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Thursday, January 31, 2019

Is adrenal fatigue “real”?

Substance use disorder treatment takes time and financial resources. With over 14,500 substance use disorder treatment facilities in the United States, it is challenging to assess which ones offer quality treatment to help people begin the process of recovery. Your loved one’s life can depend on a successful outcome, so how do you find an effective program?

In a blog post for Psychology Today, the Recovery Research Institute has detailed 11 indicators of a high-quality addiction treatment center. Here we share six important things families should look for.
1. Nationally recognized accreditation from a quality monitoring agency

Accreditation from external regulatory organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), and the Council on Accreditation (COA) requires that any program offering minimum levels of evidence-based care must be open to a random audit of its clinical care. The same is true of state-licensed programs. Ask the treatment center about its national accreditation, call the certifying group, or ask your health insurance company.
2. Personalized, evidence-informed practices

Programs that deliver services founded on scientific research and available best practices tend to have better outcomes. Evidence-based care includes taking an individualized, comprehensive assessment and history of a range of substance use disorders and related conditions, including any physical or mental health conditions. This is followed by an assessment of the many factors affecting the person struggling with addiction (family and social networks and available recovery resources, or “recovery capital”). High-quality treatment programs create treatment that addresses the specific needs of men and women, adolescents versus adults, and those from different minority communities (e.g., LGBTQ) or cultural backgrounds.

Evidence-based treatments involve psychological interventions and accessibility to FDA-approved medications for addiction (e.g., buprenorphine/naloxone, methadone, naltrexone/depot naltrexone, acamprosate), as well as medication for people who have other mental health diagnoses (depression, anxiety, etc.). Motivational incentives to encourage patients to stick with their treatment plan are also part of evidence-based treatment.
3. Measures of program performance, including during-treatment “outcomes”

A further indicator of quality treatment is having reliable, valid measurement systems in place to track patients’ response to treatment. Similar to regular assessment of blood pressure at each check-up in treating high blood pressure, addiction treatment programs should collect “addiction and mental health vital signs” in order to monitor the effectiveness or ineffectiveness of the individualized treatment plan, and adjust it accordingly when needed.
4. Qualified multidisciplinary staff

A high-quality center should have a multidisciplinary staff (e.g., addiction, medicine, psychiatry, spirituality). A diverse staff can help patients uncover and address a broad array of needs that can aid addiction recovery and improve functioning and psychological well-being. One indicator of a higher quality program is staff who have graduate degrees and adequate licensing or board certification in specialty areas. In addition, clinical supervision and team meetings should take place at least once or twice a week for outpatient programs, and three to five times a week for residential and inpatient programs.
5. Strategies to engage and retain patients in treatment

Dropout from addiction within the first month of care is around 50% nationally, and this leads to worse outcomes. It is vital to employ strategies to keep patients engaged and committed to sticking with treatment. Involving significant others and loved ones in treatment increases the likelihood that the patient will stay in treatment, and that progress will be sustained after treatment has ended. Approaches that help the family adapt to changes that occur during recovery include techniques to clarify family roles, reframe behavior, teach management skills, encourage monitoring and boundary setting, help people access community services, and formulate re-intervention plans. A respectful and dignified treatment environment is also important because those suffering from substance use disorders often feel as if they’ve lost their self-respect and dignity. A respectful environment helps them regain it.
6. A comprehensive approach from initial treatment through transition

Treating the whole person will improve the likelihood of substance use disorder recovery. Patients in treatment may have a range of health concerns, from psychiatric disorders (like depression and anxiety) to issues like hepatitis C, alcoholic liver disease, or sexually transmitted diseases, and programs should directly address these issues and link patients to needed services. Programs should connect patients to community resources, ongoing health care providers, peer support groups, and recovery residences. This “warm hand-off” or personalized introduction to potential peers and resources in the recovery community produces substantially better outcomes. Migraine is a common medical condition, affecting as many as 37 million people in the US. It is considered a systemic illness, not just a headache. Recent research has demonstrated that changes may begin to occur in the brain as long as 24 hours before migraine symptoms begin. Many patients have a severe throbbing headache, often on only one side of the head. Some people are nauseated with vomiting. Many are light sensitive (photophobic) and sound sensitive (phonophobic), and these symptoms can persist after the pain goes away.

There are a variety of migraine subtypes with symptoms that include weakness, numbness, visual changes or loss, vertigo, and difficulty speaking (some patients may appear as if they are having a stroke). The disability resulting from this chronic condition is tremendous, causing missed days of work and loss of ability to join family activities.

It is sometimes possible for people to use an “abortive” medication, which, when taken early, can arrest the migraine process. For many patients, a preventive medication can decrease both the frequency and the severity of the migraines. But to date, many of the medications available for migraines have been developed primarily for other causes: seizures, depression, high blood pressure, and muscle spasms, for example. Researchers have been working for decades to develop a “targeted” preventive therapy specifically for migraine, and now we are finally close to having an exciting new treatment.
What does “targeted” therapy mean?

Calcitonin gene-related peptide (CGRP) is a molecule that is synthesized in neurons (nerve cells in the brain and spinal cord). It has been implicated in different pain processes, including migraine, and functions as a vasodilator — that is, it relaxes blood vessels. Once scientists identified this target molecule, they began trying to develop ways to stop it from being activated at the start of migraines, as a kind of abortive treatment. An agonist makes a molecule work more efficiently, and an antagonist blocks or reduces the molecule’s effect. The CGRP antagonist did work to decrease migraine pain based on certain measures, but there were some serious side effects including liver toxicity.

Back to the drawing board.
Monoclonal antibodies: Cutting-edge translational science

You have likely seen ads for monoclonal antibody (mAb) cancer and autoimmune therapies. There are lots of different types of mAbs, and while some harness a person’s own immune system to block replication of cancer cells, others stop a reaction in the body by binding to a target molecule or receptor and inhibiting it, thus preventing the reaction from continuing. The CGRP mAbs have this effect, and because they have a long duration of action (called a half-life), they can be administered much less frequently than typical migraine medications that are taken daily (with the exception of botulinum toxin, which is injected every 90 days). These new migraine medications are injected under the skin monthly, and have thus far demonstrated a statistically significant decrease in days of migraine. Four different drug companies are developing these new molecules, with two versions already sent to the FDA for approval.
What’s next?

If you think you may be a candidate for this new type of migraine medication, talk with your doctor, and perhaps ask for a consult with a neurologist or headache specialist who can help you understand more about the medication. Monoclonal antibody therapy is expensive, and there will likely be regulations about for whom s the treatments are appropriate. Much more research needs to be done about who is the best candidate for this therapy. But for many migraine patients who have not responded to the standard treatments, or who have had intolerable side effects such as cognitive dysfunction, low blood pressure, weight loss or gain, or other issues, CGRP monoclonal antibodies are safe and well tolerated, and are an exciting new development for migraine therapies.
In November 2017 the American Heart Association and the American College of Cardiology changed the definition for high blood pressure. One day your blood pressure of 130/80 was normal — the next day you had stage 1 hypertension, and suddenly you found yourself in a higher risk category formerly reserved for people with blood pressure of 140/90. While you probably don’t feel like celebrating the change, it may actually be a good thing.

“These guidelines have been long anticipated and are very welcome by most high blood pressure experts,” says Dr. Naomi Fisher, associate professor of medicine at Harvard Medical School. “They may seem drastic, but in putting the knowledge we’ve gained from large trials into clinical practice, they will help thousands of people,” says Dr. Fisher.

If you are in this 130/80 range, reducing your blood pressure can help protect you from heart attack, stroke, kidney disease, eye disease, and even cognitive decline. The goal of the new guidelines is to encourage you to treat your high blood pressure seriously and to take action to bring it down, primarily using lifestyle interventions. “It is well documented that lifestyle changes can lower blood pressure as much as pills can, and sometimes even more,” says Dr. Fisher.

The good news is that it doesn’t take a major life overhaul to improve your blood pressure. Small steps add up to big changes. Here are six simple steps that can help you get, and keep, your blood pressure in a healthy range.

1.  Lose a few pounds. By far the most effective means of reducing elevated blood pressure is to lose weight, says Fisher. And it doesn’t require major weight loss to make a difference. Even losing as little as 10 pounds can lower your blood pressure.

2.  Read labels. Weed out high-sodium foods by reading labels carefully. “It is very difficult to lower dietary sodium without reading labels, unless you prepare all of your own food,” says Dr. Fisher. Be particularly aware of what the American Heart Association has dubbed the “salty six,” common foods where high

6.  Relieve stress with daily meditation or deep breathing sessions. Stress hormones can not only constrict your blood vessels and lead to temporary spikes in blood pressure, but over time can also trigger unhealthy habits that put your cardiovascular health at risk. These might include overeating, poor sleep, and misusing drugs and alcohol. For all these reasons, controlling stress should be a top priority. As I review these findings, I think there are at least two ways to interpret them: 1) colonoscopy is helpful at detecting colorectal cancer in elderly people, but the effect is quite small; and, 2) this study supports the recommendation to stop performing routine screening colonoscopies in the elderly, though it’s unclear whether the “stop time” should be age 70, 75, or some other age.
What’s your situation?

If you’re 70 or older, this new study about colonoscopy may be of particular interest to you. For younger people, the benefits of colonoscopy are clearer — this includes healthy people at average risk, as well as those with risk factors for colon cancer. Those include people with a prior history of colon cancer or certain types of colonic polyps (called adenomas), a strong family history of colon cancer, and inflammatory bowel disease. Complications of colonoscopy (such as bowel perforation) are rare, but they are more common in the elderly. The prep alone can take a toll on older individuals, especially if they are already frail or ill.

Look for new and better screening tests for colon cancer and other diseases. This is an active area of research and it’s likely the list of recommended screening tests will change in the future. Even before the official recommendations change, however, it makes sense to consider foregoing screening tests that may cause more harm than good. Low energy and tiredness are among the most common reasons patients seek help from a doctor. Despite being so common, it is often challenging to come up with a diagnosis, as many medical problems can cause fatigue. Doctors engage in detective work, obtaining a medical history, doing a physical exam, and doing blood tests. The results often yield no explanations. It can be frustrating for clinicians and patients when a clear-cut diagnosis remains elusive. An attractive theory, called adrenal fatigue, links stress exposure to adrenal exhaustion as a possible cause of this lack of energy.
But is adrenal fatigue a real disease?

The adrenals are two small glands that sit on top of the kidneys and produce several hormones, among them, cortisol. When under stress, we produce and release short bursts of cortisol into the bloodstream. The adrenal fatigue theory suggests that prolonged exposure to stress could drain the adrenals leading to a low cortisol state. The adrenal depletion would cause brain fog, low energy, depressive mood, salt and sweet cravings, lightheadedness, and other vague symptoms.

Numerous websites mention how to diagnose and treat adrenal fatigue. However, the Endocrinology Society and all the other medical specialties do not recognize this condition. The Endocrinologists are categorical: “no scientific proof exists to support adrenal fatigue as a true medical condition.” This disconnect between conventional and complementary medicine adds to the frustration.

A recent review of 58 studies concluded that there is no scientific basis to associate adrenal impairment as a cause of fatigue. The authors report the studies had some limitations. The research included used many different biological markers and questionnaires to detect adrenal fatigue. For example, salivary cortisol is one of the most common ordered tests used to make a diagnosis. The cortisol level, when checked four times in a 24-hour period, was no different between fatigued and healthy patients in 61.5% of the studies. The review raises questions around what should get tested (blood, urine, and/or saliva), the best time, how often, what ranges are considered normal, and how reliable the tests are, to name a few. In summary, there is no formal criteria to define and diagnose adrenal fatigue.
But what if I have symptoms of adrenal fatigue?

If you have tiredness, brain fog, lack of motivation, among other symptoms, you should first have a thorough evaluation with a medical doctor. Anemia, sleep apnea, autoimmune diseases, infections, other hormonal impairments, mental illnesses, heart and lung problems, and kidney and liver diseases are just some among many medical conditions that could cause similar symptoms. If the workup from your medical professional turns out normal and you believe you might have adrenal fatigue, I would recommend you consider a fundamental question: Why would your adrenals be drained? Take a better look at what types of stress might be affecting you. For many, the hectic pace of modern life is to blame.

The lack of a biological explanation can be disappointing. To make things worse, it’s not unusual for doctors to say “there is nothing wrong with you” or “this is all in your head.” The overwhelming amount of information on the Internet that recommends many types of treatment causes even more stress. Mental health conditions, such as depression or anxiety, may have symptoms similar to adrenal fatigue and may not respond well to antidepressants and counseling. And some patients do not believe that a mental health concern is the primary cause of their symptoms and many refuse medications due to concerns about their side effects.
So what’s a person to do?

Navigating this ocean of uncertainty is not an easy task. Symptoms associated with adrenal fatigue probably have multiple causes. Frequent follow-up visits and a strong patient-clinician partnership are critical elements for success. Alternative and complementary clinicians often have better results, because the appointments tend to last longer and they view patients through a more holistic lens. An important word of caution: some medical professionals prescribe cortisol analogs to treat adrenal fatigue. Cortisol replacement can be dangerous even in small doses. Unintended consequences can include osteoporosis, diabetes, weight gain, and heart disease.

Regardless of what we call it, there are millions of people suffering from similar symptoms, and a personalized plan that involves counseling, medications, supplements, lifestyle change, among others could work for many. Improvement following these programs is slow, and the evidence is weak, but I hope advances in big data, genomics, and its relationship with the environment and the microbiome, may shine a light on how to better help people who suffer from these ailments.

The adrenal fatigue theory may fit like a glove to explain your symptoms, which are very real. But before buying expensive protocols over the Internet to treat something we’re not even sure exists, take a deep dive and reexamine your lifestyle. The path to feeling better may be closer than you think.

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