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Thursday, January 31, 2019

Dairy: Health food or health risk

For 30 years, I have talked to people about their memories and, as a neuropsychologist interested in amnesia, I am very interested in brain areas that mediate learning and forgetting.
How memories work

A core brain structure for memory is the hippocampus. The hippocampus (the Greek word for seahorse) is shaped like its namesake. It plays a key role in the consolidation of new memories and in associating a new event with its context (e.g., where it took place, when it happened). For example, you might hear the name Princess Diana. The hippocampus may activate verbal associations (e.g., she was part of the Royal Family), as well as memories of particular images or experiences. When I hear the name Princess Diana, I recall my brother telling me of her death as I descended the stairs of his home on Cape Cod. I can picture that moment in my “mind’s eye.” Despite my age, my (relatively) intact hippocampus allows me to retrieve a complex set of images and ideas that remind me where I was and who I was with when I heard the sad news of Princess Di’s death.
Memories that last

Some memories seem to age well. Recall of specific “flashbulb” events, such as the death of John F. Kennedy, or where you were on September 11th, 2001, seems unblemished and unchanged over time. However, in reality all memories, even flashbulb events, are malleable; they change as a result of the passage of time. They shift each time you call a memory to mind, as they are affected by other memories that have overlapping elements. As a student of memory, I am just as interested in long-term forgetting as I am in remembering. I am particularly intrigued by changes that take place with regard to autobiographical memory. Autobiographical memory is the foundation on which we derive a sense of who we are, what we find rewarding, and how we define our world. It is integral to how we construct meaning and purpose in our lives.
Autobiographical memory as we grow older

As we age our personal memories become fragile. They become less accurate and lose context. People with neurodegenerative conditions such as Alzheimer’s disease are particularly vulnerable to the loss of personal memories, due to the combined effects of their neurological condition and the aging process. They no longer have the same access to important milestones that helped define them. The importance of autobiographical memory is often overlooked. People come to me to ask for assistance with memory skills. I teach them all I know about mnemonic techniques to enhance face–name associations. I review cognitive strategies for new learning. I rarely talk about old memories… their first day of school, their first kiss, music from teenage years.
Tending to autobiographical memory

More recently I shifted my focus in conversations with people who want to talk about memory. Together with a therapist colleague, I started the “memoir project.” Why? I want to help highlight the important role of personal memories in maintaining a strong sense of self. People, even those with mild dementia, are encouraged to review important life events by using personal timelines to identify, for example, key events, food, music, and people who contributed to their sense of self. They may contact childhood friends, college roommates, and family members to remind them of shared experiences and to augment past memories. They often receive memory “gifts” as a result of these conversations — filling in the gaps in a memory that was beginning to fade. And of course, documentation and journaling are critical strategies. The stories people have shared with me have been fascinating. More important is the joy of reminiscence they experience.
If you’re the kind of person who avoids public bathrooms at all costs, you may feel validated, as well as disturbed, by a new study from researchers at the University of Connecticut and Quinnipiac University. They suspected that hot-air hand dryers in public restrooms might be sucking up bacteria from the air, and dumping them on the newly washed hands of unsuspecting patrons.

To test this theory, scientists exposed petri dishes to bathroom air under different conditions and took them back to the microbiology laboratory to look for bacterial growth. Petri dishes exposed to bathroom air for two minutes with the hand dryers off only grew one colony of bacteria, or none at all. However, petri dishes exposed to hot air from a bathroom hand dryer for 30 seconds grew up to 254 colonies of bacteria (though most had from 18 to 60 colonies of bacteria).

Were the bacteria multiplying inside the hand dryers, or were they being pulled into the hand dryers from the air inside the bathroom? To answer this question, the researchers attached high-efficiency particulate air (HEPA) filters to the dryers, which would eliminate most of the bacteria from the air passing through the dryer. When they exposed petri dishes to air from the hand dryers again, the quantity of bacteria in the dishes had fallen by 75%. As well, the researchers found minimal amounts of bacteria on the nozzles of the hand dryers. They concluded that most of the bacterial splatter from the hand dryers had come from the washroom air.

How did the bacteria get into the air in the first place? Unfortunately, every time a lidless toilet is flushed, it aerosolizes a fine mist of microbes. This fecal cloud may disperse over an area as large as six square meters (65 square feet). Aerosols from flushed toilets may be especially harmful in the hospital setting as a means of spreading Clostridium difficile.

Is there any good news from this study? Well, the vast majority of the microbes that were detected do not cause disease in healthy people, with the exception of Staphylococcus aureus. Some of the bathroom bacteria, such as Acinetobacter, only cause infections in people in the hospital, or in those with weak immune systems. The others that were found are relatively harmless. In addition, air from real-world bathrooms may contain fewer bacteria than the bathrooms in the study. The sampled restrooms were located in a university health sciences building, and at least some of the bacteria came from experiments going on in laboratories within the building.

So what’s a person to do to avoid picking up bacteria in a bathroom? You should still dry your hands, as not drying them after washing them helps bacteria to survive on them. Paper towels are the most hygienic way to dry your hands. For this reason, use of paper towels is already routine in health care settings. You may also wish to avoid jet air dryers, which have also been associated with the spread of germs in bathrooms. And remember that your chances of picking up a serious pathogen in a restroom are small. Direct contact with other people is much more likely as a means of acquiring infection.
The idea of using marijuana to mitigate the opiate crisis may seem counterintuitive to many people in the medical community. Some healthcare providers ask questions like, “Aren’t we just replacing one drug with another?” and “Doesn’t marijuana present its own set of dangers, such as addiction, dependency, and other health concerns?”

Medical marijuana is a divisive issue, and many intelligent, thoughtful people voice these concerns. Other people view cannabis research as an open and exciting field of discovery, and they want to advance marijuana as a safer option for patients who are managing chronic pain.
There is some common ground

People from both pro and con sides of the medical marijuana debate agree we need to study the medical benefits, safety, and dosing of marijuana, so that we can use it for difficult-to-manage diseases, such as opiate addiction and chronic pain. We now have data on how access to marijuana via medical marijuana dispensaries affects opioid use, and it’s positive. According to two studies recently published in JAMA Internal Medicine, the rate of opiate prescriptions is lower in states where medical marijuana laws have been passed.
Let’s look more at research

One of the studies, a longitudinal analysis of the number of opioid prescriptions filled under Medicare Part D, showed that when medical marijuana laws went into effect in a given state, opioid prescriptions fell by 2.21 million daily doses filled per year. When medical marijuana dispensaries opened, prescriptions for opioids fell by 3.74 million daily doses per year. These reductions in daily opioid doses were particularly notable for hydrocodone (Vicodin) and morphine prescriptions.

The other study analyzed Medicaid prescription data from 2011 to 2016, and that analysis showed that states that have implemented medical marijuana laws have seen a 5.88% lower rate of opioid prescribing, and when they implemented adult-use (i.e., recreational use) marijuana laws, there was a 6.38% reduction in opiate prescribing.

In the editorial accompanying these studies, the authors noted, “We do not know whether patients actually avoided or reduced opioid use because of increased access to cannabis (marijuana).” However, given that millions of prescriptions for opiates were not written, and consequently there were millions fewer bottles of prescription opiates consumed, sold, diverted, or abused, it does not seem to be too big a leap to infer that opiate use was avoided, or at least reduced.

In the same editorial, the authors make two more important points. The first alludes to research that shows opiates and cannabinoids (the active molecules in marijuana) use overlapping signaling systems in the body having to do with drug tolerance, pain, and dependence. This common mechanism would support and help explain stories of patients who describe a decreased need for opiates to treat chronic pain after starting to use medical cannabis. Second, the authors cited a 2014 study, also published in JAMA, which showed that “states with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws.” The fact that opioid overdose deaths appear to be falling in states with medical marijuana laws complements this new research that suggests that fewer opiates are being prescribed.
Doctors and their patients can discuss medical marijuana

Just as there is disconnect among different members of the medical community about fundamental conceptions of marijuana, there is a large disconnect between patient and physician approval ratings of medical marijuana. Patients are loudly clamoring for more and better quality information from their doctors. An April 2017 Quinnipiac University poll showed that 94% of Americans support “allowing adults to legally use marijuana for medical purposes, if their doctor prescribes it.”

Healthcare providers, whether they are pro-, neutral, or anti-medical marijuana, need to leave their prejudices outside the exam room. Physicians need to create a climate where patients feel they can be open with us, so that we can know if and how they are using medical marijuana. Physicians can be in a position to advise them on the risks and benefits of safe usage, and meaningfully contribute to the conversation (assuming that we ourselves have a modicum of education on this issue). Once we are all on the same page, guided by evidence in new studies about reduced opiate use and adding medical marijuana to the pain relief arsenal, we can start helping patients to minimize their use of opiates.

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