On the nature of addiction

June 12, 2014 at 12:22 pm | Posted in Conditions, Ethics, Media, Opinions | 2 Comments

This is going to be a complex post in which I will make a certain very uncomfortable admission that I’ve never made in public before. For that reason it might ramble slightly. Bear with me.

First of all, news today that the European Court will rule on whether obesity is a disability. I have some thoughts about that.

Obesity isn’t a disability. People become disabled because they are obese. Disability is the symptom, not the cause.

Take that one step further though: Obesity is also a symptom. It’s a symptom of addiction; addiction to over-eating, and specifically to sugar.

See, this is why we have angry fat acceptance activists like “This Is Thin Privilege” (I’m not providing a link, because they’re honestly borderline psychotic and I don’t need the aggro) and the like; pointing out to an obese person that their obesity is a problem is exactly the same as pointing out to a junkie or an alcoholic or a gambling addict that they have a problem – Until they’re ready to accept it, all you’re going to get in return is anger and denial. And some of them will never be ready to accept it.

Obese people aren’t disabled, they’re addicts.

And here’s where it gets really messy:

If a patient comes in to my care having seizures from alcohol withdrawal, maybe with a case of hepatic encephalopathy, then we can dry that patient out. We can give them benzos to control their seizures and withdrawal, we can give them IV Pabrinex to save their liver, we can get that person back on their feet, and we can say with complete honesty: “You cannot drink alcohol ever again, or it will kill you”.

How do we say that to a food addict? “You can’t eat ever again or you’ll… Oh… Wait… Never mind”.

See, abstinence is EASY. Alcoholic? Don’t drink. Heroin addict? Don’t take heroin? Smoker? Don’t fucking smoke.

It’s a piece of cake. Honestly.

Know what’s hard? Moderation. Tell somebody with an addiction that they can have just a little bit of what they’re addicted to? They’re ADDICTED to it. One drink will become twelve really quickly. That’s what recovering food addicts have to deal with: They can’t just avoid their addiction entirely. They have no choice but to have a little bit of their poison, at least three times per day, ever single day.

Quitting booze and cigarettes is easy. Getting slim is a bastard.

And I know this for several reasons. Firstly, I smoked (heavily) for thirteen years and quit without incident the first time I seriously attempted to. Secondly, I am a recovering fatty. My BMI is 32, and it’s not because I don’t exercise, it’s because I eat too damned much sugary, high calorie food. I’m doing my best to moderate it, but it’s bloody hard. Thirdly, and this is where I make an uncomfortable admission, I have an alcohol problem. If I’m drinking, then brother I am DRINKING. I am addicted to alcohol. I am an alcoholic. I’ve never said that before. Feels weird. But good.

But I can cope with my alcohol addiction. Really, it’s not difficult at all. I either drink nothing whatsoever (the default state of being for the last few months), or if I drink at home I buy four 330ml bottles of beer and no more (never any spirits, and oh my God do I miss single-malt Scotch whisky). When I’m out and exposed to unlimited booze, any of my friends will tell you: I drink. I really, really drink. Which is why I don’t go out very often.

The problem is, none of these strategies work for food addicts. You cannot abstain from food entirely. Neither can you have a house in which there is no food (not and maintain a marriage anyway). I guess the challenge for the 21st century is to find a way to break the addiction. Methadone for sugar.

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On homeopathy

July 2, 2013 at 4:02 pm | Posted in Ethics, Opinions | 5 Comments

Homeopathy is a system of treatment invented in 1796 by a German physician named Samuel Hahnemann. “Medicine” in the eighteenth century was not exactly evidence based, and Hahnemann correctly realised that a lot of it did more harm than good; however unlike some of his contempories (such as Edward Jenner and Anton van Leeuwenhoek) , Hahnemann didn’t really grasp the scientific process with both hands.

Hahnemann knew that, through experiment, effective drugs were being developed to treat illnesses, and he wanted to be a part of improving medicine; he tested many substances to observe their effects on the human body. It is pretty clear that he understood the nature of experimentation through trial and error, and he even got so far as formulating a hypothesis to explain some of his observations. Unfortunately, he also had some fairly large gaps in his knowledge. In combination with what I suspect might have been a little too much enthusiasm to make a name for himself in medicine, this lead him to some very simple errors. It should be noted before I continue that aside from homeopathy, Hahnemann’s other major hypothesis was that disease was caused by coffee. I mention that here just to give some insight into the mind of the man I’m going to talk about.

While working on the translation of a treatise on malaria, Hahnemann began to self-experiment with the bark of the cinchona tree – Commonly known as Jesuit’s Bark, or Quinine. For many years, Quinine was the only effective remedy for malaria. It was so good that British explorers made infusions of it called “tonic water” and drank it with gin (Edit: that might or might not be where gin and tonic comes from, this may be apocryphal, but there doesn’t seem to be a huge weight of evidence either way). Sadly, malaria has long since evolved an immunity to it.

Despite translating the work of others, Hahnemann was no expert on the use of Quinine. Whilst testing its effects on himself, he took an overdose and made himself extremely ill. What followed is the invention of the founding principle of homeopathy – Forged from pure ignorance.

Despite having little or no knowledge of malaria as a disease, Hahnemann seems to have unilaterally declared that the symptoms he experienced due to an overdose of Quinine were exactly the same as those experienced in the acute onset of malaria. Ten seconds on Google will be enough to demonstrate that he was quite wrong.

On the basis of this extremely shaky logical foundation, Hahnemann went on to make two even shakier logical jumps: Since he knew that Quinine cured malaria, and since he thought that Quinine induced the same symptoms as malaria, and since he had found that a large dose of Quinine was nearly fatal (or at least extremely unpleasant), it followed in his mind that 1) Any disease could be cured by a preparation of any substance that could induce the same symptoms as the disease in the person taking it (the “doctrine of opposites”, and 2) The smaller the dose given, the more effective this “medication” would be.

I trust I’m not going to have to point out the logical fallacies there.

Homeopathy has been developed (if that’s the right word – perhaps “completely made up” would be better) from that beginning. One interesting aspect (that completely trashes the “doctrine of opposites”) is the technique homeopathists use to dilute their preparations. Let me start by saying that mathematics is probably not their strong suit.

First, a solution of the substance to be used in the “medication” is prepared by diluting it one part in ten with distilled water. The vial containing this dilution is then struck hard against a leather bound book, ten times (bear with me, I’m not making this up – Hahnemann did that). The solution so produced is then further diluted, by taking one tenth of it, and diluting it again one part in ten with distilled water. Bang the book ten times and voila, you have a one part in one hundred dilution.

And now it gets a little tricky: Homeopathists believe that the more times you repeat this process, the more potent the medication becomes. Homeopathic remedies are often sold as a “potency” of “6C” – In real terms, one part in one trillion of the original ingredient, diluted in distilled water. A 12C concentration would be equivalent to a single pinch of salt in the Atlantic Ocean. But that’s not even where it gets really absurd – Some homeopathic treatments are diluted up to 200C. To give you a rough idea of what that means in real numbers, 40C would be the dilution given by one single atom of the original substance, diluted in all of the mass in the known universe, if it was all distilled water. To be sure of containing any of the “active” ingredient, a 200C dilution would actually require the existence of 10^320 more universes that this one, all made entirely of distilled water, and between them containing just one atom of the original substance.

But wait! There’s more! You might have noticed that homeopathic remedies don’t tend to be in liquid form – And you’re quite right, they don’t. They tend to be pills. And that’s because, having gone to all the trouble of contaminating distilled water and then diluting it so heavily that the contaminant is completely undetectable even compared to the chemicals the water leaches from the sides of its glass container, homeopathists then take this “preparation” (read: “water”) and put a single drop of it on to a sugar pill. They then allow it to evaporate (i.e. the pill to dry out). And the resulting sugar pill is what they sell in pharmacies and health food shops all over the world as homeopathic remedies.

Was ever a process so long-winded, so complicated and so utterly pointless?

Unsurprisingly, the research evidence (yes, people have wasted their time researching it) on homeopathy is unequivocal: It has no effect whatsoever beyond placebo. It revolves around people assuming that natural regression to mean is the same as cure. It does nothing. It is quackery at its absurd finest.

Edited 02/07/2013 to reflect uncertainty over the history of tonic water. Sources:

http://goo.gl/daT0F
http://goo.gl/yuDag (Athens or Wiley login required)

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Hospitals are Not Entertainment

February 11, 2013 at 3:17 pm | Posted in Death, Emergency Unit, Ethics | Leave a comment

For my first proper post, I thought I’d talk about a placement I had as a student, at a large Emergency Department (ED) and some of the experiences I had there. Then I thought about it some more and realised that the vast majority of them were probably not fit for public consumption (for example, the man with a broken-off neon light-bulb tube in his rectum, always a good one for Foreign Object Top-Trumps) and that I should be a little bit careful about what I talked about. So I decided I’d talk about TV crews.

TV crews are maladjusted.

I’ll let that sink in.

Sunk in?

Good. Now I’m going to justify it.

I had the terrible misfortune to spend a couple of months working in an ED at the same time that a well-known TV company were there filming for a fly-on-the-wall documentary program about amusingly lodged foreign objects the sterling work of the heroic medical professionals who staff these bastions of all that is good about humanity.

Some of what the TV crews did caused me to have… Let’s call them “ethical doubts” about their presence.

Case 1: Morbidly Obese Man in Cardiac Arrest.

Most EDs have a Resuscitation Room (“Resus” for short) right next to the ambulance entrance. It’s where you’re taken if you’re:

a) Already dead and we want to try to bring you back, or;
b) Looking like you’re about to die and we want to try to stop you.

Think of a big, brightly lit room full of excitingly medical looking kit (a surprising amount of which is used for putting various tubes in various orifices) and wired-looking people in scrubs. Now add a slightly nervous looking yet ruggedly handsome student nurse to the picture and you’ll have it about right.

On the day in question, an ambulance came in under blues and twos (blue flashing lights and two-tone siren) with a very obese man on board in cardiac arrest (his heart had stopped). The paramedic was pumping on his chest as the doors opened, and we got him out and on the table in double-quick time. Pretty quickly he had various tubes inserted in various orifices, various needles inserted in various vessels, various sticky things stuck on various exposed flesh, and the tightly controlled chaos of a crash unfolded.

Folks, this bit is going to shock you: “ER” is full of crap. Most crash calls are not successful. Even the few that are successful are very rarely followed by successful rehabilitation and discharge of the patient. If you have a cardiac arrest, it is extremely likely that you will die.

So our very obese man passed away in a frenzy of activity.

Do you remember the picture you formed earlier of Resus? Kit, tubes, caffeine-addicts, student nurse? Add three more people to the scene.

A camera man.
A sound man.
A producer.

Now imagine the events of the day again, but this time imagine the TV crew filming the whole thing, from the back of the ambulance and through Resus.

Imagine, if you will, your ruggedly handsome student nurse threatening to turn the boom mic into just another Amusing Foreign Object, sans lubrication, if the sound man doesn’t get it out of the damned way of the damned lights. Imagine the crash team, already under immense pressure to get every single decision right because every single one of them might dictate whether their patient lives or dies, and now imagine how much more pressure is on them because it’s being filmed for national TV. Imagine how the patient would have felt – stripped to his underwear, bowels and bladder voided on the table, wobbly bits wobbling. Imagine a nurse doing chest compressions and having to pump hard enough to break the patient’s sternum just to get his chest moving – Crack! “That’s great TV!”, says the producer.

Afterwards, I asked the producer to explain the ethics of their presence to me.

“Well,” he said “If the patient lives, we ask permission to film afterwards. You know, retrospectively. If they die, we ask their family.”

I think I must have looked puzzled at this point, because he went on to say a lot more, using much longer words like “demographics” and “public right to know”. It didn’t really add content to the opening reply, though.

Case 2: Dying Lady who Didn’t Know She Was Dying

Later the same day, we had a patient brought in by her family following a collapse and loss of consciousness at home. Much testing and scanning revealed that she was in the extremely advanced stages of cancer and had collapsed due to metastases in her spine and brain. Oncology gave her a few days to live, and were frankly baffled that she’d still been upright and able to mask the symptoms from her family for so long. The job of breaking the news to the family fell to a young, newly qualified doctor, who was accompanied by a nurse (nurses are generally better communicators than doctors) and a student nurse (who needed to learn how these things are done).

Unknown to us at the time, there was also a TV camera poking through a gap in the curtain, filming the exchange.

News was broken. Weeping ensued from family, comfort was given as far as possible by medical persons present, grief counsellor was recommended via information leaflet.

And then: Curtain is drawn back, smiling TV producer with clip-board in hand turns to family and says:

“I wonder if I might talk to you about consenting for us to show that discussion you just had on TV. You want to be on TV, right?”

The TV crew were forcibly ejected by nursing staff at that point.

I’ll end this post, which is already longer than I planned, by telling you that I refused to sign a consent for the TV company to show any footage of me – so they couldn’t use any of the film they shot that day, because I was in almost all of it.

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