconnect between researchers’ findings and the lived reality of cannabis users?

New research highlights the problems of withdrawal, but provides an incomplete picture

A recent meta-analysis published in JAMA cites the overall prevalence of cannabis withdrawal syndrome as 47% among “individuals with regular or dependent use of cannabinoids.” The authors of the study raise the alarm that “many professionals and members of the general public may not be aware of cannabis withdrawal, potentially leading to confusion about the benefits of cannabis to treat or self-medicate symptoms of anxiety or depressive disorders.” In other words, many patients using medical cannabis to “treat” their symptoms are merely caught up in a cycle of self-treating their cannabis withdrawal. Is it possible that almost half of cannabis consumers are actually experiencing a severe cannabis withdrawal syndrome — to the point that it is successfully masquerading as medicinal use of marijuana — and they don’t know it?

Unfortunately, the study in JAMA doesn’t seem particularly generalizable to actual cannabis users. This study is a meta-analysis: a study which includes many studies that are deemed similar enough to lump together, in order to increase the numerical power of the study and, ideally, the strength of the conclusions. The authors included studies that go all the way back to the mid-1990s — a time when cannabis was illegal in the US, different in potency, and when there was no choice or control over strains or cannabinoid compositions, as there is now. One of the studies in the meta-analysis included “cannabis-dependent inpatients” in a German psychiatric hospital in which 118 patients were being detoxified from cannabis. Another was from 1998 and is titled, “Patterns and correlates of cannabis dependence among long-term users in an Australian rural area.” It is not a great leap to surmise that Australians in the countryside smoking whatever marijuana was available to them illegally in 1998, or patients in a psychiatric hospital, might be substantively different from current American cannabis users.

Medical cannabis use is different from recreational use

Moreover, the JAMA study doesn’t distinguish between medical and recreational cannabis, which are actually quite different in their physiological and cognitive effects, as Harvard researcher Dr. Staci Gruber’s work tells us. Medical cannabis patients, under the guidance of a medical cannabis specialist, are buying legal, regulated cannabis from a licensed dispensary; it might be lower in THC (the psychoactive component that gives you the high) and higher in CBD (a nonintoxicating, more medicinal component), and the cannabis they end up using often results in them ingesting a lower dose of THC.

Cannabis withdrawal symptoms are real

All of this is not to say that there is no such thing as a cannabis withdrawal syndrome. It isn’t life-threatening or medically dangerous, but it certainly does exist. It makes absolute sense that there would be a withdrawal syndrome because, as is the case with many other medicines, if you use cannabis every day, the natural receptors by which cannabis works on the body “down-regulate,” or thin out, in response to chronic external stimulation. When the external chemical is withdrawn after prolonged use, the body is left in the lurch, and forced to rely on natural stores of these chemicals, but it takes time for the natural receptors to grow back to their baseline levels. In the meantime, the brain and the body are hungry for these chemicals, and the result is withdrawal symptoms.

Getting support for withdrawal symptoms

Uncomfortable withdrawal symptoms can prevent people who are dependent on or addicted to cannabis from remaining abstinent. The commonly used treatments for cannabis withdrawal are either cognitive behavioral therapy or medication therapy, neither of which has been shown to be particularly effective. Common medications that have been used are dronabinol (which is synthetic THC); nabiximols (which is cannabis in a mucosal spray, so you aren’t actually treating the withdrawal); gabapentin for anxiety (which has a host of side effects); and zolpidem for the sleep disturbance (which also has a list of side effects). Some researchers are looking at CBD, the nonintoxicating component of cannabis, as a treatment for cannabis withdrawal.

Some people get into serious trouble with cannabis, and use it addictively to avoid reality. Others depend on it to an unhealthy degree. Again, the number of people who become addicted or dependent is somewhere between the 0% that cannabis advocates believe and the 100% that cannabis opponents cite. We don’t know the actual number, because the definitions and studies have been plagued with a lack of real-world relevance that many studies about cannabis suffer from, and because the nature of both cannabis use and cannabis itself have been changing rapidly.

How do you know if your cannabis use is a problem?

The standard definition of cannabis use disorder is based on having at least two of 11 criteria, such as: taking more than was intended, spending a lot of time using it, craving it, having problems because of it, using it in high-risk situations, getting into trouble because of it, and having tolerance or withdrawal from discontinuation. As cannabis becomes legalized and more widely accepted, and as we understand that you can be tolerant and have physical or psychological withdrawal from many medicines without necessarily being addicted to them (such as opiates, benzodiazepines, and some antidepressants), I think this definition seems obsolete and overly inclusive.

For example, if one substituted “coffee” for “cannabis,” many of the 160 million Americans who guzzle coffee on a daily basis would have “caffeine use disorder,” as evidenced by the heartburn and insomnia that I see every day as a primary care doctor. Many of the patients that psychiatrists label as having cannabis use disorder believe that they are fruitfully using cannabis to treat their medical conditions — without problems — and recoil at being labeled as having a disorder in the first place. This is perhaps a good indication that the definition doesn’t fit the disease.

Perhaps a simpler, more colloquial definition of cannabis addiction would be more helpful in assessing your use of cannabis: persistent use despite negative consequences. If your cannabis use is harming your health, disrupting your relationships, or interfering with your job performance, it is likely time to quit or cut down drastically, and consult your doctor. As part of this process, you may need to get support or treatment if you experience uncomfortable withdrawal symptoms, which may make it significantly harder to stop using.

About the Author

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Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Struggling with migraine hangovers? Read this

Bright yellow background and pink silhouette print of a woman from the shoulders up, wearing glasses and looking pained, head slightly tipped and the fingers of one hand on her temple

When the trademark throbbing from a migraine finally lifts, the relief is profound. But for many people regularly stricken with these potentially debilitating headaches, their distress isn’t over just because the pain ends. Instead, a distinct phase of migraine called the postdrome leaves them feeling achy, weary, dazed, and confused — symptoms eerily similar to another affliction altogether.

Dubbed the “migraine hangover,” this constellation of post-headache symptoms is remarkably common, following up to 80% of migraine attacks, according to research published in Neurology. Scientists are increasingly turning their focus to this previously underrecognized component of migraine, according to Dr. Paul Rizzoli, clinical director of the Graham Headache Center at Brigham and Women’s Faulkner Hospital.

“Not knowing it’s an accepted part of migraine, patients come up with some creative ways to tell us about their postdrome symptoms — they feel washed out, their head feels hollow, or they feel like they have a hangover but weren’t even drinking,” Dr. Rizzoli explains. “Until recent years, science hadn’t paid attention to this facet of the syndrome, but it’s a natural progression from focusing on the problem as a whole.”

The four phases of migraine

The typical migraine can be a wretched experience, with stabbing head pain joined by nausea, brain fog, and extreme sensitivity to light and sound, among other symptoms. Nearly 16% of Americans are affected by migraines, which strike women at nearly twice the rate as men. Severe headaches are also one of the top reasons for emergency room visits.

Spanning hours to days, migraine headaches can include four clear phases, each with its own set of symptoms. The pre-pain prodrome and aura phases may include various visual changes, extremes of irritability, difficulty speaking, or numbness and tingling, while the headache itself can feel like a drill is working its way through the skull.

Lingering migraine symptoms: The hangover

After that ordeal, one to two days of postdrome symptoms may sound tame by comparison, Dr. Rizzoli says. But the lingering fogginess, exhaustion, and stiff neck can feel just as disabling as the headache that came before. Since migraine is believed to act as a sort of electrical storm activating neurons in the brain, it’s possible that migraine hangover results from “some circuits being electrically or neurochemically exhausted,” Dr. Rizzoli says. “It just takes time for the brain to return to normal function, or even replace some chemicals that have been depleted in the process.”

But much is still unknown about migraine postdrome, he adds, and research has found no consistent association between factors such as the type of migraine medication taken and duration of any subsequent hangover.

Tips to ease a migraine hangover

Following these steps regularly may help you ward off lingering symptoms after a migraine:

  • Drink plenty of water.
  • Practice good headache hygiene by maintaining regular eating and sleeping patterns and easing stress.
  • If possible, try to lighten your load for next 24 hours after the headache pain ends.
  • Stop taking pain medicine once the headache is gone.

For migraine hangover sufferers so distracted by their inability to return to normal activities even after migraine pain lifts, physicians sometimes prescribe medications typically meant for conditions such as memory loss, depression, or seizures. While they may differ from the usual drugs used to treat migraine, some of these medicines have been observed to help postdrome syndrome or act as a preventive for headache.

“Think of the headache you just had like you’ve run a marathon or done some other stressing activity,” Dr. Rizzoli says. “Your body needs to recover, which is not the same as staying in bed with the lights off. Ease up, but stay functional.”

About the Author

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Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

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HEALTHY-FOOD NATURAL-BEAUTY YOGA

Talking to your doctor about your LGBTQ+ sex life

photo of a woman doctor talking with a man patient sitting by a window, view is over patient's shoulder

Editor’s note: in honor of Pride Month, we’re re-publishing a 2019 post by Dr. Cecil Webster.

Generally speaking, discussing what happens in our bedrooms outside of the bedroom can be anxiety-provoking. Let’s try to make your doctor’s office an exception. Why is this important? People in the LGBTQ+ community contend not only with a full range of health needs, but also with environments that may lead to unique mental and physical health challenges. Whether or not you have come out in general, doing so with your doctor may prove critical in managing your health. Sexual experiences, with their impact on identity, varied emotional significance, and disease risk, are a keystone for helping your doctor understand how to personalize your healthcare.

Admittedly, talking about your intimate sexual experiences or your gender identity may feel uncomfortable. Many LGBTQ+ patients worry that their clinicians may not be knowledgeable about their needs, or that they’ll to have to educate them. Finding a LGBTQ+ adept doctor, preparing ahead of time for your next appointment, and courageously asking tough questions can give you and your health the best shot.

Finding a skilled clinician who is LGBTQ+ adept

Many large cities have healthcare institutions whose mission centers on care for LGBTQ+ peoples. However, these organizations may prove inaccessible to many for a variety of reasons. Regardless of your location, asking friends, family, or others to recommend a clinician may be a game changer. If your trans friend had a relatively painless experience visiting an area gynecologist, perhaps your Pap smear may go smoothly there as well. If your coworker has a psychiatrist who regularly asks him about his Grindr use, perhaps it may be easier to navigate your gay relationship questions with her.

Word of mouth is often an undervalued method of finding someone skilled and attentive to the needs of LGBTQ+ individuals. Online, many clinicians offer a short bio with their areas of expertise, and there are provider directories featuring trusted clinicians. Further, some doctors regularly write articles and give talks that may offer clues about desired knowledge. A simple Google search of your provider may yield a bounty.

Next, give your doctor or healthcare organization a call. Don’t be shy about requesting someone whose practice matches your specific needs. Your health information is protected, and generally, physicians hold your clinical privacy dear. Keep in mind that not all clinics will know or share whether or not your doctor is, for example, also a lesbian, but they may pair you with someone well suited to your request or point you in the right direction.

Preparing for your appointment

Let’s say you are nervous about coming out to your doctor. A little preparation may ease this burden. Here are some quick tips:

  • Let them know you’re nervous at the start of the conversation.
  • Be as bold as you can tolerate.
  • Write down what you are excited about, nervous about, and/or curious about.
  • Go in with a few goals and start with what’s most important.
  • Maximize your comfort. If your partner is calming, bring them. If Beyoncé soothes what ails you, bring her along too.
  • Lightly correct or update your clinician if they get something wrong.

Ask tough questions, give clear answers

As a psychiatrist who works with kids and adults, I often hear questions like, “I don’t know really how to say this, but I started experimenting with other guys. Does this mean I’m gay?” I may start by asking if you’ve enjoyed it. My colleagues in health care might begin with the same question.

Pleasurable experiences come in all sorts of constellations, and healthy exploration is part of being human. Additionally, clinicians need to assess and address your safety. Many LGBTQ+ people are at higher risk of intimate partner violence. We may ask about your use of condoms, how many partners you’ve had recently, your use of substances during sex, and how these experiences may shift how you see yourself. Give clear answers if possible, but don’t fret if you’re uncertain. Your doctor will not likely provide a label or pry unnecessarily. They may offer constructive information on the use of condoms, reasons to consider using PrEP (which can effectively prevent HIV), and places you can go for more guidance. Physicians enjoy giving personalized information so that you may make informed healthcare decisions.

There is no end to what is on people’s minds. Be bold. Will tucking reduce my sperm count? Maybe. Does binding my breasts come with risk? Likely. Was Shangela robbed of her RuPaul’s Drag Race: All Stars 3 crown? Utterly, but let’s get back to your cholesterol, shall we?

Remember that it is often impossible to squeeze everything into one appointment. Afterward, take time to catch your breath, reflect on what you’ve learned, and come up with more questions for next time. We’re here for that.

About the Author

photo of Cecil R. Webster, Jr., MD

Cecil R. Webster, Jr., MD, Contributor

Dr. Cecil R. Webster, Jr. is a child, adolescent, and adult psychiatrist in Boston. He is a lecturer in psychiatry at McLean Hospital and Harvard Medical School, and consultant for diversity health outreach programs at the … See Full Bio View all posts by Cecil R. Webster, Jr., MD