The science, not ethics, of unverified Ebola drugs

The Ebola Virus. Image from NIAID (Ref. 2).
The Ebola Virus. Image from NIAID (Ref. 2).

I haven’t posted in a while. The current global Ebola panic, spread mostly by social media and the media and not so much by the actual global threat of Ebola, has spurred me from complacency. Specifically, a WHO ethics panel today unanimously authorized the use of unproven, untested, experimental Ebola drugs in the field. But missing from the public discussion of this move is a key question: what is the scientific benefit (or downside) of this decision? In this short post, I hope to address the issue of using unproven drugs on Ebola patients from the perspective of the scientific method.

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Bad science reporting on Mayo Clinic Proceedings “Prescription Drug Use” paper

CBS demonstrates the inability to even read the abstract of a scientific paper when reporting on prescription drug use.
CBS demonstrates the inability to even read the abstract of a scientific paper when reporting on prescription drug use.

I saw on Facebook today some repeats of a CBS article from Atlanta entitled “Study: 70 Percent Of Americans On Prescription Drugs” [1]. The news article cites this actual scientific article from the Mayo Clinic’s “Mayo Clinic Proceedings,” entitled “Age and Sex Patterns of Drug Prescribing in a Defined American Population” [2].

The CBS article claims right in the first paragraph of their story that

“Researchers find that nearly 70 percent of Americans are on at least one prescription drug, and more than half receive at least two prescriptions.” [1]

This is demonstrably a false statement, as reading the abstract of the paper will tell you:

“Objective: To describe the age and sex patterns of drug prescribing in Olmsted County, Minnesota.” [2]

So, the authors say NOTHING of how many generic Americans are taking at least 1 prescription drug. Later on, at the very end of the paper they note that

“In general, drug-prescribing patterns in this population are consistent with those in previous population-based studies in the United States . . . Our findings cannot be compared directly with findings from these previous studies because of differences in methods (weekly or monthly use vs annual use and data derived from drug prescriptions vs self-reports, pharmacy records, or insurance claims).” [2]

but that is about the grandest statement they make. They don’t note that the data is anomalous with expectations based on drugs prescribed to certain age classes, etc. They report this as data-gathering to help inform healthcare system studies, but they don’t consider these numbers representative of “abuse.”

The CBS article also makes the outcomes of the study sound horrible by using the weasel word, “prescription drug,” but when you read the data breakdown in the paper the numbers actually make a lot of sense and, if anything, reflect the current trend toward obesity in the United States (in other words, then negative connotations of the paper are more aligned with a known underlying health problem in the U.S. whose symptoms can be treated with a range of prescription drugs).

Taking all age groups together:

  • 26% are taking an antibiotic or erythromycin of some kind – not a surprise, since bacterial infections are common and this is how they are treated.
  • 11% are taking vaccines of some kind. That’s great news!
  • 10% are taking anti-asthmatics – again, not a surprise, since asthma affects an estimated 7% of the U.S. population and anti-asthmatics can be used to treat other related diseases [3]. So these numbers are in-line with the affected population.
  • 9% are taking anti-infective/anti-inflammatory drugs – that’s good. Preventing inflammation and infection are not bad things, and thank goodness we have drugs to help control these issues.
  • 6% are taking drugs (throat and nasal agents) that would be used to treat symptoms or complications associated with nose, chest, or throat infections (e.g. flu, severe cold, etc.). No surprise there. For instance, the percentage of people that get the flu each year varies between 6-20% [4].
  • 14% are taking drugs for digestive reasons (laxative, etc.).
  • 7% are taking diuretics, which are used in the treatment of heart, kidney, and other problems – the most heavily using sub-population of these was people over 50 . . . so not a surprise, because that’s when heart, liver, and kidney problems begin to crop up.

A few other categories had 5% or fewer usage, but they are all explainable for a variety of diseases that are common in sub-populations.

The ones to watch out for are the fraction on medications intended to treat blood pressure or heart issues, or depression:

  • 11% take anti-lipemic agents, chemicals designed to lower cholesterol
  • 7% take beta-blockers and 7% take ACE inhibitors, which help treat heart and blood pressure issues
  • 13% take anti-depressents
  • 12% take opioid analgesics, which can be habit-forming (which is why they are given on prescription, of course)

Let’s consider the 11% who take anti-cholesterol drugs and the 14% that take a drug intended to treat the heart in some way. About 1/3 of the U.S. adult population is obese [5], and obesity raises your risk factors for heart and cholesterol-related problems (I myself have struggled with high blood pressure, which is very well-controlled by keeping my BMI below 30 . . . but that is just me, and should not be mistaken for the actual copious medical evidence that obesity increases significantly all the risks to your heart and lungs). So it’s not a huge surprise that a non-trivial fraction of the population takes drugs to control problems associated with one of the largest health issues facing our nation. If anything, it’s worth focusing on the obesity issue and less on the drugs issue, which is more a symptom than a cause.

The other concerning issue is the number of people taking anti-depressents, but . . . again . . . taking anti-depressants is a response to the underlying cause:

An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year. [6]

We’ve gotten better at identifying how behaviors are related to the chemistry of the mind, and especially to depression and related classes of mental state. Right now, effective treatments for many people involve drugs. Perhaps, in the future, we’ll find other ways to control depression, but the reality is that now we have classes of drugs that can have positive effects on people fighting with depression.

All of the numbers simply reflect the fact that we know how to treat a lot of disease classes using drugs, and so drugs get prescribed. Keep in mind, again, that CBS blew their reporting on this article in the first line of their story, when they said it applied to all Americans. Wrong. Just wrong.

[1] http://atlanta.cbslocal.com/2013/06/19/study-70-percent-of-americans-on-prescription-drugs-one-fifth-take-5-or-more/

[2] http://www.mayoclinicproceedings.org/webfiles/images/journals/jmcp/jmcp_ft88_7_2.pdf

[3] Fanta CH (March 2009). “Asthma”. New England Journal of Medicine 360 (10): 1002–14. doi:10.1056/NEJMra0804579PMID 19264689

[4] http://www.webmd.com/cold-and-flu/flu-statistics

[5] http://www.cdc.gov/obesity/data/adult.html

[6] http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml#Intro

My Carcinoma

One of my friends insisted I document the process of having a basal cell carcinoma (scary name, 99% treatment success rate) removed from my face. I was hesitant at first, but it seems silly not to write about the process of having this surgically removed. After all, what is the purpose of a personal blog if it doesn’t get personal every now and then? For those of you who think blogs are self-indulgent ego-trips, stop reading and go do something for yourself. The way I look at it, maybe somebody else might want to know about the personal experience of having a carcinoma removed via the Mohs Surgical Procedure, and maybe they will stumble on this. Maybe this will be helpful to someone.

My own little basal cell carcinoma, just below my left eye. Hurray.
My own little basal cell carcinoma, just below my left eye. Hurray.

Here is an image of my face on about May 1. The carcinoma is the red, misshapen dot and the mis-formed skin around it. The whole thing is just below my left eye (mirror-reversed in the image, of course). When this  little guest is not destroying the healthy tissue on my face and generally acting annoying and bleedy, it looks like a chicken pox or acne scar. Such a simple thing, and easy for someone who is not a trained physician to overlook. Thankfully, I have an attentive general practitioner in my corner.

You May Already Be A Winner

Basal_cell_carcinoma_-_2_-_intermed_magPeople talk about getting cancer like they talk about winning the state lottery. Winning the state lottery is, by design, an extremely improbable event. Unlike the state lottery, most of us stand a fair chance of getting cancer at least one time in our lives. And unlike for winners of the state lottery, where past success is totally independent of future chances of winning again, for those who win the cancer lottery the chances of winning a second time go up significantly. I’m not talking about brain cancer, or prostate cancer, or some other specific horrible cancer that makes headlines. I’m talking about any cancer – any alteration of our own genetic code that leads to the successful development of aggressive tissues that cannot be corrected or eliminated by the body’s mechanisms for weeding out mistakes.

It’s, in some ways, remarkable that most of us don’t get cancer more often. Every time our cells divide, unzipping our DNA to prepare for replication, there is a chance that one or more base pairs will be erroneously copied, leading to a flaw in the replication process. It’s also possible for strong chemical reactions to lead to disruptions in copying, initiated by the ionizing of molecules due to effects like exposure to ultra-violet light or the random interaction of a high-energy cosmic ray inside our tissues (something that happens quite a lot). The good news is that most errors in copying lead to genes that cannot function properly, or that result in the production of molecules that fail to support cellular mechanisms. For a variety of reasons, cells tend to die off after such mutations and are simply removed by the body as waste. Most people are blissfully unaware of the sheer numbers of mistakes their own bodies are constantly dealing with in an attempt to perpetuate the life of the host, thus increasing the chances of passing along host’s genes and propagating the species.

The fact that cancer is not the leading cause of death, or a process that affects 100% of all humans all the time, is a testament to the long march of biology over millions of years. Driven by the simple process of environmental pressures, be they physical, chemical, or biological, the process of cellular reproduction has evolved with checks and balances in place to minimize errors in duplication. While errors can be troublesome or useless, they can also be useful – in fact, mutation is the essential agent of biological change while natural selection picks the winners and the losers. But that same process can sometimes result in tissues whose growth is unlike the parent cells. In their own effort to procreate and perpetuate, they invade neighboring tissues or hitch a ride in the bloodstream and land in some other poor organ. Cancer is, quite simply, what happens when mutation results in a new organism that is unable to live symbiotically with the host, or to be destroyed by the host. It’s a sideways march of natural selection, one of those accidents whose chances can be increased by sun exposure or exposure in large doses to certain classes of chemicals. It doesn’t tend to end well for the host.

The consequences for the host can vary, from physical deformation to death. The treatments for cancer can vary; the body can already do a lot to evict troublemakers, but when it fails a person can be faced with a range of choices, from chemical treatments to surgery.

I say all of this because it’s recently been made clear to me that I have won the cancer lottery. My prize is thankfully small – a growth of basal cell carcinoma on my face, just below my left eye. Basal cell carcinoma is probably the most easily treated cancer, with a scary name, a very high success rate, and only in the very rarest of cases leads to complications that can be life-threatening. The growth of the carcinoma is usually very slow, but left unchecked it will eventually do serious damage to surrounding healthy tissues. Treatments vary, but the most successful currently documented treatment is the Mohs Surgical Method. This is what I will receive. I like the Mohs Method because it appeals to me as a scientist.

In the Mohs Method, a minimal section of skin will be removed from my face, going deep enough and wide enough to try to encompass the carcinoma. I’ll be awake for the whole process, with a local anesthetic applied to my face. After the first removal, I’ll be able to sit in a waiting area while the skin section is frozen, stained, and sliced. The tissue will be assessed under a microscope, looking at all the edges to see where basal cells extend beyond the periphery of the surgeon’s cuts. Those locations on my face will then be revisited with the scalpel, removing more tissue for further scrutiny. The cutting stops when the basal cell growth no longer crosses the surgeon’s cut boundaries. This process is expected to take no longer than four hours, which seems like a pretty minor investment for a 98-99% success rate.

The wound will be sutured in such a way as to follow the wrinkles (smile lines) on my face, so that any long-term scarring will blend with natural lines forming with age on my face. I’ll be sent home to rest for about seven days, and I’ve been told to expect significant swelling on the left side of my face. The surgeon said that after a few days it will look like somebody socked me in my left eye, so this will be a new experience for me. I’ve been prescribed total rest for that period, and no lifting of anything over 10 pounds to avoid popping the stitches. After about seven days, assuming the wound is healing well, the sutures will be removed and I’m essentially free to go about my life after that. The scarring will largely vanish over the course of about three weeks.

To be fair, I had this coming. After all, as a physicist I spend my life modeling nature, designing cuts to select interesting phenomena, and then applying those cuts to better isolate and understand the world. Nature just seems to want to return the favor . . . and I can respect that.