merging of the minds - synapse - home · of multifaceted ideas that capture our theme of “merging...

PB | SYNAPSE | Fall 2016 Fall 2016 | SYNAPSE | 1

SYNAPSEPENN’S UNDERGRADUATE MEDICAL CONNECTION

FALL 2016

EATING DISORDERS

What are they really, and what we can do

about them

T-CELLS TARGETING

TUMORSA new type of

immunotherapy

ANTIBIOTIC RESISTANCE

Reversing time for modern superbugs

A LIFE WORTH LIVING?Analysis of the debate

on euthanasia

MERGING OF THE MINDSReconceptualizing Age-Old Health Issues

2 | SYNAPSE | Fall 2016 Fall 2016 | SYNAPSE | 3

EXECUTIVE BOARD

GENERAL BOARDSAssociate EditorsLeah GoldbergJenna HarowitzRyan LeoneEric ZhuSarah DeVaroLaurel LeavittChloe ChengMadeline Fagen

Design StaffCaroline CaseyLucy FerryAlicia Go

Business StaffMahip GrewalEmily HongCatherine Huang

ADVISORY BOARDKent Bream, MD: Assistant Professor of Clinical Family Medicine and Community Health, Hospital of the University of PennsylvaniaPhyllis Dennery, MD: Chief of Neonatology and Newborn Service, Children’s Hospital of PhiladelphiaJohn Heon, PhD: Professor of English and Writing, College of Arts and Sciences Lisa Mitchell, PhD: Assistant Professor of South Asian Studies, College of Arts of Arts and SciencesBrendan Maher: Features Editor, NatureMark Pauly, PhD: Bendheim Professor of Healthcare Management, The Wharton SchoolPhilip Rea, PhD: Professor of Biology, College of Arts and SciencesHarvey Rubin, MD, PhD: Professor of Medicine, Penn School of MedicineMichael Topp, PhD: Professor of Chemistry, College of Arts of SciencesNicholas Wilcox: Founder of SYNAPSE

MANY THANKS TOEXECUTIVE BOARD

BACK (L to R): Ajay Patel, Eshwar Inapuri, Scott Massa, Tiberiu Mihaila, Claire Song, Claire Beamish

FRONT (L to R): Sebastian de Armas, Hannah Fagen, Celena Chen, Radhika Gupta, Busra Gungor, Victoria Siu

Celena Chen, Ajay PatelSebastian de ArmasClaire Beamish, Hannah Fagen, Busra Gungor, Eshwar Inapuri, Scott MassaVictoria Siu, Claire SongRadhika GuptaTiberiu Mihaila

Editors-in-ChiefExecutive VP

Editorial

VP DesignVP Finance

VP Marketing

Dear Readers,

Since the dawn of modern medicine, the fusion of ideas and technologies in healthcare has never been greater. There is a pressing need to increase access and quality of care, beyond just the operating table. With the advent of groundbreaking technologies, healthcare policy, and innovative medicine, individuals and entire industries are joining forces to confront healthcare’s biggest challenges.

SYNAPSE reaches beyond the realm of conventional medicine and into the coalescence of multifaceted ideas that capture our theme of “Merging of the Minds: Reconceptualizing Age-Old Health Issues”. Our feature articles delve into both the technical and abstract dimensions of medicine. We illuminate the rise of age-old superbugs that threaten the return of microbial dark ages. We explore the innovation of T-cell technology to better target cancerous cells and how they can mitigate toxic effects. In the other sphere of healthcare – we analyze the eating disorder epidemic from the unique lens of students in their most formative years and investigate the debate on euthanasia. Regardless of focus, all of our articles seek to piece together the industry-wide shift in fusing ideas to better target healthcare issues.

In the fourteenth installment of SYNAPSE, we would like to sincerely thank every member of our Editorial, Design & Layout, and Business teams for their contribution this semester and over their collegiate careers. Without the dedication and hard work of our team, this issue would not have been possible.

Ajay Patel and Celena ChenEditors-in-Chief

Tiffany HuangAdhiti Rajesh

Emily HongPhyllis Parkansky Kuan Yu

Alex ShazadPranay VissaSai AbhishekHyuntae ByunSid RameshJoan LimTiffany SimJulian Roessler


Interested in writing for SYNAPSE? Go online to www.upennsynapse.com or email [email protected] for more information.

CONTENTS

EATING DISORDERS What are they really, and what we can do about them

Gabrielle Ramirez

4

CONTEMPORARY CARE FOR MENTAL HEALTH 6

POSITIVE PSYCHOLOGYStudying the art of thinking

happy thoughts

Jens Honack

8

10

neuropsychology

SUGAR INDUSTRY SCHEME LEAVES BITTER TASTESugary marketing not as sweet as it sounds

Sarah Devlin

24THE PHARMACEUTICAL INDUSTRYIs it on your side?

Evanie Anglade

26FGLI STUDENTS AND THE FRESHMAN 15is the freshman 15 inevitable for some?

Kamaljot Gill

30

32

HAS GENETICS HIT A BRICK WALL?Comparing original expectations to present reality

Dan Leapman

20

UPSTREAM, WITHOUT A DOCTORThe crippling impact of the American

physician shortage

Ryan Leone

OVERSPECIALIZATION WITHIN THE MEDICAL FIELDAn improvement or failure?

Ahmed Farhan

22social issues

THE NEURAL PROCESSING OF DISGUST AND ITS RAMIFICATIONSThe science behind the emotion

Jonathan Zou

14

ASMR: INTERNET BRAINGASMS?A new mode of mental stimuli

Phyllis Parkansky

16

molecular biology

12

BYSTANDER CPR: TRAINING THE PUBLIC TO SAVE LIVESImproving countrywide heart attack mortality

Jimmy Qian

18

DEPLOYING T-CELLS TO TARGET TUMORSA new type of immunotherapy

Mahip Grewal

ANTIBIOTICS AND THE RETURN OF THE MICROBIAL DARK AGESReversing time for modern superbugs

Matthew Andersen

physician practice

28A LIFE WORTH LIVING?Analysis of the debate on euthanasia

Hafsa Bhatty

34EPIDEMIC OPIOID ABUSEIs marijuana a solution?

Alex Shazad

Why is mental heath treatment still behind the times?

Liam Bartie

ON THE COVERThis issue’s cover art was designed by Victoria Siu, an undergraduate major-ing in Biological Basis of Behavior and minoring in Creative Writing. The im-age expresses duality and integration of the emotional and analytical side of

healthcare.


Anorexia does not just result in thinness; it is a slow path to self-destruction. Common symptoms include osteoporosis (which typically occurs after menopause in non-anorexics), brittle hair and nails, yellowish skin, and feelings of around-the-clock coldness.⁷,⁸ If left untreated, the disease will progressively become worse and could even result in an abnormally slow heart rate, muscle loss, multi-organ failure, and infertility. It is not shocking for an anorexic to experience amenorrhea, a condition that causes an individual to miss her period for more than three months. If the disorder has taken a severe toll on an anorexic, he or she may suffer a sudden heart attack and die. A young woman with anorexia is 12 times more likely to die than other women her age without anorexia.9

Anorexia Nervosa

BULIMIA NERVOSA

At first, only sometimes, I would run the shower so my parents wouldn’t hear, and vomit in the toilet. Now I take a plastic bag up to my room every night and after eating a large meal… I turn up my music and vomit.10

Bulimia Nervosa is characterized by an excessive ingestion of food, followed by purging. Typically, bulimics can consume between 1,500 and 3,500 calories in a single binge.11 After a period of excessive food

NEUROPSYCHOLOGY

EATING DISORDERS ON COLLEGE CAMPUSES

BY GABRIELLE RAMIREZ

College is a place where we can finally determine our everyday lifestyle. There are campaigns on campus to guide us toward making healthy decisions: some include getting a flu shot, following a regimented diet plan, and exercising regularly. Yet amidst all of this campaigning lies a world of struggling students—those with eating disorders.

As much as I want to change, I think I don’t. I need this ED; if I didn’t have it, I don’t know what I would do with myself. It consumes my life. Food is everything I think about. But the truth of the matter is that I am a professional at this. This is my full-time job. I read every book, article, or info on food, body image, ED, etc.1

EATING DISORDERS: AS (WE THINK) WE KNOW THEM

The American Psychological Association defines eating disorders as “abnormal eating habits that can threaten a person’s health or even his or her life.”2 Yet, eating disorders are often trivialized and commonly viewed as a lifestyle choice or a luxury disorder Contrary to popular belief, eating disorders are serious psychological disorders that can have detrimental effects on an individual’s health. Tragically, these disorders have even been the cause of many preventable deaths.3 Studies have shown that 5-10% of anorexics die within ten years of disease onset. Within 20 years of onset, the death rate jumps to 18-20%. Ultimately, only one in two anorexics will survive the disorder.4 According to the American College Health Association’s National College Health Assessment in Fall 2015, 1.1% of participants reported being diagnosed or treated for anorexia. In the same survey, 1.0% of participants reported being diagnosed or treated for bulimia. It is important to note that these statistics are only based on participants that sought medical care. This data does not account for those who remain unreported, either because of stigma surrounding eating disorders or simply because they lack the guidance to find help.

ANOREXIA NERVOSA

I am 5’3 and 103 lbs…As much as I want to stop, I don’t think I can because I believe [anorexia] is what has control over keeping my weight down. I have fear of gaining even a pound.1

Despite being dangerously thin, individuals who have anorexia believe they are fat and consequently, restrict their eating to the point of starvation.2 They can be heard making frequent comments about feeling “fat” despite clear weight loss.5 While the recommended caloric intake for a healthy college woman is between 1,800-2,000 calories a day, an anorexic will consume less than 500 calories, due to an intense fear of gaining weight.⁷,⁸ As a result, anorexics will form unhealthy habits and develop a distorted image of themselves. For instance, they may refuse to eat certain foods, and later build up to cutting out whole entire food groups, such as fats.

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consumption, an individual will forcibly vomit, use laxatives, fast, or excessively exercise as a way of compensating for his or her binge. An individual will fluctuate between feeling disgusted and ashamed as he or she binges, and then later feeling relieved of tension and negative emotions once his or her stomach is empty again.2 Since bulimia is associated with a feeling of being out of control during binge-eating episodes, those who suffer from the illness often binge in secrecy. Evidently, a bulimic’s self-esteem relies on his or her body image and thus, he or she undergoes these unhealthy measures in order to preserve his or her physique.12 However, unlike anorexics, people with bulimia usually maintain a normal weight.5

Though bulimia may provide individuals with a way to maintain normal weight, it is linked to physiological imbalances and damage. The consequences of the illness include an inflamed and sore throat, swollen salivary glands in the neck and jaw area, dental issues, and acid reflux disorder. At its worst, bulimia can cause an electrolyte imbalance that could result in a stroke or heart attack.5 The electrolyte imbalance is triggered by dehydration and loss of potassium and sodium from the body, a direct consequence of purging behaviors.12

Though victims of bulimia may recognize that their behaviors are unusual, it is often difficult for them to discontinue their bulimic habits. Bulimia is frequently associated with depression and difficulties in adjusting to a new social setting. For bulimics, the risk of death from suicide or medical complications is higher.12

AT THE ROOT OF THE PROBLEM

Though there are several studies related to the topic of eating disorders, it is almost impossible to make a definite causal argument. It is virtually impossible to shadow people with eating disorders on a 24/7 basis, and then compare them to those without. Nonetheless, researchers have been able to develop a type of correlation model called the biopsychosocial model.

Think of it as an inverted cone. At the broad top, there are cultural factors; for example, cultures that usually have an abundance of food are more inclined to favor thinness. However, this cannot be the cause of eating disorders; otherwise, there would be a much larger population of people with eating disorders.

The middle level encapsulates familial and social factors. For instance, in college, most students are trying to fit in. Especially at competitive universities, many students feel the pressure to be perfect at everything: academics, sports, social life, attire, and so on. This stress can later transfer to food, and then lead to disordered eating. In questionnaires, college students with eating disorders admitted to comparing their food choices with food on other peers’ plates.13 Clearly, the competitive nature mixed with the desire to fit in are drivers of eating disorders. However, once again, researchers can only assume that correlation exists. At the tip of the cone exists individual factors. Personal factors are the best indicators of whether a person is at-risk for an eating disorder. These factors include personality, cognition, and physiology. High levels of perfectionism and low self-esteem are associated with both anorexia nervosa and bulimia nervosa. Personality characteristics associated with anorexia nervosa include: rigidity, perfectionism, and inflexible thinking.1⁴ Feelings of inadequacy, helplessness,

ineffectiveness, guilt, and self-doubt are all linked to bulimia.1⁵

In general, someone with an eating disorder has experienced a stressful life event that has affected his or her self-esteem. Furthermore, an individual prior to having an eating disorders may feel as if he or she has lost control of his or her life. In desperation, he or she will turn to anorexia or bulimia in hopes of restoring some control and distracting himself or herself from other quotidian problems.1⁶

BYSTANDER OR SAVIOR?

What do you do? How do we become normal? I don’t want to obsess over [my eating disorder] or food anymore.1 I can’t tell [anyone because everyone] knows me only as this great college athlete and soon-to-be doctor.10

College students often do not seek treatment because of the stigma surrounding having an eating disorder. However, there should be no shame in seeking treatment. Eating disorders are serious, deadly illnesses that can take over an individual’s life. So, what should you do if you see someone with an eating disorder? Don’t be a bystander—this article cannot stress this enough.

Dr. Giang Nguyen, Executive Director of Student Health Services, recommends that a student contact Student Intervention Services right away. Once contacted, SIS staff will check on the student with the eating disorder; the person who contacted SIS remains anonymous. Timing is important. The longer an eating disorder is left untreated, the more likely an individual will suffer greater permanent damage.

If you are aware that you have an eating disorder, please schedule an appointment with CAPS or SHS as soon as possible. College is stressful and everyone copes in different ways. Sometimes, we all need a little guidance to direct us back to a correct, healthy path. As Dr. Nguyen emphasizes: Penn’s services are there. It’s up to the student to use them.

References1. Y. (2005, December). This ed is my best friend. Retrieved October 21, 2016, from http://www.health-

boards.com/boards/eating-disorder-recovery/358604-ed-my-best-friend.html#ixzz4O3gw3fxl2. (n.d.). Retrieved October 21, 2016, from http://www.apa.org/topics/eating/3. Eating Disorder Statistics • National Association of Anorexia Nervosa and Associated Disorders.

(n.d.). Retrieved October 21, 2016, from http://www.anad.org/get-information/about-eating-disor-ders/eating-disorders-statistics/

4. Practice guideline for eating disorders. American Psychiatric Association. (n.d.). Retrieved October 1, 2016, from http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.150.2.212

5. NIMH » Eating Disorders. (n.d.). Retrieved October 1, 2016, from https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml

6. What Is the Normal Calorie Intake Needed for a College Student? (n.d.). Retrieved October 3, 2016, from http://healthyeating.sfgate.com/normal-calorie-intake-needed-college-student-5544.html

7. Burd, C., Mitchell, J. E., Crosby, R. D., Engel, S. G., Wonderlich, S. A., Lystad, C., . . . Crow, S. (2009). An Assessment of Daily Food Intake in Participants with Anorexia Nervosa in the Natural Environment. Retrieved October 4, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584709/

8. What is Osteoporosis. (n.d.). Retrieved October 9, 2016, from https://nos.org.uk/about-osteoporo-sis/what-is-osteoporosis/consequences-of-osteoporosis/

9. Sullivan, P. F. (1995, July). Mortality in anorexia nervosa. Retrieved October 4, 2016, from http://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.152.7.1073

10. W. (2003, July 10). A friend who understands and could help? Bulimia/An. Retrieved October 21, 2016, from http://www.healthboards.com/boards/eating-disorder-recovery/44419-friend-who-un-derstands-could-help-bulimia.html#ixzz4O3miZW2Q

11. Kaye, W. H., Weltzin, T. E., Hsu, L. G., McConaha, C. W., & Bolton, B. (1993, June). Amount of calories retained after binge eating and vomiting. Retrieved October 21, 2016, from http://ajp.psychiatry-online.

12. Types & Symptoms of Eating Disorders. (n.d.). Retrieved October 4, 2016, from https://www.natio-naleatingdisorders.org/types-symptoms-eating-disorders

13. Eating Disorders College Students [PDF]. (n.d.). Multi-service Eating Disorders Association.14. Personality Characteristics Associated with Eating Disorders. (n.d.). Retrieved October 21, 2016,

from http://glossary.feast-ed.org/6-associated-or-co-morbid-conditions/personality-characteris-tics-associated-with-eating-disorders

15. Anderson, L. L. (2004). Personality Characteristics of Bulimic Behavior in College Women Analyzed With the Myers-Briggs Type Indicator (Unpublished doctoral dissertation). Liberty University. Retrieved October 21, 2016, from http://digitalcommons.liberty.edu/cgi/viewcontent.cgi?arti-cle=1315&context=doctoral

16. Polivy, J., & Herman, P. (2002, February). Causes of Eating Disorders. Retrieved October 4, 2016, from http://www.annualreviews.org/doi/10.1146/annurev.psych.53.100901.135103org/doi/10.1176/ajp.150.6.969


Science has only recently procured the ability to assess and under-stand the brain; naturally, medicine has followed suit. Knowledge of physical ailments and their treatments has steadily increased since the time of Hippocrates, whereas mental illnesses were often historically attributed to “madness” or even demonic possession. The lagging understanding of neurological processes has left a dis-tasteful mark on the status of mental health in society: conditions like anxiety, depression, and schizophrenia are shrouded in stig-ma from all sides. This stigmatization, along with the drawbacks of current treatment options, creates an inadequate environment for people suffering from mental illnesses to receive the care they deserve. Publicly, beliefs about mental health contribute to an unsupport-ive social climate that can worsen symptoms and further deplete self-confidence. A study by Corrigan and Wassel, two professors from the Illinois Institute of Technology, defines three different types of stigmatization that mental health patients experience—public, self, and label avoidance. Public stigma involves mass per-petuation of stereotypes; for instance, the popular misconception that those with mental illness are unpredictably prone to lash out. Self-stigma occurs when individuals internalize harmful stereo-types, which leads to worrying and further emotional deteriora-tion. Lastly, those who fear a negative social response to their con-dition display label avoidance when they fail to receive diagnosis or treatment.1 Although many people know someone affected by mental health disorders, they often fail to grasp how the condition influences the daily life of their family member, friend, or acquaintance. A study surveying the Dutch population conducted over the course of 21

The Problem of Contemporary Care for Mental Health BY LIAM BARTIE

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years illustrates the negative effects of this lack of understanding, finding that the general desire for social distance from people with schizophrenia has increased significantly in the past two decades and has remained strong regarding those with clinical depression.2 This trend exists partially because the symptoms are not readily observable and are intrinsically linked to the patient’s personal thoughts, emotions and identity. As stated by Dr. Paul Summer-grad, Psychiatrist-in-Chief at the Tufts University School of Medi-cine, mental illnesses are “irrespective of cause—the most intimate and personal of medical disorders, and challenge expectations for self-control and more traditional views of human nature.”3 How someone copes with their depression is an intimate affair linked to every aspect of their being, including the people around them and even the most trivial daily experiences. Thus, the variability of these mental conditions from case to case leads them to be consid-ered more often as outstanding personal issues than dire medical concerns, a misunderstanding from which treatment suffers mas-sively. Adding to the hurdle presented by an adverse social climate, draw-backs to the available pharmaceuticals also create a dilemma. Soci-ety has begun to recognize the widespread danger of making pow-erful opiates readily obtainable for use as painkillers, and the class of drugs that treats a variety of mental conditions from anxiety to insomnia—benzodiazepines (BDZs)—is another imminent dan-ger. This class of drugs, often referred to colloquially as “benzos,” includes names such as Xanax, Valium, and Klonopin. Benzodi-azepines have been shown to work by changing the conformation of the γ-aminobutyric acid (GABA) type A receptor, which is the site showing affinity for the brain’s most prominent inhibitory neu-rotransmitter GABA.⁴ Their inhibitory activities slows brain func-


tionality, relaxing neurotransmission and leading to a physiological state of sedation which explains their widespread use in treating mental health issues, from insomnia to schizophrenia, that require a dampening of synaptic excitation. A faculty group working together from both the Harvard and University of Geneva medical schools has noted the prevalence of benzos in the pharmaceutical industry and explored their neurobiological target. Four BDZs are among the 200 most frequently prescribed drugs in the U.S., with the three aforementioned names nearing closer to the top of the list.⁴ However, in spite of their popularity, BDZs often overstep their pharma-cological boundaries. In fact, a news report from as early as 2004 explains that benzodiazepines were cut from Medicare benefits because they had extensive side ef-fects, including drowsi-ness, depression, mem-ory loss, confusion, and physical weakness. Es-pecially when combined with alcohol or other medications, benzodi-azepines have the po-tential to threaten lives, inducing serious cardiac and respiratory condi-tions. The drugs are also habit-forming, making it difficult or impossible to introduce alternative treatment.⁵ Given these undesirable effects, it is clear to see why many mental health patients would choose to deny being prescribed these substances, as they could easily compound existing chemical imbalances. Similarly, a brain weakened by depression or anxiety can be more suscepti-ble to the addictive nature of the drugs, and addiction is a crippling mental illness in its own right. Fortunately, pharmaceuticals are not the only option for treating mental health issues. The highly personal nature of these disorders makes interpersonal psychotherapy (IPT) a particularly serviceable option. A conglomerate of clinical psychology researchers has set out to prove its effectiveness through a meta-analysis of over 90 studies and thousands of individual cases. Taking cases from mul-tiple nations, the researchers calculated the power of different treat-ment options using Hedges’ g, which is a measure of effectiveness. Results indicated that IPT was the most effective among different treatment options compared to a control group with a value of g = 0.60, surpassing other types of therapy (g = 0.06) and pharma-ceuticals (g = -0.13). The effectiveness of IPT is heavily linked to the discussion of relevant personal experiences, so the treatment is directly targeting necessary emotions.⁶ Yet, seeing a therapist is costly and comes with an attached stigma, so clinical care remains a less-than-accessible solution for most mental health patients. Part of the issue is that mental health patients do not receive priority in

clinical situations. Jane Zhu, a research fellow at Penn’s Perelman School of Medicine studying healthcare systems, recently re-leased a groundbreaking study showing the deficiency of clinical care for patients with mental health disorders. Findings revealed that the number of available inpatient care beds has been steadily declining, down almost 400,000 from 1970, and that hospital pa-tients for mental illness are subject to a stall-and-transfer rate six times higher than that of any other category of patients, postpon-

ing necessary treatment. The study also highlights that the disparity between care for mental and physical ail-ments cannot be explained by the differences in the na-ture of the conditions and the care they require.⁷ Thus, the implication is that sig-nificant improvements could be made to the processes for supplying needed treatment in healthcare management, most notably in hospital and emergency department situ-ations. While technology and med-ical techniques continue to evolve on a daily basis in to-day’s society, treatment for mental health continually lags due to a lack of prioriti-zation. A poor social climate fostered by different forms of stigmatization and general lack of knowledge wrongly

makes the cases appear less medically compelling. Available clin-ical treatment options lack accessibility, while pharmaceuticals, specifically benzodiazepines, have been shown to be significant-ly less effective despite their abundance and prevalence. Great-er public education on the nature of mental illnesses is slowly spreading, eventually shifting clinical care efficiency. Paradigms in neuro-pharmaceutical research have shown potential avenues for safer, alternative treatment options that modulate the GABA type A receptor. Thus, there is potential for marked improvement in treatment for mental health, as well as adequate scientific ca-pacity to achieve such a wide-reaching goal.

References1. Corrigan, P. W., & Wassel, A. (2008). Understanding and Influencing the Stigma of Mental Illness.

J Psychosoc Nurs Ment Health Serv Journal of Psychosocial Nursing and Mental Health Services, 46(1), 42-48.

2. Angermeyer, M. C., Matschinger, H., & Schomerus, G. (08/01/2013). British journal of psychiatry: Attitudes towards psychiatric treatment and people with mental illness: Changes over two decades. Royal Medico-psychological Association.

3. Summergrad, P. (2016). Investing in global mental health: The time for action is now. The Lancet Psychiatry, 3(5), 390-391.

4. Kelly R. Tan, Uwe Rudolph, Christian Lüscher, Hooked on benzodiazepines: GABAA receptor sub-types and addiction, Trends in Neurosciences, Volume 34, Issue 4, April 2011, Pages 188-197

5. HASKELL, M. (10/05/2004). Bangor daily news: New law cancels drug benefit valium, xanax among rx cuts Bangor Pub. Co.

6. Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis. Pim Cuijpers, Tara Donker, Myrna M. Weissman, Paula Ravitz, and Ioana A. Cristea. American Journal of Psychiatry 2016 173:7, 680-687

7. Jane M. Zhu, Astha Singhal and Renee Y. Hsia. Emergency Department Length-Of-Stay For Psychiatric Visits Was Significantly Longer Than For Nonpsychiatric Visits, 2002−11 Health Affairs 35, no.9 (2016):1698-1706

8. Shannon M. Peters, Kendra Quincy Knauf, Christina M. Derbidge, Ryan Kimmel, Steven Vannoy, Demographic and clinical factors associated with benzodiazepine prescription at discharge from psychiatric inpatient treatment, General Hospital Psychiatry, Volume 37, Issue 6, Novem-

Benzodiazepine binding site GABA agonist binding site

GABA antagonist binding site

BENZODIAZEPINES HAVE BEEN SHOWN TO WORK BY CHANGING THE CONFORMATION OF THE Γ-AMINOBUTYRIC ACID (GABA) TYPE A RECEPTOR.

GRAPHIC/VICTORIA SIU


French physicist and philosopher Blaise Pascal once said, “All men seek happiness. This is without exception. Whatever different means they employ, they all tend to this end.”1 Three hundred and 46 years later, his statement has not lost its relevance. Today, the field of positive psychology seeks to understand what it means to be happy, and how one can attain this state of subjective well-being. Through empirical investigation, positive psychology intends to identify, understand, and help individuals implement the mental processes that allow humans to live satisfactory lives. Martin Seligman, a University of Pennsylvania psychologist and the ‘father’ of positive psychology, defines positive psychology as “[a] science of positive subjective experience, positive individual traits, and positive institutions promises to improve quality of life and prevent the pathologies that arise when life is barren and meaningless.”2 Unlike most branches of psychology, positive psychology does not focus on understanding mental pathologies, but rather tries to shed light on what defines a happy person.

According to Seligman, psychology has three goals: “curing mental illness, making the lives of all people more productive and fulfilling, and identifying and nurturing high talent.”1 In the decades following World War II, treating and healing of mental diseases took over the academic spotlight due to its profitability. This disease-focused model turned psychology into a discipline devoted to healing which, as a consequence, made research on well-being and personal development less widespread. It was not until the 1960s, when humanistic psychology emerged as a response to psychoanalysis and behaviorism, that experts in the field ceased to consider the individual a “passive vessel responding to stimuli,”1 but rather “decision makers,” with choices and preferences”1. This

Positive Psychology: Contemporary Academia’s Way of Helping us to Think Happy Thoughts

BY JENS HONACK

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MARTIN SELIGMAN...DEFINES POSITIVE PSYCHOLOGY AS “[A] SCIENCE OF POSITIVE

SUBJECTIVE EXPERIENCE, POSITIVE INDIVIDUAL TRAITS, AND POSITIVE INSTITUTIONS

PROMISES TO IMPROVE QUALITY OF LIFE AND PREVENT THE PATHOLOGIES THAT ARISE WHEN

LIFE IS BARREN AND MEANINGLESS.”

change paved the way for the emergence of positive psychology. While

the aims of positive psychology have their origins in classical philosophy and ancient Buddhist sutras, the field remains young with its first international conference held only in 2003.3

Two concepts currently dominating positive psychology literature are flow and mindfulness. Flow is the phenomenon colloquially described as being ‘in the zone’. Distinguished Professor in psychology and Management at the Claremont Graduate University Mihaly Csikszentmihályi was the first to use the term flow, and has dedicated his studies to the nature and effects of a


References 1. Pascal, B., & Granges, C. D. (1962). Pensées: Blaise Pascal. Paris: Garnier. 2. Seligman, M. E., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American

Psychologist, 55(1), 5-14. doi:10.1037//0003-066x.55.1.53. Compton, William C (2005). An Introduction to positive psychology. Wadsworth Publishing. ISBN

0-534-64453-8.4. Sobel, D. (1995, January). Interview: Mihaly Csikszentmihalyi. Omni, 73-90.5. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper &

Row.6. “What is Mindfulness”. Retrieved from http://greatergood.berkeley.edu/topic/mindfulness/

definition.7. Hofmann SG, Sawyer AT, Witt AA, et al. (Apr 2010). The effect of mindfulness based therapy on

anxiety and depression: a meta-analytic review. J Cons Clin Psych. 78 (2): 169–183. doi:10.1037/a0018555.

8. Killingsworth, M. (2010, November 12). A wandering mind is an unhappy mind. Since. doi:10.1037/e634112013-170

9. Authentic Happiness. (2016). Retrieved October 27, 2016, from https://www.authentichappiness.sas.upenn.edu/content/about-us

10. Peterson, C. (2000). The future of optimism. American Psychologist, 55, 44-55.11. Seligman, M.E.P., Reivich, K., Jaycox, L., & Gillham, J. (1995). The Optimistic Child. New York:

Houghton Mifflin.12. Seligman, M. E. (2007). positive psychology, Positive Prevention, and Positive Therapy. Retrieved

October 20, 2016, from http://www.sas.upenn.edu/psych/seligman/ppsnyderchapter.htm 13. Held, B. S. (2004). The Negative Side of positive psychology. Journal of Humanistic psychology,

44(1), 9-46. doi:10.1177/002216780325964514. Riskin, John H. et. al. (1996). For Every Malady a Sovereign Cure: Optimism Training. Journal

of Cognitive Psychotherapy. Retrieved October 25, 2016, from https://www.researchgate.net/profile/John_Riskind/publication/232703516_For_Every_Malady_a_Sovereign_Cure_Optimism_Training/links/0046351b13f0a4679f000000.pdf

15. Killgore, L. (2009). Merit and Competition in Selective College Admissions. The Review of Higher Education, 32(4), 469-488. doi:10.1353

16. 16. Pluskota, Anna. The Application of positive psychology in the Practice of Education. Springer-Plus 3.1 (2014): 147.

Several advocates for positive psychology intend to bring their theoretical findings closer to the public. The “Authentic Happiness” initiative at the University of Pennsylvania, for instance, aims to “provide free resources where people can learn about positive psychology through readings, videos, research, opportunities, conferences, questionnaires with feedback and more.”9 With these tools, anyone can learn how to increase positive emotions and engagement in everyday activities. For example, the initiative suggests individuals to practice yoga, which can be considered a “very thoroughly planned flow activity. [It tries] to achieve a joyous, self-forgetful involvement through concentration, which in turn is made possible by a discipline of the body.”4 Another such initiative, the ‘World Well-Being Project’, based out of the Positive Psychology Center at Penn, promotes interdisciplinary collaboration to establish “scientific techniques for measuring psychological well-being and physical health based on the analysts of language in social media.” Data made accessible through social media usage can be useful in helping experts identify recurring pointers that can indicate possible physical and psychological malady. The ongoing research into subjective well-being combin ed with its practical application is known as positive intervention. It consists of approaches that seek to increase happiness and thus prevent or promote the rehabilitation from mental disorders. Anxiety and depression have been repeatedly proven to arise from self-reinforcing, undisputed, pessimistic thinking.1⁰,11 Workshops such as ‘learned optimism’ training programs are meant to “teach both children and adults to recognize their own catastrophic thinking and to become skilled disputers.”12 Individuals that underwent this training were found to be more motivated, self-secure and engaged in daily life.13

RECENT MINDFULNESS STUDIES HAVE SUGGESTED THAT AN ACTIVE AWARENESS OF THE PRESENT REDUCES STRESS AND ANXIETY.

“person’s body or mind [being] stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile.”4 Csikszentmihályi describes a situation that gives way to flow as a “reality that [has] clear rules and goals,”3 thus providing an organized framework to the entropy that “is the normal state of consciousness.”5

Mindfulness is a prominent buzz-term in mainstream culture that has its roots in philosophical and religious thought and has found its way into contemporary psychology. The Greater Good Science Center at UC Berkeley defines mindfulness as “maintaining a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and surrounding environment.”6 Recent mindfulness studies have suggested that an active awareness of the present reduces stress and anxiety.7 In a study undertaken by Harvard University psychologists Matthew Killingsworth and Daniel Gilbert, volunteers reported mindfulness and happiness levels at regular intervals. Individuals reported mindlessness at least 30% of the time during any given activity other than sexual encounters. The study found consistent correlations between mindfulness and happiness; this suggests that subjective well-being experienced during any given activity correlates with an active concentration on the task.8

CRITICISMPositive psychology’s unconventional research focus and methodologies are controversial in mainstream academia. In a 2000 American psychology Association panel entitled “The (overlooked) Virtues of Negativity,” Bowdoin College Research Professor of Psychology and Social Sciences Barbara Held pointed out the “tyranny of the positive attitude.”14 She warned about the separatism generated within psychology by overwhelmingly optimism-centered approaches as presented by positive psychology. According to Held, universal psychological theories should not neglect the importance of negative feelings for the human experience. She also argues that an entirely positivity-centered approach may impair or even prevent mental rehabilitation.13 “If people feel bad about life’s many difficulties and they cannot manage to transcend their pain no matter how hard they try [(to learn optimism), they could end up feeling even worse; they could feel guilty or defective for not having the right (positive) attitude, in addition to whatever was ailing them in the first place.”13

Positive psychology has sparked the interest of researchers in neighboring fields. In Poland, Nicolaus Copernicus University Professor of Sociology Anna Pluskota is advocating for an approach to education that is inspired by positive psychology research. The increasingly fast-paced, competitive educational systems that exist in our globalized world are seen as one of the possible sources of the “depression epidemic” among young people.15 16 The application of positive psychology principles to education could allow schools to “become a place to enable young people to achieve large-scale development, and increase their personal resources and their mental well-being,” says Pluskota.16

Positive psychology is far from discovering a happiness recipe. Yet, ongoing research continues to provide insights into how subjective well-being can be increased in everyday life. positive psychology is academia’s contribution towards bringing fulfillment closer to everyone.


The Neural Processing of Disgust and its Ramifications

Emotions are often thought to be beyond mental control and characterized by a gut reaction. Interest in the neuroscience of emotions has increased due to the relatively recent introduction of functional magnetic resonance imaging (fMRI), which moni-tors blood oxygenation levels. While previous research in the field relied on other analysis methods, such as electrophysiological and lesion studies, these more recent fMRI results form the basis for neuroscientific models of emotion that guide research in the rap-idly growing field.

Disgust is one of the most prominently featured emotions in re-search, possibly because it is more easily measured and recog-nized than other emotions. For example, comparisons of obser-vations of emotional responses between disgusting odorants and other stimulant odorants demonstrated that olfactory and visual responses were stronger when feeling disgust than when feeling other emotions provoked by the stimuli.1 Likely having evolved from eating habits that protect organisms from ingesting unsafe foods, disgust has served an important role in the basic protection from infectious, inedible, or unsanitary events.2 As such, many sensory systems have been found to contribute to the feeling of disgust, including those of gustation, olfaction, and interoception, the sense of the body’s physiological condition.3 The insula, a region of the brain in the cerebral cortex, integrates information from these multiple sensory modes and has been implicated in the neural processing of disgust.1

The functional and anatomical relationships between experienc-ing, expressing, and recognizing disgust remained unclear for some time. In 2003, researchers found a bilateral or left-sided involvement of the insula in stroke patients with a deficit in dis-gust recognition. However, the specific insula regional correlation to disgust processing remained unclear.4,5 Despite the evidence for selective insular activation in disgust processing, other results suggested a less specific role, citing a similar nonspecific neural activation of fear. In a separate study, no specific deficit in disgust recognition was found in 15 consecutive cases of patients with se-lective resection of the insular cortex.⁶

At this point in time in the field, it was clear that researchers did not agree on the extent and characteristics of regional specificity of disgust processing. In 2016, to thoroughly test for the selective role of the insula in facial disgust recognition, emotion recognition was studied in thirteen patients before, during, and after direct electrical stimulation of the insula. The researchers tested for the recognition of happiness, fear, anger and disgust. After electrical stimulation of the left insula, there was a statistically significant reduction in emotion recognition exclusively for the emotion of disgust.⁷ This substantiates the notion that the left insula has a se-

THE LEFT INSULA HAS A SELECTIVE ROLE IN THE PROCESSING AND RECOGNITION OF DISGUST.

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lective role in the processing and recognition of disgust.

To understand the neural mech-anism for comprehending the emotions of others, fMRI was used to study the differences in activated regions of the brain while subjects were either expe-riencing or observing emotion-al reactions. First, participants were exposed to different odor-ants intended to produce strong feelings of disgust. Later, the same participants observed vid-eo clips depicting the emotional facial expression of disgust. Ob-serving the facial expressions of disgust and actually experienc-ing disgust, due to the odorants, activated the same sites in the anterior insular cortex and, to a lesser extent, the anterior cin-gulate cortex.1 The similarities discovered between observing and experiencing disgust provide a deeper understanding of the connection between our emotions and our perception of others.

Disgust also has important social ramifications. An analysis of the neural basis of disgust perception in racial prejudice found that disgusted faces of races different from that of the viewer resulted in higher engagement of the amygdala and insula when compared to faces of the viewer’s own race. The study measured the implicit ra-cial prejudice of participants by measuring their response time dif-ference in correctly identifying adjectives as being positive or neg-

ative and names as being native or foreign in two scenarios. The stimuli were either “compatible” (correlating positive emotions with names of the viewer’s own race or unpleasant emotions with names of a foreigner) or “incom-patible” (correlating unpleasant emotions with those of the view-er’s own race or positive emo-tions with names of a foreigner). Disgust sensitivity of the partic-ipants was determined through fMRI by measuring the level of neural activation when shown images of various faces either making neutral or disgusting ex-pressions. Individual differences in disgust sensitivity were found to be predictive of implicit racial prejudice.⁹ Taken together, these results suggest a crucial role of insula-centered circuits in racial prejudice.

Furthermore, participants of a study on whether specific emotions would have an effect on the expression of the emotions themselves were exposed to a disgusting odorant and asked to evaluate their feelings towards a variety of social groups. Subjects’ views towards different individuals were then measured through a self-reporting scale ranging from 0 (cold) to 100 (warm). Results indicated that participants exhibited less warmth toward gay men after being ex-posed to a disgusting odorant than if they were not exposed to that odorant. This effect of inducing disgust was found to be equally strong irrespective of the subjects’ political ideologies.10 Accord-ingly, external stimuli that lead to disgust may play a role in the perceptions of social groups. The feeling of disgust, when induced by environmental stimuli, can lead to more negative views towards specific social groups and potentially heighten social tensions re-garding sexual orientation.

Disgust thus acts as a medium through which the surroundings can influence social interactions. Since disgust has a role in shap-ing attitudes relevant to current societal issues, it is essential to bet-ter understand the neural processing of disgust and its effects on our behavior and perceptions.

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A DEPICTION OF THE OVERLAP (WHITE) BETWEEN BRAIN ACTIVA-TION DURING THE FEELING (RED) AND OBSERVATION (BLUE) OF

DISGUST AS FOUND BY WICKET ET AL.

vision of disgust(neutral)

disgusting odorant(rest)

overlap vision & olfaction of disgust

References1. Wicker, B., Keysers, C., Plailly, J., Royet, J., Gallese, V., & Rizzolatti, G. (2003). Both of Us Disgusted in My

Insula. Neuron, 40(3), 655-664. doi:10.1016/s0896-6273(03)00679-22. Rozin, P., & Fallon, A. E. (1987). A perspective on disgust. Psychological Review, 94(1), 23-41.

doi:10.1037//0033-295x.94.1.23 3. Miller S (2004): Disgust: The Gatekeeper Emotion. Hillsdale, NJ: The Analytic Press, Inc.4. Adolphs, R., Tranel, D., & Damasio, A. R. (2003). Dissociable neural systems for recognizing emotions.

Brain and Cognition, 52(1), 61-69. doi:10.1016/s0278-2626(03)00009-5 5. Calder, A. J., Keane, J., & Young, A. W. (n.d.). Loss of Disgust: Impaired Perception of Disgust Following

Brain Injury. PsycEXTRA Dataset. doi:10.1037/e501882009-164 6. Boucher, O., Rouleau, I., Lassonde, M., Lepore, F., Bouthillier, A., & Nguyen, D. K. (2015). Social informa-

tion processing following resection of the insular cortex. Neuropsychologia, 71, 1-10. doi:10.1016/j.neuropsychologia.2015.03.008

7. Papagno, C., Pisoni, A., Mattavelli, G., Casarotti, A., Comi, A., Fumagalli, F., . . . Bello, L. (2016). Specific disgust processing in the left insula: New evidence from direct electrical stimulation. Neuropsycho-logia, 84, 29-35. doi:10.1016/j.neuropsychologia.2016.01.036

8. Lamm, C., & Singer, T. (2010). The role of anterior insular cortex in social emotions. Brain Structure and Function, 214(5-6), 579-591. doi:10.1007/s00429-010-0251-3

9. Liu, Y., Lin, W., Xu, P., Zhang, D., & Luo, Y. (2015). Neural basis of disgust perception in racial prejudice. Human Brain Mapping, 36(12), 5275-5286. doi:10.1002/hbm.23010

10. Inbar, Y., Pizarro, D. A., & Bloom, P. (2012). Disgusting smells cause decreased liking of gay men. Emotion, 12(1), 23-27. doi:10.1037/a0023984

MANY REGIONS OF THE BRAIN ARE INVOLVED IN PERCEIVING OR EXPERIENCING DISGUST.

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Thousands of people stare aimlessly at their phones before finally rolling over and falling asleep. However, increasingly more people have begun a very different pre-slumber ritual. Before laying down their devices to charge for the night, many people put in head-phones, log on to their favorite media streaming site, and watch ASMR videos. They become nearly entranced by the seemingly peculiar videos of people whispering to the camera, tapping on ordinary objects, and performing dull, quiet tasks. To an outsider of the ASMR world, this content seems eerily boring-- confusing, even. But for those in this subculture of the Internet, this media triggers a physiological response that remains a mystery largely unexplored by science.

ASMR is an acronym for Autonomous Sensory Meridian Re-sponse, and it refers to a phenomenon in which certain audito-ry and visual stimuli trigger a tingling sensation, precipitating a unique, nonsexual euphoria. The term was originally coined in a Facebook group created to unite people experiencing the colloqui-ally described ‘head orgasms’ or ‘braingasms.’⁴ Those that experi-ence ASMR contend that it provides relief from depression, stress, and chronic pain as an alternative form of medicine.2 Because of the influx of ASMR media in recent years, a community of thou-sands has been established on the Internet, in which they discuss and relate to one another through their shared experience. In par-ticular, YouTube has become the media source of choice because of the many ASMR channels that create videos specifically to trigger the response. ‘ASMRtists’, the name these media-makers have giv-

en themselves, have experienced a surge in popularity since 2014, with many of their channels attracting some millions of views per month.⁵

ASMRtists create videos with different stimuli that are meant to trigger the sensation. According to a 2015 survey about those who view ASMR videos, 75% were triggered by whispering, 69% were triggered by personal attention, and more than 50% were triggered by slow movements, repetitive movements, and crisp sounds such as tapping and scratching of various surfaces.2 These sounds were then compared to sounds not typically associated with ASMR, such as laughing, vacuum cleaner noises, and airplane noises; less than 3% of those surveyed were triggered by these sounds.2 ASMRtists try several triggers and many experiment with un-conventional materials and means of presenting their videos. For example, a genre of ASMR that has gained popularity is roleplay. The ASMRtist pretends to be a doctor, spa specialist, or even just

a friend, and speaks directly to the camera as if speaking directly to the viewer, giving them the feeling of personal attention. Then, they perform various actions in front of the camera such as tapping a table, whispering into binaural microphones, which simulate whispering from ear to ear, or blowing into the air while making graceful hand movements.

“IT’S A PLEASANT, TINGLING FEELING THAT YOU EXPERIENCE...THIS TINGLING SENSATION

IS EUPHORIC. IT STARTS IN THE BACK OF YOUR HEAD, TRAVELS DOWN THROUGH YOUR

SPINE, INTO YOUR LIMBS, RELAXING YOU, GIVING YOU A FEELING OF WELL-BEING.”

-ASMRTIST MARIA, WHO GOES BY HER PSEUDONYM GENTLE WHISPERING

ASMR REFERS TO A PHENOMENON IN WHICH CERTAIN AUDITORY AND VISUAL STIMULI TRIGGER A TINGLING SENSATION, PRECIPITATING A UNIQUE, NONSEXUAL EUPHORIA.

GRAPHIC/TIFFANY HUANGBY PHYLLIS PARKANSKY

ASMR:BRAINGASMS?

INTERNET


Very little science backs ASMR, which is why it is so controversial. Many reject ASMR as a distinct phenomenon or speculate that it is a variation of previously studied sensations. Synesthesia, which is one of these phenomena, is a neurological sensation in which the stimulation of one sense leads to an involuntary experience in a second sense. Many have drawn comparisons between ASMR and auditory-tactile synesthesia, in which sounds induce sensations as if being touched.⁷ This is evident in the many videos that simulate brushing the viewer’s hair or giving them a massage. Another re-search article suggests that ASMR is a variation of the mind-body experience of frisson.⁶ Frisson is an intensely pleasurable reaction to music, and given the definition of ASMR, it is possible that ASMR is a “softer, quieter version of the same phenomenon.”⁶

A 2016 study by the University of Winnipeg sought to shed some light on ASMR. Researchers explored the resting-state function of the brains of those who have experienced ASMR. The default mode network, which is the brain’s resting-state network, consists of parts of the prefrontal cortex, parietal cortices, and cingulate gyrus, and the research suggests that it may function slightly differently in those that experience ASMR than in those who do not. In the study, the default mode network of eleven self-identified ASMR-ex-periencers was compared to that of eleven non-ASMR-experienc-ers through fMRI processing. The results showed that those with ASMR showed significantly less connectivity than that of their controls between the frontal lobes and sensory and attentional re-

WHETHER ASMR MEDIA SERVES TO TRIGGER A SENSATION TO HELP SOMEONE

WITH ANXIETY, DEPRESSION OR ANY OTHER CONDITION, OR SIMPLY TO HELP SOMEONE

FALL ASLEEP, ITS BENEFITS AS AN ALTERNATIVE FORM OF MEDICINE ARE CLEAR.

References:1. Smith, S. D., Fredborg, B. K., & Kornelson, J. (2016, May 31). An examination of the default mode

network in individuals with autonomous sensory meridian response (ASMR). Taylor & Francis, 1-5. Retrieved October 4, 2016.

2. Barratt, E. L., & Davis, N. J. (2015). Autonomous Sensory Meridian Response (ASMR): A flow-like mental state. PeerJ, 3. doi:10.7717/peerj.851

3. G. (2014). What is ASMR? Retrieved October 30, 2016, from http://www.youtube.com/watch?v=Kb27NHO_ubg

4. Autonomous Sensory Meridian Response Group [Facebook group for those who experience ASMR]. (2010, February 25).

5. U. (n.d.). YouTube Statistics, Twitch Statistics, Instagram Statistics - SocialBlade.com. Retrieved October 30, 2016, from http://socialblade.com/

6. Campo, M. A., & Kehle, T. J. (2016). Autonomous sensory meridian response (ASMR) and frisson: Mindfully induced sensory phenomena that promote happiness. International Journal of School & Educational Psychology, 4(2), 99-105. doi:10.1080/21683603.2016.1130582

7. Naumer, M. J., & J. J. F. Van Den Bosch. (2009). Touching Sounds: Thalamocortical Plasticity and the Neural Basis of Multisensory Integration. Journal of Neurophysiology, 102(1), 7-8. doi:10.1152/jn.00209.2009

gions in the precuneus and parietal cortex. Reduced connectivity between these regions has been linked to reduced emotional in-hibition in patients, so it is possible that ASMR reflects a reduced ability to suppress sensory-emotional experiences.1

Though this study presents interesting evidence and hypotheses, the validity of ASMR as a distinct medical phenomena remains unclear. The study found some evidence in favor of ASMR as a dis-tinct condition, showing that most participants could dampen the intensity of their experience at their own will, which significantly distinguishes it from synesthesia. However, the study also shows that those experiencing ASMR have decreased connectivity of the thalamus, which is a significant feature of synesthesia.1 In fact,

the aforementioned 2015 survey found that 5.9% of the subjects had experiences with synesthesia, which is a relatively high preva-lence.2 Additionally, the University of Winnipeg study emphasizes that the differences found between the default mode networks of

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THE STUDY SHOWS THAT THOSE EXPERIENCING ASMR HAVE DECREASED CONNECTIVITY OF THE THALAMUS, WHICH IS A SIGNIFICANT FEATURE OF SYNESTHESIA.

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the subjects and controls do not indicate that only certain individ-uals have the ability to experience ASMR, which backs the claim of many ASMRtists that anyone can experience it. Very few scientific studies have been performed regarding ASMR, so perhaps with a larger testing population and measures of brain activity before, during, and after ASMR media, science can confirm ASMR as a valid and distinct phenomenon.

With the little research on the subject, it is difficult to come to many definitive conclusions about ASMR’s burgeoning popularity and its effect on people. The research that has been done raises more ques-tions than answers: Can anyone experience ASMR? What causes it? Is it even a real phenomenon? Science still cannot affirm its va-lidity as a distinct sensation. However, to the ASMR community, it is a very real and meaningful part of their lives. Whether ASMR media serves to trigger a sensation, to help someone with anxi-ety, depression or any other condition, or simply to help someone fall asleep, its benefits as an alternative form of medicine are clear. ASMR may not be its own phenomenon but it surely has made its own place on the Internet.


PHYSICIAN PRACTICE

Bystander CPR: Training the Public to Save Lives

BY JIMMY QIAN

About 720,000 people in the United States suffer heart attacks each year, with cardiac arrest being the third leading cause of death in the U.S.1 According to the American Heart Association (AHA), over 80% of cardiac arrests occur in home settings.2, 15 Nationally, less than 6% of people experiencing an out-of-hospital cardiac ar-rest (OHCA) survive. Many factors, such as local emergency pro-vider protocol, determine local survival rates, but differences in rates of bystander CPR intervention cause wide disparities in pa-tient survival rates across the nation. In many large cities, such as New York City and Chicago, OHCA survival rates are in the single digits, while in Seattle and overarching King County, over a fifth of OHCA victims survive (King County’s cardiac arrest survival rate is 62%, four times the national average). If the entire coun-try adopted the policies of King County, where bystander CPR response rates are significantly higher, over 30,000 lives could be saved annually, according to one estimate.3 According to Dr. Ben-jamin Abella, director of the Center for Resuscitation Science and Vice Chair of Research of the Department of Emergency Medicine at the University of Pennsylvania’s Perelman School of Medicine, “Bystander CPR is probably the most important thing people can do to save lives. As physicians we often concentrate on medications and other sophisticated ways of saving lives, but in truth, all of that pales in comparison to bystander CPR.” As OHCA survival rates have remained stable for nearly 30 years, initiatives to increase by-stander CPR intervention should be implemented in earnest.

“WE OFTEN CONCENTRATE ON MEDICATIONS AND OTHER SOPHISTICATED WAYS OF SAVING LIVES, BUT IN TRUTH, ALL OF THAT PALES IN COMPARISON TO BYSTANDER CPR.”

CPR AND BYSTANDER RESPONSE

A wealth of research has shown that the time between the onset of cardiac arrest and the first chest compression during CPR is a key determinant of the probability of survival. The goal of CPR is to restore breathing and circulation, but if nothing is done, perma-nent brain damage is possible after just four minutes and very like-ly after 6 minutes.15 Similarly, the amount of time elapsed prior to defibrillation (delivery of electrical shocks to the heart to allow it to re-establish a normal rhythm) greatly affects patient outcomes 4-6. Since the time elapsed before care is very important, OHCA victims require a timely response from bystanders. One land-mark meta-analysis found that survival rate doubles when OHCA is witnessed by a bystander and quadruples when the bystander performs CPR.7 Furthermore, numerous studies have shown that layperson CPR (usually compression-only CPR without assisted breathing) and defibrillation are greatly associated with increased patient survival compared to no bystander intervention. 2, 8-10 Al-

though 53% of OHCAs are witnessed by bystanders, only 32% of these victims receive bystander CPR. Thus, increasing the amount of bystander intervention and public access to automatic external defibrillators (AEDs) is a top priority to increase OHCA survival rates. This includes encouraging CPR-certified laypersons to pro-vide care and increasing public access to CPR training. According to the AHA, 70% of Americans feel helpless to act during a cardiac emergency because they either never learned CPR or their train-ing had significantly lapsed. 11 Another study found that annual rates of U.S. CPR training are low and vary widely across commu-nities, with most areas in the single digits.12 Based on a survey of over 9,000 adults in one of his studies, Dr. Abella estimates the na-tional rate of CPR training as 18%, a number he finds “really low.”

FIXING THE PROBLEM

There are many ways to increase layperson CPR training rates. Education departments can integrate CPR and AED training into graduation requirements, and cities can organize free communi-

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ty-based CPR training at libraries and churches. More important-ly, family and friends of at-risk individuals should all be trained in CPR, especially since 80% of cardiac arrests occur at home.2 When cardiac patients are in the hospital, the hospital should provide CPR training to family and friends. Current barriers to such CPR programs include cost of training materials (such as mannequins), course duration (usually four hours), the need for CPR-certified instructors, and low motivation for CPR training.

However, research by Dr. Abella has suggested ways around these barriers. One study demonstrated that video-only CPR training, known as video self-instruction (VSI), provides the same quality of education as VSI with mannequins, while greatly reducing course duration and cost.13 This is important because the effectiveness of VSI CPR training has already been demonstrated in many studies by different research groups.14 If VSI without mannequins is as good as VSI, which is in turn as good as traditional CPR courses, then there may be a shift towards video-only CPR training for everyone. Doing so would significantly decrease the cost and time of training and make it easier to integrate into high school curriculums and even waiting rooms in hospitals, airports, and DMVs. Dr. Abella’s group also developed a smartphone application to teach CPR, and a current study aims to determine whether this app teaches CPR as well as VSI with mannequins. The app can send notifications to users when their training has lapsed to encourage them to watch a refresher video, and is easy to distribute in a smartphone-dominat-ed world. These are two scalable methods that can greatly increase accessibility to CPR training. Dr. Abella points out that it may be more prudent to provide some form of training to large numbers of people rather than teaching perfect CPR to a small number of individuals, since any bystander CPR is much better than no CPR.

IT MAY BE MORE PRUDENT TO PROVIDE SOME FORM OF TRAINING TO LARGE NUMBERS OF PEOPLE RATHER THAN TEACHING PERFECT CPR TO A SMALL NUMBER OF INDIVIDUALS, SINCE ANY BYSTANDER IS MUCH BETTER THAN NO CPR.

Telecommunicator CPR, in which 911 dispatchers provide CPR instructions by phone in real time (this is currently not avail-able in most areas), can help increase bystander participation and CPR quality. Also, increased public availability to AEDs and smartphone apps showing where AEDs are located can help lay-people quickly locate a defibrillator. In telecommunicator CPR, if AED locations are registered with the appropriate emergen-cy medical officials, 911 dispatchers can guide bystanders to the nearest AED. In some places, health departments are encourag-ing people to download smartphone apps that alert bystanders who can perform CPR whenever there is a cardiac arrest; these bystanders often arrive before emergency personnel can. Depart-ments of health and education should partner with community groups, service providers, and professional organizations to pro-mote public education and scalable training. For example, the Mobile CPR Project (another Dr. Abella project) travels to pub-lic places in Philadelphia to train people for free. It is supported by the city government, police department, fire department, and several hospitals – an inspirational community collaboration.

However, in order to replicate such initiatives, the disconnect be-tween policy and research must be overcome. It is unclear which governmental body should take the lead – currently, no federal agency has cardiac arrest as a priority. The system is fragmented and it is up to local communities to implement their own solu-tions, hence the large disparities across counties. A national gov-ernmental organization must spearhead the fight against OHCAs with the same passion with which the government introduced the War on Cancer. Perhaps one day, an OHCA will no longer be a death sentence, but rather a medical emergency that entire com-munities can work together to help fight. But for now, we have a lot of work to do.

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ABOUT 720,000 PEOPLE SUFFER HEART ATTACKS EACH YEAR

LESS THAN 6% OF PEOPLE EXPERIENCING OHCA SURVIVE

OF CARDIAC ARRESTS OCCUR AT HOME80%

References: 1. “Heart Disease: Scope and Impact.” Heart Disease Facts. The Heart Foundation, n.d. Web. 06 Oct.

2016.2. Institute of Medicine. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Washington, DC:

The National Academies Press, 2015. doi:10.17226/21723.3. Peikoff, Kira. “CPR Survival Rates Can Differ Greatly by City.” The New York Times. The New York

Times, 7 Dec. 2015. Web. 6 Oct. 2016.4. Caffrey, S. L., P. J. Willoughby, P. E. Pepe, and L. B. Becker. 2002. Public use of automated defibrilla-

tors. New England Journal of Medicine 347(16):1242-1247.5. Chan, P. S., H. M. Krumholz, G. Nichol, and B. K. Nallamothu. 2008. Delayed time to defibrillation

after in-hospital cardiac arrest. New England Journal of Medicine 358(1):9-17.6. Field, J. M., M. F. Hazinski, M. R. Sayre, L. Chameides, S. M. Schexnayder, R. Hemphill, R. A. Samson, J.

Kattwinkel, R. A. Berg, F. Bhanji, D. M. Cave, E. C. Jauch, P. J. Kudenchuk, R. W. Neumar, M. A. Peberdy, J. M. Perlman, E. Sinz, A. H. Travers, M. D. Berg, J. E. Billi, B. Eigel, R. W. Hickey, M. E. Kleinman, M. S. Link, L. J. Morrison, R. E. O’Connor, M. Shuster, C. W. Callaway, B. Cucchiara, J. D. Ferguson, T. D. Rea, and T. L. Vanden Hoek. 2010. Part 1: Executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(18 Suppl 3):S640-S656.

7. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out‐of‐hospital cardiac arrest: a systematic review and meta‐analysis. Circ Cardiovasc Qual Outcomes. 2010;3:63–81.

8. Bobrow BJ, Spaite DW, Berg RA, Stolz U, Sanders AB, Kern KB, Vadeboncoeur TF, Clark LL, Gallagher JV, Stapczynski JS, LoVecchio F, Mullins TJ, Humble WO, Ewy GA. Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest. JAMA. 2010;304(13):1447-1454. doi:10.1001/jama.2010.1392

9. Malta Hansen C, Kragholm K, Pearson DA, Tyson C, Monk L, Myers B, Nelson D, Dupre ME, Fosbøl EL, Jollis JG, Strauss B, Anderson ML, McNally B, Granger CB. Association of Bystander and First-Responder Intervention With Survival After Out-of-Hospital Cardiac Arrest in North Carolina, 2010-2013. JAMA. 2015;314(3):255-264. doi:10.1001/jama.2015.7938

10. L. Avalli, E. Maggioni, F. Formica, et al. Favourable survival of in-hospital compared to out-of-hospi-tal refractory cardiac arrest patients treated with extracorporeal membrane oxygenation: an Italian tertiary care centre experience. Resuscitation, 83 (2012), pp. 579–583

11. “CPR Statistics.” CPR Statistics. American Heart Association, June 2011. Web. 06 Oct. 2016.12. Anderson ML, Cox M, Al-Khatib SM, et al. Cardiopulmonary Resuscitation Training Rates in the Unit-

ed States. JAMA internal medicine. 2014;174(2):194-201. doi:10.1001/jamainternmed.2013.11320.13. Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital

Discharge: A Multicenter Pragmatic Trial. Audrey L. Blewer, Mary E. Putt, Lance B. Becker, Barbara J. Riegel, Jiaqi Li, Marion Leary, Judy A. Shea, James N. Kirkpatrick, Robert A. Berg, Vinay M. Nadkarni, Peter W. Groeneveld, Benjamin S. Abella, and on behalf of the CHIP Study Group. Circ Cardiovasc Qual Outcomes. 016; CIRCOUTCOMES. 116.002493 published online before print October 4 2016, doi:10.1161/CIRCOUTCOMES.116.002493

14. B. Lynch, E.L. Einspruch, G. Nichol, L.B. Becker, T.P. Aufderheide, A. Idris. Effectiveness of a 30-min CPR self-instruction program for lay responders: a controlled randomized study. Resuscitation, 67 (2005), pp. 31–43.

15. Emergency Care and Transportation of the Sick and Injured. 11th ed. N.p.: n.p., 2017. Emergency Care and Transportation of the Sick and Injured. American Academy of Orthopaedic Surgeons. Web. 14 Oct. 2016.


The Guardian described the completion of the The Human Ge-nome Project (1990-2003) as “Biology’s Holy Grail.”1 The public and scientific community believed they had uncovered the blue-print-- the biological programming -- that generates genetic disor-ders and all the traits that make us who we are.

Naturally, the excitement shifted from characterizing the human genome to designing preventative and specialized care. As Paul Horn suggested 17 years ago, wouldn’t it be possible to predict your genetic disposition for certain disorders, and take steps to prevent them?

Fourteen years after the human genetic code was declared se-quenced with 99.99% accuracy, we would expect to be able to con-trol our environment and behavior, or even modify our own genet-ic makeup to change our hereditary destiny. These ambitions have applications in both disease prevention and genetic healthcare.

While burgeoning technologies exist, the Human Genome Project still hasn’t achieved the goals it was projected to complete, such as clinical genome sequencing and genetically-tailored doctor visits. Huge gaps in our expectations have yet to be filled. Understanding the challenges that genetics has faced explains not only why these expectations came to be but also helps us predict the future of the field.

Has the study of genetics hit a brick wall, or will the field break through into extraordinary achievements?

Perhaps some of the perceived “holes” that we currently see in ge-netics were due to excess enthusiasm that was not congruent with actual advancements in the field. Whether advancements in map-ping, sequencing, and DNA replication before 1990 were enough

to merit the scope of the Genome Project, the success of its mission to map the entire human genome, and its $3 billion public invest-ment, is up to individual discretion.

As James Watson was the main source of enthusiasm for the Ge-nome Project and genetics in general, we strive to understand his intentions for the field through the lens of his contributions and status in science.

In 1953, Watson worked alongside Francis Crick to create a model of DNA that both matched Rosalind Franklin’s x-ray crystallogra-phy data and explained all of its properties. Watson was offered a position at Harvard University in 1956 and a Nobel Prize in 1962.2

Modern Library named his autobiography the Double Helix one of the 100 Best Nonfiction Books of the 20th Century.3

Watson was the world’s most popular geneticist, the head of the NIH, and the director of the Human Genome Project.⁴ It is no wonder why he might angle the NIH and the operations of many of the best laboratories in the world toward genetics, whether sup-ported by hard evidence or not. Due to Watson, our inflated ex-pectations for genetics may be partially responsible for the field’s shortcomings.

The Human Genome Project did complete many individual sci-entific feats over its course. However, to understand the apparent shortcomings of the field, we must understand the medical chal-lenges that genetics has faced.

In 1984, at the age of 3, Jesse Gelsinger was diagnosed with orni-thine transcarbamylase (OTC) deficiency, a disorder where one’s genes do not have the complete sequence that codes for OTC, a necessary enzyme produced by the liver5. The year 1994 marked a surge of articles that supposed that viral vectors could be used for gene therapy.⁶

The idea was that if a person lacked a certain gene, a virus could infect the target cells and, like viruses do, implant its own DNA. If the virus carried the gene that the person lacked, the individual’s genetic code would effectively gain that gene.⁷ By 1999, viral vec-tor therapy would come into fruition, and Gelsinger would be the first human trial. A long awaited 15 years after his first diagnosis, under the oversight of the University of Pennsylvania, his liver was injected with a crippled adenovirus that carried the gene necessary

HIGH EXPECTATIONS

DISASTER STRIKES

BY DANIEL LEAPMAN

Has the Study of Genetics Hit

a Brick Wall?

“ONE DAY YOU’RE GOING TO BE ABLE TO WALK INTO A DOCTOR’S OFFICE AND HAVE A COMPUTER ANALYZE A TISSUE SAMPLE, IDENTIFY THE PATHOGEN THAT AILS YOU AND THEN INSTANTLY PRESCRIBE A TREATMENT BEST SUITED TO YOUR SPECIFIC ILLNESS AND INDIVIDUAL GENETIC MAKE-UP”– PAUL HORN, SENIOR VP OF IBM, 2001.


to produce the OTC enzyme, and the virus began to enter his cells.⁸

Two days later, Gelsinger was dead. According to a death report, the virus spread beyond Jesse’s liver to other organs, and his body reacted with an inflammatory response that brought his fever to 104.5 and put him in a coma. The ventilator could not oxygenate his blood via his fluid-filled lungs.⁹

The subsequent lawsuits (whose settlements totalled $517,496 from UPenn and $514,622 from Children’s National Medical Cen-ter in Washington, D.C) caused hesitation among the scientific community regarding gene therapy.⁹ Whereas the government had reviewed 331 gene-therapy trials by August of 1999,10 by the com-ing January, the FDA had cancelled all trials at the University of Pennsylvania and had begun investigations on 69 others.11 There was great skepticism among scientists about the viability of gene manipulation as a medical technique, and some hesitation among medical doctors to put gene therapy into practice. It seemed as though the Gelsinger case was a death sentence for genetics. Would genetic medical therapies ever see the light of day?

While the study of genetics has had a certainly tumultuous past, the pursuit of genetic technologies has been all but fruitless. There have certainly been major advancements resulting from research succeeding the Human Genome Project.

One of these advancements is screening tests for newborns. The CDC describes the procedure as “using a few drops of blood from the newborn’s heel, [to test] for certain genetic, endocrine, and metabolic disorders..[including] hearing loss and critical con-genital heart defects (CCHDs)”.12 The American Association for Clinical Chemistry repeatedly emphasizes that the importance of screening tests is that they can determine disorders that cause enzyme deficiencies and other disorders not visible through tradi-tional medical examination techniques, saving babies every day.13

BRCA1 testing represents another accomplishment extending from the Human Genome Project. The BRCA1 gene produces an enzyme that suppresses tumor growth and repairs damaged DNA,

and the procedure can identify if you have a mutation in that gene. Mutations in that gene are associated with predispositions to common cancers such as breast (both male and female), ovarian, prostate, and more.14 Based on this finding, the scientific commu-nity has gained insight into the genetic basis of the formation of tumors. Perhaps more importantly, however, BRCA1 testing is a key preventative care measure, as individuals identified to possess mutations in the gene have an opportunity to regulate their lifestyle factors and environment to reduce their current and future risk for cancer.

Despite the setbacks that genetics has faced, studying genetics has undoubtedly generated life-saving technologies, and expanded the frontier of human knowledge.

Despite issues that genetics has encountered, scientists in the field continue to improve in their ability to treat and prevent genetic disorders. Looking back, we must be aware of instances where our institutions fail us, and stop anticipating a “holy grail” in any dis-cipline of scientific research. The reality is that science is a slow, exponential process that includes both successes and failures. This is the basis of the scientific method. The more hurdles that we hit, the more opportunity we have to change our viewpoints, pursue viable alternatives, and grow beyond expectations.

ADVANCEMENTS IN GENETIC TECHNOLOGY

FUTURE

GRAPHIC/VICTORIA SIU

DESPITE THE SETBACKS THAT GENETICS HAS FACED, STUDYING GENETICS HAS UNDOUBTEDLY GENERATED LIFE-SAVING TECHNOLOGIES, AND EXPANDED THE FRONTIER OF HUMAN KNOWLEDGE.

1990Launch of the Human Genome

Project: The Department of Energy and the National

Institutes of Health announce a plan for a 15-year project to sequence the human genome.

FUTUREIt will take decades of research to understand all of the information

within the human genome. In time, more human diseases will be understood at the molecu-lar level, leading to dramatic

changes in medicine, including genetic testing to individualize

treatments.

1999 Chromosome 22 Sequenced:First finished, full-length se-quence of a human chromo-

some is produced.

2003 Human Genome Project Completed:

All 3.2 billion letters of the human genome are sequenced with at least

99.99% accuracy.

References

1. Meek, J., & Ellison, M. (2000). On the path of biology’s holy grail. Retrieved October 08, 2016, from https://www.theguardian.com/science/2000/jun/05/genetics.uknews1

2. James Watson - Biographical - Nobel Prize. (2014). Retrieved October 20, 2016, from http://www.nobelprize.org/nobel_prizes/medicine/laureates/1962/watson-bio.html

3. 100 Best Nonfiction « Modern Library. (n.d.). Retrieved October 20, 2016, from http://www.modern-library.com/top-100/100-best-nonfiction/

4. Collins, F. (2015, April 25). DNA’s Double Anniversary | NIH Director’s Blog. Retrieved October 20, 2016, from https://directorsblog.nih.gov/2013/04/25/dnas-double-anniversary/

5. Gelsinger, P. (2000). Jesse’s intent. Guinea Pig Zero, 8, 7-17.6. Flotte, T. R., & Carter, B. J. (1995). Adeno-associated virus vectors for gene therapy. Gene therapy,

2(6), 357-362.7. Hawley, R. G., Lieu, F. H., Fong, A. Z., & Hawley, T. S. (1994). Versatile retroviral vectors for potential

use in gene therapy. Gene therapy, 1(2), 136-138. Chicago8. Marshall, E. (2000). Gene therapy on trial. Science, 288(5468), 951-9579. Couzin, J., & Kaiser, J. (2005). As Gelsinger case ends, gene therapy suffers another blow. Science,

307(5712), 1028-1028.10. Stolberg, S. G. (1999, November 28). The Biotech Death of Jesse Gelsinger - The New York Times.

Retrieved October 22, 2016, from http://www.nytimes.com/1999/11/28/magazine/the-biotech-death-of-jesse-gelsinger.html

11. Somia, N., & Verma, I. M. (2000). Gene therapy: trials and tribulations. Nature Reviews Genetics, 1(2), 91-99.

12. Home | Newborn Screening | NCBDDD | CDC. (2016, February 23). Retrieved October 20, 2016, from http://www.cdc.gov/ncbddd/newbornscreening/index.html

13. Screening Tests for Newborns. (n.d.). Retrieved October 14, 2016, from https://labtestsonline.org/understanding/wellness/a-newborn-1/a-newborn-2/

14. BRCA1 and BRCA2: Cancer Risk and Genetic Testing Fact ... (2015, April 1). Retrieved October 20, 2016, from https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet


upstream,

Picture this: You have just purchased health insurance for the first time from your state’s online health insurance exchange. Your timing was impeccable since you happened to come down with a nasty cold two days later. You call up your family doctor’s office, expecting to schedule an appointment within 48 hours or so, but you are shocked to find out that there are no openings for the next two months. This situation sounds unimaginable, given that primary care doctors typically don’t need more than a few minutes to diag-nose and prescribe medication for a simple illness. Unfortunately, the reality of this situation is not too far off.

BY RYAN LEONE

OVERALL, IT IS CLEAR THAT MENTAL HEALTH IS AN ISSUE THAT MUST BE ADDRESSED TO

PREVENT PHYSICIAN BURNOUT FROM TAKING PLACE AND TO REDUCE THE NUMBER OF MEDICAL STUDENTS OR PHSICIANS WHO

SUFFER FROM MENTAL ILLNESSES


without adoctor

31,100PHYSICIAN SHORTAGE OF UP TO...

63,700...IS PREDICTED IN THE NEXT DECADE

PRIMARY CARE

NON-PRIMARY CARE DOCTORS

DOCTORS

Medical care is often taken for granted by insured individuals, but what happens when the patient population becomes too dense for the limited amount of doctors to support them? The answer to that question is unfortunately unfolding before our eyes; a physician shortage of up to 31,100 primary care and 63,700 non-primary care doctors is predicted in the coming decade.1 This shortage has the potential to increase wait times dramatically and reduce the number of individuals who have access to care at any given time.

The factors contributing to this shortage are varied and some-what disparate. For example, one pressure faced by the physician workforce is the aging population of patients. As the elderly de-mographic gets larger and larger, the many chronic conditions and patient cases they bring with them increase, but it is clear that they are not always receiving proper care for their maladies. One study showed that many elderly patients who were formally diagnosed with having a “lack of community support” were actually suffering from true, tangible illnesses. In addition to the fact that elderly patients require greater amounts of medical attention, the increas-ing life expectancy of Americans means that they will live longer

than members of previous generations and require care for a longer period of time.2,3

Similarly, the inexorable aging of patients is paralleled by the aging of physicians who care for them. The growing number of physi-cians who are nearing or surpassing retirement age in recent de-cades means that there will be a significant decrease in the popula-tion of physicians over a short span of time when they retire in the near future. There are further concerns that those physicians who choose to stay in practice during their “golden years” might not be in the right mindset to practice. It may be necessary to evaluate the competency of these elderly physicians to ensure that they are able to provide proper medical attention to patients, with whom they may be facing the same health issues. If some physicians do not pass an established set of competency standards, the workforce size will continue to decrease even further.⁴

On the opposite end of the age spectrum, the millennial generation is altering healthcare in a variety of ways. With 15% of physicians being under the age of 35, the issues facing millennial doctors are increasingly relevant to the healthcare field. These include the find-ings that over 50% of physicians reported at least one symptom of burnout. This also corresponded with an 8% decrease in satisfac-tion with work-life balance amongst physicians across the coun-try.⁵ Additionally, the rate of physician suicide is noticeably higher than the rate in the general population. In fact, the yearly rate av-erages to one physician suicide per day.⁶ The measured increase in

stress levels and mental health issues in medical students is seen as a product of medical school training since the students typically enter school with stress levels similar to their peers in other fields.⁶ Overall, it is clear that poor mental health is an issue that must be addressed to prevent physician burnout and to reduce the number of medical students or physicians who suffer from debilitating and life-threatening mental illnesses.


prescriptions and practice independently, the need for extensively trained physicians to spend their time dealing with less intensive patient cases could be reduced. Physician’s assistants could also help alleviate the burden on doctors by working with patients who do not need prescriptions or complex procedures.

Furthermore, employing medical scribes could help doctors in-crease the amount of time they spend seeing patients by reduc-

ing the time it takes to compose notes. Scribes would record the information that is released during patient-physician conver-sations, saving it for use by the physician at another time and opening the physician up to see more patients every day. These changes might not make signif-icant impacts on their own, but collectively, they could prevent this shortage from worsening over the next several decades.

While the physician shortage is an inevitable shortcoming of the

American healthcare system, sup-port for the aforementioned initiatives and cooperation between providers, insurers, and patients can optimize our limited resourc-es to reduce the burden of illness faced by Americans.References1. Physician Supply and Demand Through 2025: Key Findings. (n.d.). Retrieved

October 30, 2016, from https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf

2. Weinberg, S. (2014, January 6). Americans Living Longer Than Ever: CDC. Retrieved October 30, 2016, from https://consumer.healthday.com/senior-citizen-information-31/age-health-news-7/americans-living-longer-than-ever-cdc-683595.html

3. Barr, P. (2014, January 14). Baby Boomers Will Transform Health Care as They Age. Retrieved October 30, 2016, from http://www.hhnmag.com/articles/5298-Boomers-Will-Transform-Health-Care-as-They-Age

4. Clark, C. (2015, June 29). Aging Doctors: Time for Mandatory Competency Testing? Retrieved October 30, 2016, from http://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/52363

5. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Pinsky, C., Satele, D., Sloan, J., & West, C. P. (2015, December). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 90(12), 1600-1613. http://dx.doi.org/10.1016/j.mayocp.2015.08.023

6. Dijamco, C. (2015, September 8). Staying Sane: Addressing the Growing Concern of Mental Health in Medical Students. Retrieved October 30, 2016, from http://www.amsa.org/staying-sane-addressing-the-growing-concern-of-mental-health-in-medical-students/

7. Dewan, S. (2012, February 25). Moral Hazard: A Tempest-Tossed Idea. Retrieved October 30, 2016, from http://www.nytimes.com/2012/02/26/business/moral-hazard-as-the-flip-side-of-self-reliance.html?_r=0

8. The Resident Physician Shortage Reduction Act of 2015 (H.R. 2124). (n.d.). Retrieved October 30, 2016, from https://www.aamc.org/download/431122/data/theresidentphysicianshortagereductionactof2015.pdf

9. 4 things students should know about the new GME bill. (n.d.). Retrieved October 30, 2016, from https://wire.ama-assn.org/education/4-things-students-should-know-about-new-gme-bill

10. Creating Health Care Jobs by Addressing Primary Care Workforce Needs. (n.d.). Retrieved October 30, 2016, from http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/creating-health-care-jobs-by-addressing-primary-care-workforce-needs/index.html

50%OVER

OF PHYSICIANSREPORTED ATLEAST ONE SYMPTOM OF

BURNOUT

ONEPHYSICIAN SUICIDE

DAYPER


THIS SITUATION MERELY INCREASES THE NUMBER OF INDEBTED GRADUTES WHO CANNOT MAKE IT THROUGHT THE BOTTLE-NECK PROCESS THAT LIMITS THE AMOUNT OF SPOTS IN RESIDENCY

THIS WIDE VARIETY OF CAUSES LEADS TO A COMPLEX DILEMMA, BUT A POTENTIALLY

SIMPLE SOLUTION - MEDICAL SCHOOLS SHOULD STOP REJECTING SO MANY

APPLICANTS AND INCREASE THE CLASS SIZES

On the patient side, it is clear that the Affordable Care Act’s focus on increasing access to healthcare has resulted in more previously uninsured individuals obtaining insurance. The growing insured population will consequently be able to see doctors more often and the principle of moral hazard - a term describing the tendency of insured individuals to be more careless about using medical re-sources - dictates that they are likely to use even more healthcare resources than before.⁷ Given that they will not have to pay in full or at all for their healthcare, insured patients are likely to worry less about their behavior since they view insurance as a safety net.

This wide variety of causes leads to a complex dilemma with a po-tentially simple solution - medical schools should stop rejecting so many applicants and increase the class sizes to produce more doc-tors in the long run. Only 21,643 of the 52,536 applicants to med-ical school in the 2015-2016 application cycle were accepted; this means that 58.81% of medical school applicants were rejected this past year, so a lack of aspiring doctors is certainly not the problem.⁵ Accepting more students to medical school and waiting for them to become doctors sounds like a reasonable solution, right?

In reality, this situation merely increases the number of indebted graduates who cannot make it through the bottleneck process that lim-its the amount of spots in residency, a training period that is necessary for medical school graduates to become certified practitioners.

A Congressional bill called The Resident Physician Shortage Reduction Act of 2015 is focused on increasing residency slots, but our current polit-ical gridlock does not bode well for the timely passage of this bill.8,9 If it were passed, the bill would create another 15,000 residency spots across a 5-year period of time, so it is imperative that the bill be put at the forefront of Congressional voting decisions. Coupling these political complications with the increasing concerns about physician and medical student mental health, we see an occupation that faces many obstacles in the coming decade.⁶

The lack of primary care physicians is being addressed systemati-cally by components of the Affordable Care Act.10 The Obama ad-ministration has approved measures to alleviate the shortage. For instance, it has taken steps toward increasing investment in prima-ry care training programs in hospital and community clinics, ex-panding mental and behavioral health training, strengthening the National Service Health Corps, and providing monetary incentives

for individuals who enter primary care fields.

Another alternative could be increasing the responsibilities of nurse practitioners and physician’s assistants.10 If laws were passed in each state that give nurse practitioners the freedom to write


On March 14, 2016, the American Board of Medical Specialties approved certification for yet another new subspecialty: addiction medicine. The novel specialty aims to prevent, screen, intervene, and treat substance use and the corresponding physical and psy-chological complications coming from addiction. However, fol-lowing its creation, several have questioned its use. Only 10% of the American population requires attention for drug abuse, and there is already certification for addiction psychiatry from the American Board of Psychiatry and Neurology.1 Additionally, crit-ics feel that general practitioners have the knowledge and tools to treat such cases and feel that a separate physician focused on these cases is not required.2

The above example highlights the general trend within medicine of increased specialization and subspecialization that many are worried will fragment our already fractured system of patient care. By adding so many different types of specialties and subspecialties to our healthcare system without a reliable system of organization and communication between physicians, patient care will become uncoordinated, with an excess number of physicians dedicated to each clinical case and a surfeit of procedures performed by these different specialists. From the physician’s perspective, this trend will force doctors to have a much more narrow and limited focus within their fields, and it will also influence how the next gener-ation of doctors will be evaluated and labeled. And the hospitals and healthcare networks housing the physicians will be forced to dedicate more funds towards hiring these various specialists,

which can be financially challenging with the large salaries some specialists command. Hospitals which cannot afford large numbers of specialists will lose their ability to provide comprehensive care.

The increased specialization of our healthcare providers has led to an increased level of disorder and incoordination within the health-care system. Currently, there are over 120 medical specialties and subspecialties reported by the American Board of Medical Special-ties (ABMS), and it continues to receive requests for several new subspecialties, including medical informatics, clinical pharmacol-ogy, vascular medicine, and obesity medicine.⁴ With so many dif-ferent specialists available, physicians increasingly rely on referrals, with referral rates in the past decade doubling from 5% to 9%, and the care of each patient has become increasingly distributed over too many physicians.1 Communication among these several doc-tors for a single clinical case is difficult to maintain and thus has not always been executed adequately. This slew of specialists with little

The Terrible Expense of Overspecialization within the Medical Field

BY AHMED FARHAN

coordination has led to an excess of medical procedures, diagnostic tests, and medical expenses. In fact, from 1940, when there was little specialization, to 1975, when various medical boards for Oph-

?

THIS SLEW OF SPECIALISTS WITH LITTLE COORDINATION HAS LED TO AN EXCESS OF MEDICAL PROCEDURES, DIAGNOSTIC

TESTS, AND MEDICAL EXPENSES


thalmology, Psychiatry, and others began to be founded, medical expenses increased from $3 billion to $75 billion.⁴ Unfortunately, this excess has not always benefitted patients.

Already, there have been a number of observations by several not-ed physicians on the negative consequences of such a trend. In “One Patient, Too Many Doctors: The Terrible Expense of Overspe-cialization,” Dr. Sandeep Jauhar de-scribes how his 50-year-old patient had a month long stay at the hospi-tal for shortness of breath. During this time, he was treated by a he-matologist, an endocrinologist, a kidney specialist, two cardiologists, a cardiac electrophysiologist, an infectious-disease specialist, a pul-monologist, an otolaryngologist, a urologist, a gastroenterologist, a neurologist, a general surgeon, a thoracic surgeon, and a pain spe-cialist. He left the hospital having undergone 12 procedures. The net result was only minimal improve-ment in his condition, a bill to his insurance company for upwards of $100,000, and scheduled follow-up visit from seven specialists.2 Need-less to say, the system failed the pa-tient in this case.

The trend has also had a significant impact on the medical pro-fession itself. Physicians within broad specialties such as gastroen-terology and radiology are being forced to limit their focus even

References1. Smith, D. E. (2011, December). The Evolution of Addiction Medicine as a Medical Specialty. AMA

Journal of Ethics, 13(12), 900-905.2. Jauhar, S. (2014, August 19). One Patient, Too Many Doctors: The Terrible Expense of Overspecial-

ization. http://time.com/3138561/specialist-doctors-high-cost/3. ABMS. (2016, April). ABMS Guide to Medical Specialties. http://www.abms.org/media/114634/

guide-to-medicalspecialties_04_2016.pdf4. AAMC. (2014, April 30). AAMC List of Medical Specialties. https://www.aamc.org/cim/specialty/

exploreoptions/list/5. Cassel CK, Reuben DB. Specialization, subspecialization, and subsubspecialization in internal

medicine. N. Engl. J. Med. 2011; 364: 1169–73.

further to one specific organ or clinical technology, becoming what are called “subspecialists.” For instance, radiologists are increas-ingly pressured to become further specialized into interventional radiology, endovascular surgical neuroradiology, musculoskeletal radiology, etc.⁴

The rise of subspecialists have caused many to question how we should evaluate and label the upcoming generation of physicians.5

If a radiologists chooses only to focus on musculoskeletal cases and does not maintain his knowledge and skill in other areas of radiol-ogy, can he still be considered a radiologist? If required, such as in an emergency situation, will he still be able to perform echocardio-grams or embolizations?

Increased specialization is also making it increasingly difficult for hospitals and healthcare facilities to maintain their ability to provide comprehensive care. Hospitals will be stressed to allocate more funds towards hiring a variety of different physicians, which can prove to be an expensive endeavor. A endovascular neurora-

diologist alone can make up to around $336,000.⁴ Even with fund-ing for their salaries, many specialists or subspecialists may not be readily available for hire considering limited fellowship or training positions available, significant investments in time and money to train the physicians, and the fact that most subspecialists currently decide to stay near an academic center or large referral center in

big cities to maintain a sufficient number of patients for their niche skills. The hospitals unable to hire specific specialists or subspecialists will lose their expertise in those fields and will not be able to pro-vide complete care to their patients. Rural healthcare facilities, which already have a shortage of primary care physicians (typically only 68 internists per 100,000 residents) ⁵, will have a significant challenge in acquiring the services of various specialists and subspecialists, and this unequal distribution of ad-vanced, modern medical expertise favoring big cities will only worsen rural healthcare inequalities.⁵

The environment of modern healthcare is changing and doctors are becoming more trained and specialized than any other time

in history. Unfortunately, this is leading to a lack of coordination within our healthcare system, doctors too limited in their exper-tise, and hospitals unable to provide inclusive service to patients. How can we rectify the situation? One possible measure, proposed by the Affordable Care Act, includes developing “accountable care organizations,” where teams of physicians would be paid accord-ing to their patients’ clinical outcomes. This would force teams of specialists and subspecialists with specific expertise to coordinate and formulate a general health care plan to improve the overall outcome of the patient.⁴ As for the inability of hospitals to pro-vide comprehensive care, there have been plans proposed to have several local hospitals organized under a local healthcare network. This network would then include a central hospital nearby hous-ing all the various specialists and subspecialists. The local hospitals would refer all complex clinical cases requiring further expertise to this select, nearby hospital for further care.2 Both solutions offer a potential solution to exploit the fact modern day doctors are more highly trained and focused while solving the associated waste, dis-organization, and overload associated with overspecialization.

THE ENVIRONMENT OF MODERN HEALTHCARE IS CHANGING AND DOCTORS ARE BECOMNG MORE TRAINED AND SPECIALIZED THAN ANY OTHER TIME IN HISTORY

NUMBER OF SPECIALTIES AND SUBSPECIALTIES REPORTED BY THE

AMERICAN BOARD OF MEDICAL SPECIALTIES

120


SOCIAL ISSUES

It seems like no matter what we try, obesity rates continue to rise. Why does this happen if we are constantly being told what is healthy and what is not? Fad diets targeting fat and carbohy-drates promise to make us skinny, healthy, and happy. But there is one product that has unfairly avoided the stigma of being an unhealthy food: sugar. This is largely due to a research study sponsored by the Sugar Research Foundation.

Today, sugar is in almost everything on grocery store shelves, but sugar was not always so abundant. For a long time, sugar was not accessible to our ancestors.1 Besides honey, hunter gather-ers often did not consume anything sweeter than a carrot.2 Even fruit, containing natural sugars, was smaller than the fruit grown today. Long ago, a human’s “sweet tooth” was extremely advanta-geous. When food was scarce, our ancestors could quickly con-vert the sugar into fat. As time went on and food sources were more reliable, the human craving for sweet food became less beneficial. 10,000 years ago in New Guinea people chewed the stems of sugarcane. In 500 A.D., processed sugar was used in In-dia to treat ailments. By 1700, the average Englishman consumed four pounds of sugar annually and by 1800 consumed eighteen pounds annually. In 2013, the average American consumed 77 pounds per year annually. This is equal to 22 teaspoons, or 88 grams of sugar, each day.3 As of 2016, the American Heart As-sociation recommends that men should have no more than 36 grams of sugar and women and children should have no more than 24 grams of sugar daily.⁴ The excess sugar eaten today is likely to lead to bigger problems later.

Sugar’s effects on and links to health have been realized for quite some time. In 1675, Thomas Wills, an English physician, dis-covered that the urine of people with diabetes mellitus tasted sweet. At Columbia University, Haven Emerson recognized a link between the rise in sugar consumption and the rise in deaths caused by diabetes from 1900-1920.3 Overconsumption of sugar can cause many health problems such as high blood pressure, high cholesterol and increased abdominal fat.⁵ Additionally, high sugar consumption increases risk for coronary heart dis-

ease and non - alcoholic fatty liver diseases.⁶ If sugar can be so detrimental to health, why are people generally more concerned with their consumption of fats and carbohydrates?

By the 1950s, high mortality rates from coronary heart disease in American men prompted investigations to discover the cause. In the 1960s, two prominent physiologists came to conflicting con-clusions: John Yudkin blamed sugar while Ancel Keys blamed only fat and cholesterol. It would be advantageous to the Sugar Industry if fat was the sole culprit. On July 11, 1965, the New York Herald Tribune released an article stating that new research reaffirmed the case that having a diet high in sugar increases

one’s risk of a heart attack. On July 13, 1965, the Sugar Research Foundation approved project 266, a review on carbohydrates and cholesterol metabolism, hoping to deemphasize sugar’s negative health effects. The Sugar Industry paid an equivalent of $48,000 2016 dollars to Hegsted, a professor of nutrition, and Robert McGandy, a nutritionist, to conduct this review. On July 30, 1965, Hegsted received information from the Vice President of the Sugar Research Foundation regarding the goal of the review stating:

“Our particular interest had to do with that part of nutrition in which there are claims that carbohydrates in the form of sucrose make an inordinate contribution to the metabolic condition, hitherto ascribed to aberrations called fat metabolism. I will be disappointed if this aspect is drowned out in a cascade of review and general interpretation.”

In 1967 the review was published, concluding that “the only dietary intervention required to prevent CHD [Coronary Heart Disease] was to reduce dietary cholesterol and substitute polyunsaturated

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CONTRARY TO WIDESPREAD OPINION, TOO MUCH SUGAR IN YOUR

DIET DOES NOT CAUSE DIABETES.

FROM RARE BOOST TO RISK FACTOR

INDUSTRY INFLUENCE

BY SARAH DEVLIN

Sugar Industry Scheme Leaves Bitter Taste

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Today, even a knowledgeable buyer must be wary, as products with high sugar content are marketed creatively. Some compa-nies use words associated with health and fitness or even the word “fruit” to appeal to consumers.⁹ For example, Special K original contains just four grams of sugar while Special K Fruit and yogurt contains nine.1⁰ Similarly, fat-free dressing often has more added sugar than its full fat counterparts.11 Another common advertising strategy is for companies to label products with “zero trans fats” or “contains whole wheat.”12 These claims do not mean that the prod-ucts are healthy. Another labeling approach used by food manu-facturers is to list sugar repeatedly under different names. Most consumers know that ingredients on a label are listed in descend-ing order from highest to lowest content. The true amount of sug-ar can be hidden by being cataloged under various names, giving

fat for the fat in the American Diet.” Conveniently, there was no mention of the sugar industry’s influence and role on the project.⁷ The study had a lasting effect on how Americans were advised to eat. In 1980, government guidelines prompted Americans to “avoid too much fat, saturated fat, and cholesterol.” However, the guide-lines failed to warn Americans about the possible implications of sugar consumption. For example, the guidelines stated that “the major health hazard of eating too much sugar is tooth decay,” and

“contrary to widespread opinion, too much sugar in your diet does not seem to cause diabetes.” ⁸ These guidelines strongly influenced public perception of the relative dangers of sugars and fats, mislead-ing people to focus on eating less fat while taking little note of their sugar consumption. Americans ingest less fat than they did twenty years ago but obesity rates continue to rise.3 The 1980 dietary guide-lines demonstrate how much industry sponsored research influenc-es government policy.

the illusion of a lower total content. In reality, agave nectar, brown sugar, cane crystals, dextrose, fructose, fruit juice concentrates, and maltose are all sugars and should be considered when calculating total sugar content.13 With so much to think about when looking at the nutrition facts of processed food, consumers should be aware that the whole is more than the sum of its parts. Just because a product has an appealing label does not mean it is a good choice.

Human consumption of sugar over time is a sticky situation. Long ago, eating sweets was a quick fix for a lack of energy. But in current times our bodies neither need the quick fix nor are well equipped for it. This is evident through the many disastrous health effects excess sugar can have on our bodies. Since sugar’s impact on health was brushed away in the 1960s and clever marketing strategies to push high sugar products still exist today, consumers need to be aware of what lies behind the label.

BEING SAVVY IN THE SUPERMARKET

THE TRUE AMOUNT OF SUGAR CAN BE HIDDEN BY BEING CATALOGED UNDER VARIOUS NAMES, GIVING THE ILLUSION OF A LOWER TOTAL CONTENT.

References

1. Rupp, R, (2014). Prehistoric Dining: The Real Paleo Diet. Retrieved October 05, 2016, from http://the-plate.nationalgeographic.com/2014/04/22/prehistoric-dining-the-real-paleo-diet/

2. Lieberman, D. E. (2012, June 05). Evolution’s Sweet Tooth. Retrieved October 5, 2016 from http://www.nytimes.com/2012/06/06/opinion/evolutions-sweet-tooth.html?_r=0

3. Cohen, B. R. (2013, August). Sugar. Retrieved October 05, 2016, from http://ngm.nationalgeographic.com/2013/08/sugar/cohen-text

4. By Any Other Name It’s Still Sweetener. (2016). Added Sugars/ Retrieved October 05, 2016, from http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/Added-Sugars_UCM_305858_Article.jsp#.V_ByjWOMB-U

5. Naidoo, U., MD. (2016). Sugar: Its many disguises – Harvard Health Blog. Retrieved October 05, 2016 from http://www.health.harvard.edu/blog/sugar-many-disguises-201605189590

6. Nicolanonio, J.J. Lucan, S. C., & O’Keefe, J. H. (2016). The Evidence for Saturated Fat and for Sugar Related to Coronary Heart Disease. Retrieved October 05, 2016, from http://www.sciencedirect.com/science/article/pii/S0033062015300256

7. Kearns, C.E., DDS, MBA, Schmidt, L.A., PhD, MSW, MPH, & Glantz, S.A., PhD. (2016, September 12). Sug-ar Industry and Coronary Heart Disease Research. Retrieved October 5, 2016, from http://archinte.jamanetwork.com/article.aspx?articleid=2548255#isc160005r12

8. Nutrition and Your Health: Dietary Guidelines for Americans 1980. Retrieved October 5, 1980, from https://health.gov/dietaryguidelines/1980thin.pdf?_ga=1.138197424.1038594147.1475726811.

9. Bailin, D., Goldman, G., & Phartiyal, P. Sugar-Coating Science. (2014, May). Retrieved October 5, 2016, from http://www.ucsusa.org/center-for-science-and-democracy/sugar-coating-science.html#.V_CJ-DxArIdU.

10. (2016). Calories in Special K Original Cereal. Retrieved October 5 2016, from https://www.calorie-count.com/calories-kelloggs-special-k-original-cereal-i110331.

11. Migala, J. (2016). 9 Low-Fat Foods You Shouldn’t Eat. Retrieved October 5, 2016, from http://www.health.com/health/gallery/0,,20855740,00.html.

12. Volland, A. & Haupt, A. (2012, March 30). 10 Things the Food Industry Doesn’t Want You to Know. Retrieved October 5, 2016, from http://health.usnews.com/health-news/articles/2012/03/30/things-the-food-industry-doesnt-want-you-to-know.

13. (2016). Added Sugar in the Diet. Retrieved October 5, 2016, from https://www.hsph.harvard.edu/nutritionsource/carbohydrates/added-sugar-in-the-diet/.

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hopes of containing them and the general cost of healthcare. Gov-ernment intervention and regulation of drug prices negatively affects the pharmaceutical industry in that it has “lower revenue growth, poor stock performance, the lowest number of new chemical entities (NCE) approvals and the poor late-stage R&D pipelines prevalent throughout the industry”. 3

Currently, the average price to earnings ratio of large pharmaceutical stocks is trading at a discounted rate relative to the entire market.3 Back in July of 2015, the health sector began declining and is now down 4%. Since July of 2015, Standard & Poor’s (S&P) Pharmaceuti-cals Select index has fallen 38%.9

THE BAD

In another respect, pharmaceutical companies can be viewed through a more condemning lens because some of them take financial advan-tage of their consumers. The transgressions of the industry partially derive from socioeconomic disparities evident in society. If everyone were able to afford the medications provided by the pharmaceutical industry, these wrongdoings would not be considered as egregious. The misdeeds of the pharmaceutical industry most negatively affect those who struggle to pay for medical care--members of the lower and middle class. Although the high cost of drugs seems appropriate

The pharmaceutical industry has played an increasingly pivotal role in the lives of many. Last year, 4,065,175,064 retail prescription drugs were filled at pharmacies in the US, and from 1999 to 2012, the over-all use of prescription drugs among US adults has increased 51% to 59%.1,2 Both a blessing and an affliction, this industry provides the public with the medication necessary to get and stay healthy, but it has a tendency to financially swindle its consumers. Many who are unaware of the less ethical aspects of the industry are quick to praise how far it’s come. While these companies provide remedies to treat or cure an illness or relieve suffering in some capacity, the indiscre-tions of the pharmaceutical industry make us wonder if it is truly on our side.

THE GOOD

Pharmaceutical companies can be viewed positively for the treat-ment and relief they provide to the public. By virtue of the rising pharmaceutical industry, the average life expectancy has ris-en from 45 to 77 years over the course of a century.3 The World Health Organization (WHO) has compiled a list of 325 essential drugs, most of which are available in bulk generic forms provided by low-cost suppliers.⁴ Essentially, people have access to the neces-sary drugs to treat or cure their illnesses. For example, as of now, about 1.6 million Americans live with Crohn’s disease, a chronic inflammatory bowel disease that affects the gastrointestinal tract.⁵However, Humira, a tumor necrosis factor (TNF) inhibitor that tar-gets and blocks sources of inflammation, is a popular AbbVie drug that has treated many suffering from Crohn’s.⁶

Furthermore, the pharmaceutical industry has been known to de-crease healthcare expenditures. Breakthrough therapies have re-duced medical costs in the long run, thus less money is spent on overall healthcare. For example, in the 1990s, pharmaceutical spend-ing rose 5.5% to 8.5%, while hospital expenditures decreased 37% to 33%. This trend is still observed today.7,8

Additionally, some believe the pharmaceutical industry is deserv-ing of sympathy and thus seemingly absolved of its transgressions. Pharmaceutical companies are under great fiscal duress because of political pressure; governments increasingly scrutinize drug costs in

THE MISDEEDS OF THE PHARMACEUTICAL INDUSTRY MOST NEGATIVELY AFFECT THOSE WHO STRUGGLE TO PAY FOR MEDICAL CARE–

MEMBERS OF THE LOWER AND MIDDLE CLASS.

Is the PharmaceutIcal Industry on your sIde?

BY EVANIE ANGLADE

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THE AVERAGE LIFE EXPECTANCY HASRISEN FROM 45 TO 77 YEARS OVER THE COURSE OF A CENTURY. because R&D for some drugs can be incredibly expensive, some do

not believe the pharmaceutical industry is justified in price hikes on patients. Price hikes on those who can afford it, such as health insur-ance providers enriched by Obamacare, are more appropriate.10 Take Turing Pharmaceuticals for example; this company has hiked prices on commercial insurance providers to fund R&D for drugs correct-ing Toxoplasmosis.11

One way in which consumers are taken advantage of is through ge-neric-drug monopolies. Pharmaceutical companies make a majority of their money from recently made drugs that fall under a patent. Twenty years after a patent is originally filed, other drug companies can begin making their own generic versions of the drug. However, sometimes if there is not a high demand for the drug, generic-drug companies will not invest in making a cheaper, generic version of the


Is the PharmaceutIcal Industry on your sIde?

References1. Rosenthal E. Total number of retail prescription drugs filled at pharmacies. The Henry J. Kaiser Fami-

ly Foundation. http://kff.org/other/state-indicator/total-retail-rx-drugs/?currentTimeframe=0&sort-Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed November 1, 2016.

2. Kantor ED. Prescription drug use in US adults 1999-2012. JAMA. 2015;314(17):1818–1830. doi:10.1001/jama.2015.13766. http://jamanetwork.com/journals/jama/fullarticle/2467552?result-Click=1. Accessed November 1, 2016.

3. Kola I, Landis J. Can the pharmaceutical industry reduce attrition rates? Abstract: Nature reviews drug discovery. Nature Reviews Drug Discovery. 2004;3(8):711–716. doi:10.1038/nrd1470. http://www.nature.com/nrd/journal/v3/n8/full/nrd1470.html. Accessed November 1, 2016.

4. Henry D, Lexchin J. The pharmaceutical industry as a medicines provider. The Lancet. 2002;360(9345):1590–1595. doi:10.1016/S0140-6736(02)11527-3. http://www.sciencedirect.com/science/article/pii/S0140673602115273. Accessed November 1, 2016.

5. Facts about inflammatory bowel diseases. Crohn’s & Colitis Foundation of America. http://www.ccfa.org/resources/facts-about-inflammatory.html. Accessed November 1, 2016.

6. Learn how HUMIRA works for moderate to severe Crohn’s disease. Humira. https://www.humira.com/crohns/how-humira-works-for-crohns. Accessed November 1, 2016.

7. Pharmaceutical spending lowers overall medical costs, study finds. Kaiser Health News. http://khn.org/morning-breakout/dr00006807/. Published June 11, 2009. Accessed November 1, 2016.

8. Kleinke JD. The price of progress: Prescription drugs in the health care market. Health Affairs. 2001;20(5):43–60. doi:10.1377/hlthaff.20.5.43. http://content.healthaffairs.org/content/20/5/43.full.html. Accessed November 1, 2016.

9. Light L. 3 reasons pharma stocks are still suffering. CBS News. http://www.cbsnews.com/news/3-reasons-pharma-stocks-are-still-suffering/. Published May 17, 2016. Accessed November 1, 2016.

10. Lenzner R. ObamaCare enriches only the health insurance giants and their shareholders. Forbes. October 1, 2013. http://www.forbes.com/sites/robertlenzner/2013/10/01/obamacare-enriches-on-ly-the-health-insurance-giants-and-their-shareholders/#581fcf4268c8. Accessed November 1, 2016.

11. Mullin E. Turing Pharma says Daraprim availability will be unaffected by Shkreli arrest. Forbes. December 21, 2015. hz--ttp://www.forbes.com/sites/emilymullin/2015/12/21/turing-phar-ma-says-daraprim-availability-will-be-unaffected-by-shkreli-arrest/#191ea3df2e82. Accessed November 1, 2016.

12. Ramsey L. Drug companies are reeling after the Martin Shkreli incident — and it could shake up the entire industry. Business Insider. http://www.businessinsider.com/generic-drug-pricing-monopo-ly-problem-2015-9. Published September 30, 2015. Accessed November 1, 2016.

13. Velásquez G, Boulet P. Essential drugs in the new international economic environment. Bulletin of the World Health Organization. 1999;77(3):288–292. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557623/pdf/10212525.pdf. Accessed November 1, 2016.

14. Moynihan R, Heath I, Henry D, Gotzsche PC. Selling sickness: The pharmaceutical industry and disease mongering / commentary. British Medical Journal. 2002;324(7342):886–91. http://search.proquest.com/openview/0518260d0ba93fd981e1cffcd8706f5c/1?pq-origsite=gscholar. Accessed November 1, 2016.

15. Lexchin J. Those who have the gold make the evidence: How the pharmaceutical industry biases the outcomes of clinical trials of medications. Science and Engineering Ethics. 2011;18(2):247–261. doi:10.1007/s11948-011-9265-3.

16. World Health Organization. Pharmaceuticals and Health Sector Reform in the Americas: An Economic Perspective. World Health Organization; 1998. http://apps.who.int/medicinedocs/en/d/Jh2926e-/7.3.html#Jh2926e.7.3. Accessed November 1, 2016.

drug. Therefore, the brand-name drug companies will have a simple price mo-nopoly.12 Between 2013 and 2015, prices of Daraprim, Doxycycline, Isuprel and Nitropress have increased exponentially (Daraprim from $13.50 to $750, Doxy-cycline from $20 to $1,849, Isuprel from $215.46 to $1,346.62 and Nitropress from $257.80 to $805.61).12 And to protect their exclu-sivity and monopoly, these brand-name drug compa-nies will “evergreen” their product by constantly add-ing new patents for minor, ineffectual variations made to the drug, such as chang-ing the coating, crystalline form, manufacturing pro-

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cess or delivery system.13

Furthermore, pharmaceutical companies can be looked upon neg-atively due to chronic deception present within the industry. Some drug companies have been know to be disease-mongers who pro-mote their product to healthy people who may believe they are sick. Disease mongering occurs when ordinary ailments are transformed into medical problems (e.g. baldness), mild symptoms are seen as forewarnings for serious diseases (e.g. irritable bowel syndrome), personal problems are treated as medical ones (e.g. social phobia), risks are denoted as disease (e.g. osteoporosis) and disease preva-lence estimates are framed to maximize fear of medical problems (e.g. erectile dysfunction). Often times, pharmaceutical companies, doctors and patient groups ally themselves and use media to dis-ease monger. The boundaries of what qualifies as a treatable illness have been extended to widen the market for new products, making healthy people amenable to fraudulent claims.14 The deceptive nature of pharmaceutical companies is also demon-strated through the bias present in clinical research. Studies have shown that research funded by companies is more likely to yield positive outcomes in clinical trials than research funded by other, less biased types of sponsorship, such as governmental organiza-tions. The bias in clinical research is introduced through compara-tor agents (i.e. similar drugs used to make the marketed drug seem more effective), disproportion between publication of positive trials and non-publication of negative trials, reinterpreting data submitted to regulatory agencies, dissonance between results and conclusions, conflict-of-interests, ghostwriting (i.e. recruited writers writing with a favorable “spin”) and “seeding” trials (i.e. studies done after the drug is already on the market).15 Such findings bolster the distrust the public may have in the pharmaceutical industry.

INTERVENTION

Changes have been made and must continue to be made in the pharmaceutical industry to combat its ability to financially con

and deceive its consumers. The federal government has intervened in pricing to achieve consistency of re-tail prices of the same drug across the country in order to guarantee affordability and equitable access. How-ever, this process is not per-fect for a variety of reasons, one being high pharmaceu-tical expenditures. Measures to control drug expenditures include promotion of ratio-nal drug use, use of generic names, and simple capping of expenditures. Addition-ally, financially reasonable access to pharmaceuticals can be improved through various financing methods like expansion of insurance coverage.16

Despite its medical aid to society, the pharmaceutical industry is cor-rupt in ways that recant its positive, valuable assets. Transparency is what will help affirm or reaffirm the public’s trust in this industry.


For many students, transitioning to college is a major step. It en-tails the student getting used to a new set of academic standards, moving away from parents, and having to learn how to live on their own. Low-income college students go through the same ex-perience, but without the added benefit of having financial consis-tency to rely on.

CLOSER TO HOMETaking a deeper look into the experience of college students in the United States, specifically at the University of Pennsylvania, one notices differences within the student body. Students who are First-Generation and/or Low-Income (FGLI) often have different stories to tell of their eating habits than those from more privi-leged backgrounds.

Do students from low-income backgrounds still lack access to a secure food source during college?

College is a place to gain new friends, knowledge, and passions. What most students do not hope to gain is the “freshman 15,” a phrase notoriously used to describe the amount of weight most students put on after their first year of college. While studies have shown that the weight gain is closer to 7-10 pounds, this is still a significant amount when placed in context with the age of stu-dents.1 Weight gain during the late teens and early twenties have been correlated with higher rates of obesity in later ages, and so while college provides an environment for learning, it should also instill healthy eating habits in students.1

WHY FRESHMAN 15

A great deal of research has been conducted on understanding the causes and consequences of the freshman 15. A professor at Cor-nell University, Dr. David Levitsky, has researched the root causes of the freshman 15, and connected them to ‘all-you-can-eat’ college dining halls.1 Student questionnaires reveal that students ate more in these types of dining halls and left with a greater sense of full-ness. It is important to note that both adults and students consume food that is proportional to the amount that they are served; thus, part of the reason for overconsumption and increased calorie in-take is due to the concept of college dining halls. While decreased physical activity and altered sleep patterns affect eating habits, the consumption of junk food, meal frequency, and proportion of meal size are considerably more significant indicators of weight gain in the first year of college.1 Research from Dr. Christakis and Fowler of Harvard Medical School point out that obesity and weight gain in all age groups are influenced by the appearance and behaviors of those surrounding them. Their study also found that an individ-ual’s risk of becoming obese increases by an alarming 57 percent if he or she has a friend who is gaining weight within that time period.2

TIES TO INCOME LEVEL

To frame this discussion before we begin, it must be stated that households closer to or below the poverty line are more likely to house overweight and obese individuals. The trend is the same — if not stronger — for families with lower levels of education. Families that are less educated are more likely to score lower on the Healthy Eating Index (HEI), a 100-point scale developed by the USDA to measure the quality of the total diet.3 This correlation of low socio-economic status relating to poorer health has been established by researchers in both the late 20th century and the early 21st century in several nations such as Canada, France, and the UK.3

BY KAMALJOT GILL

A WORK-STUDY STUDENT WHO WORKS MINIMUM WAGE TEN HOURS A WEEK

WILL LOSE AT LEAST A HALF OF THEIR WORK STUDY MONEY ON FOOD.

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Freshmen meal plans at the University of Pennsylvania are meant to provide easy access to dining halls for the entire ac-ademic year. One recommended dining plan is Best Food Fit meal plan (BFF), which offers around eight meal swipes a week and $500 to last approximately 110 days. This equates to $4.50 that can be spent on food per day in addition to the included meal swipes. Buying food outside the dining plan may not be an issue for higher income students; however, for low-income students, it is quite costly. Spending just $10 a day on food can quickly add up to over $1000 a semester. For a student whose family income is under the poverty line, this is a huge expense. To put this into context, a work-study student working 10 hours a week at minimum wage will lose at least half of their earned money on food. Comparatively, the average moderate cost of food for an individual between the ages of 19-50 is only $305.60 a month, which is lower than the $500-a-month at Penn if the meal plan is considered.⁴ Besides the cost of food, access to din-ing halls throughout the week also raises concern in low-income students. During weekdays, dining halls are closed between 2pm and 5pm and after midnight. On the weekends, the dining halls are open only from 11am to 3pm and 5pm to 8pm. Students on work-study may find it difficult to fit in meals if they eat late lunches or dinners.

To assess the impact of cost and accessibility on campus, a dozen Questbridge Scholars – students from low-income backgrounds who received admission to Penn under a full-ride contract – were interviewed and asked about their experiences on the meal plan. Often times work-study students and Questbridge schol-ars reported that the meal plans generally did not cover all their meals during the week. They found themselves eating bigger portions at each meal if they anticipated not being able to eat again later in the day. Even more concerning is the practice of these unhealthy habits of skipping meals and binge-eating at an early age. Katherine Tallmadge, dietician and author of Skipping Meals but Bingeing Later: Workaholics Need to Plan for Regular Meals EATING RIGHT, reports that skipping meals or eating in

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an unplanned fashion throughout the day is a frequent occurrence that significantly contributes to weight problems.⁵ This reason is of-ten overlooked when it comes to understanding the freshman 15 in FGLI students. Students from more prosperous backgrounds are able to afford outside meals. At an institution like Penn, where 52 percent of the students pay full-tuition of $51,464, being a low-in-come student is not common. While Penn’s financial aid covers the cost of meals, the meal plans may be inadequate for lower-income students who rely on it the most.

The student interviews at the University of Pennsylvania reveal that meal plans show unique eating patterns in first-generation and/or low-income students. The irregular eating habits and guilt of spend-ing money on food while on a meal plan that costs upwards of $5000 contributes to the unhealthy consumption of food in college. It comes as no surprise that these eating patterns have been correlated with the freshman 15 in college and obesity later in life. While it is easy to give freshmen advice about avoiding weight gain in their transition to college lifestyle, the problem may be deeply rooted in the availability, cost, and access to food through the meal plans.

Gaining weight in college is not inevitable. First-generation and low-income students have additional pressures of having work schedules and lack of resources to purchase meals outside of their meal plans, which can cause them to exhibit unhealthy eating behav-ior. Even in college, foundational aspects of the system in place can make it harder for low-income students to receive nutritious meals. Thus the freshman 15 belies deeper insight into why some freshmen may be struggling more than others in their transition to college.

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References:1. Cioffi CE, Levitsky DA, Pacanowski CR, Bertz F. A nudge in a healthy direction. The effect of nutri-

tion labels on food purchasing behaviors in university dining facilities. Appetite. 2015;92:7-14. doi:10.1016/j.appet.2015.04.053.

2. Xygalatas D. Journal of cognition and culture: Nickolas A. Christakis and James H. Fowler (2009), Connected: The Surprising Power of our Social Networks and How they Shape our Lives, Little, Brown, New York, NY. 353 pages. Brill Academic Publishers; 2010;10:401.

3. Drewnowski A, Specter SE. The American journal of clinical nutrition: Poverty and obesity: The role of energy density and energy costs. Journal of Clinical Nutrition; 01/01/2004;79:6.

4. Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, February 20155. Sugarman C. The Washington Post: Skipping Meals but Bingeing Later: Workaholics Need to Plan for

Regular Meals EATING RIGHT; 09/24/1991


Euthanasia, which literally means ‘good death’, was first used by the historian Suetonius to describe the Roman Emperor Augustus’ demise. He succumbed to his illness in the arms of his wife, as he had desired.1 However, as medicine progressed, euthanasia be-gan to morph into something completely different. It transformed

into what euthanasia is now – intentionally ending a life with the purpose of relieving pain and suffering. In practice, medical doc-uments signed by patients give the doctor authority to perform euthanasia while in other cases the patients may make the decision themselves. This concept of euthanasia has given rise to a debate between those who are “pro-life”, and those who are “pro-choice”. Each side has its own views on the right to end a life, similar to the debate on abortion. Both of these issues are grounded on a mixture of people’s socio-cultural, ethical, economic and political views. However, euthanasia specifically focuses on the complex reality of deciding when life is no longer worth living.

A number of social factors come into play when considering the choice of euthanasia. In many cases, terminally ill patients become physically and financially dependent on their families. The patients may want to undergo euthanasia to overcome the lack of depen-dence they feel, and to relieve the family of the burden of taking care of a dependent, which could affect the family dynamic.2 In addition, some supporters of euthanasia believe that its legaliza-tion frees humans from the belief that there is dignity in suffering. It lets people exercise their autonomy, even at their deathbeds. This is because ultimately, the decision of whether it is worth suffering through the pain of an illness rather than undergoing euthanasia

is highly subjective, as one can see through the stories of Brittany Maynard and J. J. Hanson.

Brittany Maynard, who had terminal brain cancer, made headlines when she moved from California to Oregon so she could legally take life-ending drugs.3 The pro-choice movement progressed as she helped remove part of the social stigma that surrounds eutha-nasia. Maynard’s husband continues to fight for euthanasia legal-ization after her death and her mother wrote a memoir, Wild and Precious Life, to document her experience throughout her daugh-ter’s illness. However, there are some movements that work to dis-courage individuals from choosing euthanasia, including one lead by former marine, J. J Hanson. In 2014, J. J. Hanson, was diagnosed with glioblastoma- the same aggressive brain cancer that Maynard had. Euthanasia was not legal in the state where he lived, so Han-son fought a desperate battle against his disease. He enrolled in a clinical trial, which eventually turned out to be successful. Hanson claims that if he had lethal drugs within reach when he was at his weakest and most vulnerable, perhaps he would have given up and lost his life prematurely. Ultimately, he founded the Patient’s Right Action Fund to help end physician- assisted suicide and to have a platform to share his story.

From an ethical point of view, supporters of euthanasia argue that every individual has the right to self-determination. This means that if individuals can choose the terms in which they live, they should also be able to choose the terms by which they die. No one other than the patients themselves are aware of the suffering and misery, so what gives others the right to interfere in their decision? Additionally, this decision would reduce the misery of the patients’

FROM AN ETHICAL POINT OF VIEW, SUPPORTERS OF EUTHANASIA ARGUE

THAT EVERY INDIVIDUAL HAS THE RIGHT TO SELF-DETERMINATION.

...THESE ISSUES ARE GROUNDED ON A MIX OF PEOPLE’S SOCIO-CULTURAL, ETHICAL, ECONOMIC AND POLITICAL VIEWS, BUT EUTHANASIA FOCUSES ON ONE PRIMARY QUESTION - WHEN IS LIFE NO LONGER WORTH LIVING?


A LIFE WORTH LIVING?BY HAFSA BHATTY


loved ones, who struggle as they watch their family member suf-fering.

There is also a more sinister side to the argument. Euthanasia, which was also known as “racial killing” in Nazi Germany, gained acceptance in the medical community post World War II as a way to develop a healthy master race. Hitler first endorsed euthanasia at the request of a severely disabled child’s father. Following that, he gave permission for widespread euthanasia programs, so that indi-viduals who were deemed inferior because of their disability, race, ethnicity or character traits could be eliminated. These people were believed to be a burden on the economy, and it was sometimes even argued that the exterminations were mercy killings.⁵

Germany recently passed an Assisted-Suicide Law, steering clear of putting euthanasia in its title because of its ties to Nazi Germany. Other countries have been fighting for euthanasia legalization for years; one of the earliest movements for euthanasia took place in England during the year 1835, showing that this dilemma has been unresolved for over 180 years.1 In 2014, Belgium legalized eutha-nasia for patients of all ages and in September 2016, the first child in Belgium chose to undergo euthanasia. On the other hand, some countries still struggle with this ethical dilemma; in the United States, euthana-sia is legal only in the states of Washington, Or-egon, California and Vermont. The acceptance of euthanasia is increasing in the country overall, but legalization of the procedure remains a con-troversial topic due to its histor-ical and ethical implications.

Although eu-thanasia and abortion share a common theme, in the United States they are not given the same spotlight in politics. For ex-ample, despite polling that suggests support for various forms of euthanasia conforms closely to political party allegiance, U.S. can-didates for political office are almost never asked their positions on euthanasia, as they often are on abortion. Euthanasia only spo-radically becomes a political issue because it is believed by most Americans to be a highly private and family-oriented matter, in which the government should not have a say.⁶

A few questions arise as we consider what euthanasia is and what it stands for- does it actually offer us increased control over our lives? In the face of pain, are we trying to grasp onto control, or just the illusion of control? A historical medical practice that contributes to this debate is that of Twilight Sleep--a state of semi-conscious-

IN THE FACE OF PAIN, ARE WE TRYING TO GRASP ONTO CONTROL, OR JUST THE

ILLUSION OF CONTROL?

References:1. Diaconescu, A., & Amelia Mihaela Diaconescu. (07/01/2012). Contemporary readings in law and

social justice: EuthanasiaAddleton Academic Publishers.2. Steel, B. (01/01/2014). Science and politics : An A-to-Z guide to issues and controversies:

Euthanasia CQ Press ; Thousand Oaks, California : SAGE Reference.3. Aleteia. (2016). Cancer-free former Marine continues to fight assisted suicide. Retrieved November

01, 2016, from http://aleteia.org/2016/09/29/cancer-free-former-marine-continues-to-fight-assisted-suicide/

4. Ayto, J. (2011). Brewers Dictionary of modern phrase and fable (2nd ed.) (I. Crofton, Ed.) Reference for Twilight Sleep

5. Benedict, S., Shields, L., & O’Donnell, A. J. (2009). Children’s “euthanasia” in Nazi Germany. Journal of pediatric nursing, 24(6), 506-516.

6. Dowbiggin, I., & Dowbiggin, I. (01/01/2013).Journal of policy history: From sander to schiavo: Morality, partisan politics, and america’s culture war over euthanasia, 1950-2010 Pennsylvania State University Press.

ness produced by injection that helps a woman undergo relatively painless childbirth.⁴ Women undergoing the procedure would lose partial control over their movements and get partial amnesia, and so were often strapped to the bed.

So why was this seemingly unjust practice so popular amongst women? The answer is that it gave women the illusion of control. The decision of whether or not to undergo Twilight Sleep was their own, and in an era of male-dominated medicine, women clung to this opportunity to make decisions for themselves. In reality, the women clearly ended up with less control than they would have had with normal childbirth. The psychological basis of euthanasia

works in the same way. Humans associate helplessness with fear and so as long as they feel as if they have control over their death, death does not seem as mysterious and terrifying. We try to grasp

onto dignity and control, even as it inevitably slips through our fin-gers.

In the midst of all these questions and beliefs, the decision to un-dergo euthana-sia becomes very subjective. The vehement debate on euthanasia ulti-mately boils down to a race between cutting-edge re-search and pos-sible treatments. If a disease is in-curable in 2016, it may not be that

way a few years down the road. It is no longer a matter of life versus death, but rather a disagreement about the timing and manner of an inevitable death.

IN THE UNITED STATES...

...EUTHANASIAIS LEGAL ONLY IN WASHINGTON, CALIFORNIA, OREGON, AND VERMONT.


MOLECULAR BIOLOGY

Deploying T-Cells to Target Tumors

Following heart disease, cancer is the second leading cause of death worldwide.1 Currently, the most common cancer treat-ments include surgery, chemotherapy and radiation therapy, all of which have numerous drawbacks. Chemotherapy and radiation therapy can result in extensive hair loss, nausea, blood disorders, and even organ damage, while surgery is often not an option for patients because their tumors are too complicated to safely ex-cise.2 Therefore, recent reports of successful trials with a new type of immunotherapy, adoptive cell transfer (ACT), which involves engineering a patient’s own T-cells to target the cancerous cells, have raised significant excitement and hope among doctors and patients alike. The results of such trials have led researchers to believe that immunotherapy may become a major pillar of cancer treatment.

WHAT ARE T-CELLS?

T-cells are lymphocytes, or white blood cells, that play a vital role in detecting and targeting foreign or abnormal antigens. In can-cer patients, the T-cell response is either not aggressive enough to prevent tumor growth, or the T-cell response becomes “ex-hausted.” The term “exhaustion” describes a state of dysfunction, in which T-cells cannot effectively target the abnormal antigen.3 However, over the past few years, scientists have experimented with immunotherapy, which utilizes treatments that attempt to harness and strengthen the immune system to more effectively recognize and attack cancer cells. T-cell responses are an ideal

The Process of Adoptive Cell Transfer

GRAPHIC/ALICIA GO

platform for immunotherapy because they are antigen-specif-ic, robust, can traffic to distant antigen sites, and have memory against resolved infections.4

ADOPTIVE CELL TRANSFER (ACT)

The goal of ACT therapies is to enhance the T-cell response by ex-tracting T-cells from the tumor-bearing patient, engineering the T-cells with specific tumor receptors, culturing the T-cells by the billions, and then infusing the T-cells back into the patient.⁵ There are two major approaches for ACT. The first involves gene-mod-ified T-cell receptors (TCRs), which recognize tumor antigens associated with human leukocyte antigens. The second approach employs chimeric antigen receptor T-cells (CAR T-cells). CAR T-cells connect a single-chain variable domain, or an engineered peptide linkage of the heavy and light variable regions of an an-tibody, to one or more signaling elements of a TCR complex.6,7

T-CELL RESPONSES ARE AN IDEAL PLATFORM BECAUSE THEY ARE ANTIGEN-SPECIFIC, ROBUST, CAN TRAFFIC TO DISTANT ANTIGEN SITES, AND HAVE MEMORY AGAINST RESOLVED INFECTIONS.

BY MAHIP GREWAL


ACT is a powerful example of the growing trend towards person-alized medicine in that each patient’s treatment is directly derived from his or her own immune system. However, since there is no single, general treatment that can be administered, the therapy is costly, with prices ranging from $36,000 to $204,000, as a unique “drug” has to be developed for each patient.⁴ Thus, immunothera-py could be inaccessible to those who cannot afford the high cost.

ACT TRIALS

In 1988, the first major T-cell immunotherapy trial, which utilized unmodified tu-mor-infiltrating lymphocytes (TILs) against melanoma, was led by Steven A. Rosen-berg at the National Institute of Cancer. In the trial, regression, or a decrease in tumor size, was observed in nine out of fifteen patients, and their cancer regres-sions lasted between two and thirteen months.⁸ Between 1987 and 1992, eighty-six metastatic melanoma patients were treated with TILs. The overall objective response rate, which is generally de-fined as the sum of complete responses, or total disappearances of the tumor, and partial responses, or reductions in tumor size of at least 50%, was 34%.⁹ This is particularly noteworthy because melanoma patients receiving chemotherapy only have a one-in-eight chance of having their tumors shrink.10 Later studies with mouse models suggested that ACT therapy could be improved by conducting lymphodepletion, or irradiation of the patient’s lym-phocytes via chemotherapy, prior to infusing the T-cells. Thus, a series of clinical trials conducted in the early 2000s, with a total of ninety-three patients, investigated the efficacy of administering ACT in conjunction with increasing levels of lymphodepletion. In these trials, the efficacy of ACT was gauged by the Response Eval-uation Criteria in Solid Tumors, a set of guidelines created by the national cancer institutions of the United States, Canada, and Eu-rope that indicate when a patient improves, stays stable, or worsens with treatment. Collectively, objective response rates ranged from 42% to 79%.11

Other exciting advances in ACT have recently been achieved in trials with leukemia and lymphoma patients. For example, a 2014 trial was conducted at the Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania that involved thirty acute lymphoblastic leukemia patients, whose cancers had returned after intensive chemotherapy. However, after receiving infusions of CAR T-cells, twenty-seven of the thirty patients sub-sequently experienced complete remission.13 Similarly, another study, published in 2014, investigated the efficacy of administering anti-CD19 CAR T-cells to patients with B-cell malignancies, such

GR

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IMED

IA

B-CELLS CONTAIN SPECIFIC ANTIGEN RECEPTORS THAT ALLOW

THE CELLS TO BIND WITH ANTIGENS.

as B-Cell lymphoma and chronic lymphocytic leukemia. T-cells engineered with anti-CD19 CARs recognize and kill CD19+ target B-cells. Of the fifteen patients treated, eight achieved complete re-sponses and four experienced partial responses.14

THE FUTURE OF ACT THERAPY

While these clinical trials are encouraging, it is important to recog-nize that ACT therapy has been successful predominantly in blood cancers. Therefore, perhaps the most pressing objective in immu-notherapy research is to widen the reach of the therapy and opti-mize ACT so that solid tumors can be effectively targeted. Current major areas of immunotherapy research include identifying ideal cancer antigens, finding cancer biomarkers for ACT, and working to improve in vivo persistence and survival of infused T-cells.15 A major challenge to improving immunotherapy outcomes is identi-fying cancer antigens that can be targeted without triggering severe toxicity responses.⁷ Establishing acceptable levels of toxicity will be

a key step in developing larg-er scale trials in a wider range of cancers. Furthermore, the transition from clinical trial drugs to FDA-approved treat-ments will likely require part-nerships between academia and industry. Continuing progress in the expanding field

of immunotherapy presents a promising avenue for administering more effective cancer treatments.

References: 1. Leading Causes of Death. (2016). Retrieved October 04, 2016, from http://www.cdc.gov/nchs/

fastats/leading-causes-of-death.htm 2. Desantis, C. E., Lin, C. C., Mariotto, A. B., Siegel, R. L., Stein, K. D., Kramer, J. L., Alteri, R., Robbins, A.S.

and Jemal, A. (2014). Cancer treatment and survivorship statistics, 2014. CA: A Cancer Journal for Clinicians, 64(4), 252-271. doi:10.3322/caac.21235

3. Wherry, E. J. (2011). T cell exhaustion. Nature Immunology, 12(6), 492-499. doi: 10.1038/ni.20354. Perica, K., Varela, J. C., Oelke, M., & Schneck, J. (2015). Adoptive t-cell immunotherapy for cancer.

Rambam Maimonides Medical Journal, 6(1). http://doi.org/10.5041/RMMJ.101795. Dudley, M. E., & Rosenberg, S. A. (2007). Adoptive cell transfer therapy. Seminars in Oncology, 34(6),

524-531. doi:10.1053/j.seminoncol.2007.09.002 6. Eshhar, Z., Waks, T., Gross, G., Schindler, D.G. (1993). Specific activation and targeting of cytotoxic

lymphocytes through chimeric single chains consisting of antibody-binding domains and the gamma or zeta subunits of the immunoglobulin and T-cell receptors. Proceedings of National Academy of Science, 90(2), 720-724.

7. Corrigan-Curay, J., Kiem, H., Baltimore, D., O’Reilly, M., Brentjens, R. J., Cooper, L., Forman, S., Gottschalk, S., Greenberg, P., Junghans, R., Heslop, H., Jensen, M., Mackall, C., June, C., Press, O., Powell, D., Ribas, A., Rosenberg, St., Sadelain, M., Till, B., Patterson, A. P., Jambou, R.C., Rosenthal, E., Gargiulo, L., Montgomery, M., & Kohn, D. B. (2014). T-cell immunotherapy: looking forward. Molecular Therapy, 22(9), 1564-1574. doi:10.1038/mt.2014.148

8. Rosenberg, S. A., Packard, B. S., Aebersold, P.M., Solomon, D., Topaliann, S. L., Toy, S. T., Simon, P., Lotze, M.T., Yang, J.C., & Seipp, C. A. (1988). Use of tumor-infiltrating lymphocytes and interleukin-2 in the immunotherapy of patients with metastatic melanoma: a preliminary report. New England Journal of Medicine, 19(25), 1676-1680.

9. Rosenberg, S. A., Yannelli, J.R., Yang, J. C., Topalian, S. L., Schwartzentruber, D. J., Weber, J. S., Par-kinson, D. R., Seipp, C. A., Einhorn, J. H., & White, D. E. (1994). Treatment of patients with metastatic melanoma with autologous tumor-infiltrating lymphocytes and interleukin 2. Journal of the National Cancer Institute, 86(15), 1159-1166.

10. Smyth, E. C., & Carvajal, R. D. (n.d.). Treatment of Metastatic Melanoma: A New World Opens. Retrieved October 23, 2016, from http://www.skincancer.org/skin-cancer-information/melanoma/melanoma-treatments/treatment-of-metastatic-melanoma

11. Rosenberg, S. A. & Dudley, M. E. (2009). Adoptive cell therapy for the treatment of patients with metastatic melanoma. Current Opinion in Immunology, 21(2), 233-240.

12. Rosenberg S.A., Yang J. C., Sherry R.M., Kammula, U.S., Hughes, M.S., Phan, G. Q., Citrin, D. E., Restifo, N. P, Robbins, P. F., Wunderlich, J. R., Morton, K. E., Laurencot, C. M., Steinberg, S. M., White, D. E., & Dudley, M. E. (2011). Durable complete responses in heavily pretreated patients with metastatic melanoma using T-cell transfer immunotherapy. Clinical Cancer Research, 17(13), 4550–4557.

13. Maude, S. L., Frey, N., Shaw, P. A., Aplenc, R., Barrett, D. M., Bunin, N. J., Chew A., Gonzalez V. E., Zheng Z., Lacey S. F., Mahnke Y. D., Melenhorst J. J., Rheingold S. R., Shen A., Teachey D. T., Levine B. L., June C. H., Porter D. L., & Grupp, S. A. (2014). Chimeric Antigen Receptor T Cells for Sustained Remissions in Leukemia. New England Journal of Medicine, 371(16), 1507-1517. doi:10.1056/nejmoa1407222

14. Kochenderfer, J. N., Dudley, M. E., Kassim, S. H., Somerville, R. P. T., Carpenter, R. O., Stetler-Steven-son, M., Yang, J. C., Phan, G. A., Hughes, M. S., Sherry, R. M., Raffeld, M., Feldman, S., Lu, L., Li, Y. F., Ngo, L. T., Goy, A., Feldman, T., Spaner, D. E., Wang, M. L., Cehn, C. C., Kranick, S. M., Nath, A., Nathan, D.N., Morton, K.E., Toomey, M. A., & Rosenberg, S. S. (2014). Chemotherapy-refractory diffuse large B-cell lymphoma and indolent B-cell malignancies can be effectively treated with autologous T cells expressing an anti-CD19 chimeric antigen receptor. Journal of Clinical Oncology, 33(6), 540-559. doi:10.1200/JCO.2014.56.2025

15. Wang, M., Yin, B., Wang, H. Y., & Wang, R.F. (2014). Current advances in T-cell based cancer immuno-therapy. Immunotherapy, 6(12), 1265-1278. doi: 10.2217/imt.14.86

THE MOST PRESSING OBJECTIVE IN IMMUNO-THERAPY RESEARCH IS TO WIDEN THE REACH OF THE THERAPY AND OPTIMIZE ACT, SO THAT

SOLID TUMORS CAN BE EFFECTIVELY TARGETED.


Epidemics have historically ravaged the human population since its early existence, but are they a problem of the past? Will we ever have another Scarlet Fever, Spanish Flu, or Black Plague? In 1928, Alexander Fleming discovered the antibiotic, penicillin, the first highly marketed, mass-produced antibiotic. By the early 1940s, when it was commercially produced, Penicillin was bring-ing more order to the disarrayed world of illnesses. At the time, demand for more drugs increased, and with 12 new antibiotics be-ing churned out a year,⁴ widespread disease was deemed to be un-der control from the public viewpoint. However, even after years of scientific development, the chance for an epidemic still exists.

THE COUNTING TOLL

Despite our advances, 2 million Americans are infected by drug resistant “superbugs,” and more than 23,000 of them die per year.2

Fleming warned of drug-resistant bacteria after observing that many microbes were withstanding penicillin. Sustained applica-tions of new drugs have resulted in multidrug resistant bacteri-um, such as Methicillin-resistant Staphylococcus aureus (MRSA). Methicillin used to be the primary method of treating Staphylo-coccus aureus but is now ineffective against MRSA. This resilience has had far reaching consequences. The Centers for Disease Con-trol (CDC) found that between 2000 and 2008, cases of sepsis, a life-threatening condition caused by infection, rose from 621,000 to 1,141,000, and deaths rose from 154,000 to 207,0001. Additionally, officials discovered a sample human E. coli with the mcr-1 gene for resistance to colistin,⁵ a last resort pharmaceutical used in the event that no other drug is effective. Economist Jim O’Neill projects that by 2050, an estimated ten million people will die annually due to resistant bacteria. The estimated GDP lost to resistant disease will

be $100 trillion.⁶ The impacts of antibiotic inefficacy could mean a possible throwback to the microbial dark ages, where a thorn prick can kill you and a hip transplant is no longer worth the risk.

UNDERSTANDING THE PROBLEM

Before taking the proper steps to remediate the situation, we must understand the cause. The continued exposure of bacteria to intense and diverse antibiotics has wiped any susceptible mi-crobes, naturally selecting those with the favorable mutations to survive and thrive without competition. These new strains force scientists to move to a new drug, continuing the cycle. In addi-tion to developing resistance through natural selection, bacteria have the ability to transmit resistance through the use of plas-mids, loops of self-replicating DNA in bacterial cytosol that car-ry potentially useful genes. Once resistance develops, the plas-

mid, can swap between bacteria of the same and of other species through conjugation, in which the bacterial cell membranes are connected through a pilus and the plasmid is replicated and hor-izontally transferred. However, the ability to resist an antibiotic requires resources; in order for a bacterium to produce a mol-ecule or an enzyme for defense, it must allocate resources away from another important cell function. With no exposure to an-tibiotics, these bacteria are ecologically less fit and naturally are

AS BACTERIAL RESISTANCE CONTINUES TO SPREAD, TREATMENT OPTIONS BECOME MORE LIMITED. SIMPLE OPERATIONS AND SMALL INFECTIONS CAN BECOME LIFE-TREATENING

AND THE RETURN OF THE MICROBIAL DARK AGES

surpassed by others of their kind. Resistant bacteria would be scarce in nature, however, the introduction of large doses of anti-biotics exerts an ecological stress that now favors resistant strains. Antibiotics create a naturally selective system that necessitates these survival systems that did not exist under typical conditions.

If the presence of an antibiotic is what causes resistance, one solu-tion is to reduce the use of antibiotics. Society favors the exten-sive use of antibiotics. For instance, forty million people receive antibiotics every year while only thirteen million have bacterial infections that can actually benefit from these pharmaceuticals. Accurate and economical diagnosis of patients can drastically re-duce the overuse of antibiotics. In addition, agriculture employs the widespread use of antibiotics to supplement the growth of animals. In America, 70% of the medically useful antibiotics are used in the growth and treatment of livestock, these drugs are used as dietary or growth supplements to make up for poor farming practices.⁶ Similarly, colistin is widely used in Chinese livestock.⁵ The continued usage of these drugs provide more avenues for microbes to gain resistance and transfer the gene and the resis-tance through food or contaminated soil. As bacterial resistance continues to spread, treatment options become more limited. Simple operations and small infections can become life-threat-ening. Doctors find themselves relying on colistin despite its un-ideal nature. It is a half-century-old drug that poses health con-cerns to the kidney, but with fewer viable options, physicians have no choice. Perhaps soon, even colistin will lose its efficacy.

ANTIBIOTICS BY MATTHEW ANDERSEN

Genetic Mutations Cause Antibiotic Resistance

THE PROCESS OF NATURAL SELECTION: CONTINUED USE OF INTENSE AND DIVERSE ANTIBIOTICS EVENTUALLY GIVES RISE TO SUPER-RESISTANT BACTERIA

In the presence of drugs, only bacteria

with mutations making them drug-resistant

survive (yellow)

Drug resistant bacteria thrive. Upon application of more antibiotics, the cycle

repeats

GRAPHIC/CLAIRE SONG

A few bacteria will acquire mutations (red)

on their DNA (dark blue) as they multiply


References1. “Antibiotic Resistance, The Grim Prospect.” (2016, May 21). Economist. Retrieved from http://www.

economist.com/news/briefing/21699115-evolution-pathogens-making-many- medical-problems-worse-time-take-drug-resistance

2. Deutschmann, Jennifer. (2016, Sept. 8). The Inquisitr News. Retrieved from http://www.inquisitr.com/3492396/what-is-a-superbug-antibiotic-resistant-bacteria/

3. Kupferschmidt, Kai. (2016). Resistance Fighters, Science, Vol. 352 (6287), 758-761.4. Mohammadi, Dara. (2015, July 19). The Gaurdian. Retrieved from https://www.theguardian.com/

science/2015/jul/19/antibiotics-new-research-end-of-drug-resistant-superbugs5. Sun, Lena H., and Brad Dennis. (2016, May 27). Washington Post. Retrieved from https://www.

washingtonpost.com/news/to-your-health/wp/2016/05/26/the-superbug-that-doctors-have-been-dreading-just-reached-the-u-s/

6. Yong, Ed. (2016, May 19). The Atlantic. Retrieved from http://www.theatlantic.com/science/ar-chive/2016/05/the-ten-part-plan-to-avert-our-post-antibiotic-apocalypse/483360/

7. Krans, Brian. (2014, June 22). Healthline. Retrieved from http://www.healthline.com/health/antibi-otics/why-pipeline-running-dry

8. Krans, Brain. (2014, June 22). Healthline. Retrieved from http://www.healthline.com/health/ antibi-otics/politics-pork-and-poultry-why-legislation-has-not-passed

9. Krans, Brain. (2014, June 22). Healthline. Retrieved from http://www.healthline.com/health/ antibi-otics/how-you-can-help-prevent-resistance

Having recognized several sources of the problem, why hasn’t any thing been done? With so few tools at hand, why not make more antibiotics? After Penicillin, there was a flood of pharmaceuticals hitting the market. Scientists were developing antibiotics from the dirt in their backyard. The thought of running out of more new drugs was inconceivable. However, having harvested all the low hanging fruits from the 50’s to 70’s, antibiotic production has sput-tered to a crawl. For example, the newest antibiotic discovery, as of 2016, is teixobactin. If approved (a process of 5 years), it will be the first antibiotic produced since 1987.⁴ Antibiotic production suffers from decreased availability of natural sources, as well as decreased funding. Drug investment has stagnated since the 70’s as large pharmaceutical companies dropped their antibiotic pro-grams. Why? The average expenditure per pharmaceutical is $2.5 billion and because only 1-2% of pharmaceuticals ever reach the market, companies must make many billions of dollars in profit for every successful drug they can pass.⁷ Pfizer, a pharmaceutical giant, was historically a leader in antibiotic development, manu-facturing penicillin for troops during World War II. With the ad-vent of resistant bacteria, it ended up closing antibiotic research

in 2011.⁷ This decision was made for financial reasons. The profits earned by creating expensive drugs for chronic diseases that last a patient’s lifetime disproportionately overshadowed the profits earned by acute diseases because “the customers stick around lon-ger.”1 For instance, the cholesterol-lowering drug Lipitor earned $13 billion per year for Pfizer, a profit that cheaper, temporary pills cannot compete with.⁴ This brings us to a point, posed by Matt Cooper, a medicinal chemist at the University of Queensland: “We also need to think long and hard about antibiotic drug pricing and whether it’s ethically acceptable to pay so much for life-extending drugs but still expect to pay peanuts for life-saving antibiotics.”⁴ Obviously, the threat of bacterial resistance isn’t solely attribut-ed to the production of new antibiotics. However, the practices of large pharmaceutical corporations exhibit an apparent, “mis-match between value to society and value to capitalist economics”.⁴

How about antibiotics in agriculture? Despite the FDA’s acknowl-edgement of the growing resistant trend and the role agricultural antibiotics play, the FDA has only implemented a policy of vol-untary restrictions. Current efforts in Congress include Pass the Preservation of Antibiotics for Medical Treatment Act (PAMTA), which would regulate the amount and types of antibiotics that can be used in agriculture to prevent routine use of antibiotics where they are unnecessary.⁸ However, there have been several gauntlets that have created a 1% change for bill approval. For one, there are few means of documenting the use of antibiotics in the U.S. for researchers to verify results that would support the bill. Second, if a bill involves agriculture, it is very difficult to pass the legis-lation. When bills pertaining agriculture arise, “agriculture and pharmaceutical industries have extended their well-funded lob-bying arms to push back” in order to protect their interests. To give one example, “Pfizer has filed more than 20 lobbying briefs against antibiotics legislation and has spent nearly $900,000 lobby-

WHEN BILLS PERTAINING AGRICULTURE ARISE, “AGRI-CULTURE AND PHARMACEUTICAL INDUSTRIES HAVE EXTENDED THEIR WELL-FUNDED LOBBYING ARMS TO PUSH BACK” IN ORDER TO PROTECT THEIR INTERESTS

ing against PAMTA alone.” It is obvious that once again, pharma-ceutical giants are prioritizing monetary gains over public health.

MOVING FORWARD

The looming problem of superbugs is one that can be avoided. The discovery of new antibiotics must once again be prioritized. For one, Congress has passed the Generating Antibiotic Incentives Now (GAIN) act, signed by Obama, which creates a drug develop-ment task force, extends patent exclusivity for 5 additional years, extends FDA fast track and increases FDA trial guidance.⁷ Addi-tionally, the economist O’Neill comes back with a few proposed solutions. He suggests a market-entry reward, payments for corpo-rations who develop a new antibiotic, and global innovation fund for early stage research, which could provide the economic stim-ulus to tip research back to the antibiotic arena.⁶ More important, however, is a decreased usage of antibiotics. By exposing microbes to less ecological stress, their development of resistance is im-mensely diminished. We need expansion in the diagnostic sector to enable doctors to accurately determine what type of disease they are dealing with so they can make an effective treatment procedure. Antibiotics do not need to be used in cases of non-bacterial diseas-es. There are obvious avenues where antibiotics are unnecessary. While antibiotic regulation is being stifled in Congress, ultimately regulation falls to the hands of the consumers. Choosing antibiot-ic-free meat in the store, and using antibacterial soaps sparingly are some ways of not only preventing antibiotic resistance, but also promoting personal health.⁹ Through active education of the risks of resistance, sponsoring of antibiotic research, and reduced usage of our current antibiotics - we can restrict the spread of microbe resistance before it begins to restrict the ways in which we live.

Why Aren’t We Making More Antibiotics?For every 100 drugs developed

COMPANIES MUST MAKE MANY BILLIONS OF DOLLARS IN PROFIT FOR EVERY SUCCESSFUL DRUG THEY CAN PASS

Only 1 or 2 make it onto the market

At $2.5 billion spent developing each drug, antibiotics are

not profitable enough to recoup losses

GRAPHIC/CLAIRE SONG


medication. Chronic activation of opioid receptors by medication also leads to the adaptation and desensitization of these receptors, leading to tolerance. This phenomenon means that higher doses of opioids are needed to produce the same analgesic effect.2 However, using higher doses of opioids puts patients at a greater risk of an overdose, since higher doses can lead to respiratory depression.⁴ Prescription opioids are also addictive because they activate the brain’s reward system, producing pleasure and a sense of well-being.2 Overall, the ability of prescription opioids to cause withdrawal, promote tolerance, and activate the brain’s reward system explain why they are so addictive.

Increased opioid use has resulted in more overdoses among all races; however, Caucasians and Native Americans have experienced the greatest increases in overdoses. According to the New York Times, lower rates of opioid overdoses seen in Latino and African Americans may largely be due to racial stereotypes. Studies have reported that doctors are less likely to prescribe opioids to these two groups out of fear that they will become addicted to the drugs or sell them.⁵ Rates of overdose are still higher among men; however, rates of overdose among women have risen more sharply in recent years. A major reason why rates have risen faster for women is that they’re more likely to suffer from chronic pain than men. As a result, physicians are more likely to prescribe them opioids, are more likely to give them higher doses of opioids, and are more likely to keep women on opioids for longer periods of time.⁶

THE POTENTIAL OF POT

Recent research suggests that cannabis-based therapies are effective at alleviating pain and reducing dependence on prescription opioids. Many human studies have shown that cannabis-based therapies provide significant pain relief for those who suffer from cancer, rheumatoid arthritis, and chronic neuropathic pain (pain due to nerve damage or dysfunction).⁴ There is also evidence that cannabis is effective at managing postoperative pain, pain due to multiple sclerosis, and migraine headaches. The anti-inflammatory properties

Solving the opioid CriSiS, one hit at a time

THE CURRENT SITUATION

Most people understand that heroin is a very addictive drug with great potential for abuse. What most individuals don’t realize is that prescription opioid abuse is far more common than heroin use. According to the U.S. Department of Health and Human Services, the United States is currently experiencing a prescription opioid epidemic.1 The National Survey on Drug Abuse and Health revealed in 2012 that 2.1 million Americans had a substance abuse disorder related to prescription opioids, while fewer than half a million were addicted to heroin.2 By 2013, overdoses due to prescription opioids reached over 16,000, a figure that had more than tripled since the year 2000.3 Drastic increases in opioid prescriptions, intense advertising by pharmaceutical companies, and an increased social acceptability for consuming drugs for nonmedical use have been responsible for exacerbating America’s opioid crisis.2 The crisis is likely to grow worse, and combatting this epidemic will require innovative solutions. Emerging research suggests that medical marijuana may be helpful in tackling this crisis due to its ability to alleviate opioid withdrawal symptoms and its potential to serve as a suitable substitute for treating chronic pain.

THE PROBLEM WITH OPIOIDS

Opioids are addictive due to the unique way they affect the central nervous system. The body has its own endogenous opioid system that is important in regulating pain. There are three types of opioid receptors found in the body: mu, delta, and kappa opioid receptors. The body produces its own opioids, known as endorphins and enkephalins, which bind to these receptors to block pain signals. Prescription opioids work much like the body’s own opioids, alleviating pain by binding to opioid receptors. Although, administration of synthetic opioids causes the body to greatly lower production of its own opioids. This lowered production, in turn, contributes to the severe withdrawal symptoms opioid addicts experience when they stop taking their

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of cannabis may even prove effective at treating fibromyalgia, a disease that causes generalized pain throughout the body.⁷

Studies even show that cannabis use prevents opiate withdrawal and tolerance, offering a safe way to wean patients off of prescription opiates.⁴ Cannabis is much less addictive than opioids and is practically impossible to overdose on due to the lack of cannabinoid receptors in the cardiorespiratory areas of the brainstem. As a result, unlike in the case of opioids, high doses of cannabis do not produce respiratory depression. In fact, no deaths have ever been linked to cannabis use in the United States.⁷

Despite all of the potential medical marijuana has in treating opioid abuse, the federal government has not focused its efforts on utilizing non-opioid treatments.⁸ There are no cannabis treatments approved in the U.S. to treat chronic pain. Instead,

the federal government has focused on enhancing prescription monitoring programs, opioid education initiatives, and increasing access to naloxone, which is a drug used to treat opioid overdoses.2,8 While these initiatives have shown some efficacy, they do not adequately explore alternatives to opioid medication.

At the state level, however, using medical marijuana as a treatment is being explored, and there is already evidence that cannabis is reducing opioid abuse in states with medical marijuana laws. According to a study by the University of Michigan, patients who used medical marijuana to control pain reported a 64% reduction in the use of prescription opioids.⁹ Additionally, states with medical marijuana laws have lowered rates of opioid overdoses compared to those without cannabis laws.⁸

GRAPHIC/ WIKIMEDIA

References1. U.S. Department of Health & Human Services. (2016). The opioid epidemic: by the

numbers [Data file]. Retrieved from http://www.hhs.gov/sites/default/files/Factsheet-opi-oids-061516.pdf

2. Volkow, N. D. (2014). America’s addiction to opioids: heroin and prescription drug abuse. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-con-gress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

3. Hedegaard, H., Chen, L., Warner, M. (2015). Drug-poisoning deaths involving heroin: United States, 2000-2013 [Data file]. National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db190.pdf

4. Lucas, P. (2012). Cannabis as an adjunct to or substitute for opiates in the treatment of chronic pain. Journal of Psychoactive Drugs, 44(2), 125-133. Retrieved from http://proxy.library.upenn.edu:2146/10.1080/02791072.2012.684624

5. Nolan, D., & Amico, C. (2016). How bad is the opioid epidemic? PBS. Retrieved from www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/

6. Centers for Disease Control and Prevention. (2013). Prescription painkiller overdoses [Data file]. Retrieved from www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/

7. Manzanares, J., Julian, M. D., Carrascosa, A. (2006). Role of the cannabinoid system in pain control and therapeutic implications for the management of acute and chronic pain episodes. Current Neuropharmacology, 4(3), 239-257. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430692/

8. Bacchuber, M. A., Saloner, B., Cunningham, C. O., et al. (2014). Medical cannabis laws and opioid overdose mortality in the United States. JAMA Internal Medicine, 174(10):1668-1673. doi: 10.1001/jamainternmed.2014.4005

9. Boehnke, K. F., Litinas, E., Clauw, D. J. (2016). Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. The Journal of Pain, 17(6), 739-744. Retrieved from http://proxy.library.upenn.edu:2146/10.1016/j.jpain.2016.03.002

FINAL CONSIDERATIONS MANY HUMAN STUDIES HAVE SHOWN THAT CANNABIS-BASED THERAPIES PROVIDE SIGNIFICANT PAIN RELIEF FOR THOSE WHO SUFFER FROM CANCER, RHEUMATOID ARTHRITIS, AND CHRONIC NEUROPATHIC PAIN (PAIN DUE TO NERVE DAMAGE OR DYSFUNCTION).

THE PHARMACOLOGY OF WEED

Cannabis’s psychoactive ingredient, delta-9-tetradhydrocannbinol (THC), is a natural cannabinoid that exerts its effects on the body via activation of cannabinoid receptors. The cannabinoid system is very important in modulating neurotransmission and is key in regulating pain perception, mood, appetite, and memory. The body produces its own cannabinoids—anandamide and 2-AG—and expresses two main types of receptors: CB1 and CB2. Studies have shown that anandamide is very important in regulating pain. For example, a study from Nature demonstrated that rats treated with an anandamide blocker experienced more severe and extended pain responses.⁴ Other studies have also concluded that CB1 and CB2 receptor activation results in anti-inflammatory effects and other analgesic effects that result in pain reduction. Additionally, CB2 activation indirectly leads to

activation of opioid receptors and the promotion of endogenous opioid synthesis.⁷ The ability of cannabis to increase the synthesis of endogenous opioids may account for why cannabis is able to alleviate opiate withdrawal, especially since prescription opioids lower endogenous opioid synthesis.

FINAL CONSIDERATIONS

Cannabis may prove to be a useful drug in alleviating opioid dependence and could serve as a substitute to prescription opioids. Cannabis is much safer than prescription opioids, is much less addictive, and does not produce the severe withdrawal effects seen with opioids. As more states legalize marijuana for both medical and recreational use, more people will have the chance to benefit from its medicinal properties. Perhaps, with the help of cannabis, prescription opioid use will no longer be an epidemic.

36 | SYNAPSE | Fall 2016 Fall 2016 | SYNAPSE | PB

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