Coronavirus thread

[peterb]

When I was a brand new intern, literally first month of being a doctor, our hospital hired a pain control nurse. She gave lectures to us residents, as well as medical and surgical grand rounds. She pushed hard for opioid use saying things like; “pain is the 5th vital sign, there’s no such thing as narcotic dependence or concern for overdose, and even if there was, uncontrolled pain was worse.” She’d call you up at any hour to say that the patient in 302 needed more morphine.

The only "evidence" for the "no evidence of addiction" claim was a one-paragraph letter: https://www.nejm.org/doi/full/10.1056/NEJMc1700150

"Dreamland" covered this. As I recall, a doctor did a data search of cases in his hospital system where narcotics were used to treat acute pain in hospitalized patients. He found almost no new addictions in patients with no history of addiction. He thought that was interesting, fired off the letter and went on to something else. Pharma companies saw it and began touting it as a "study" that "proved" narcotics were safe to use for chronic pain in outpatient settings.

[Nephrology]

The only "evidence" for the "no evidence of addiction" claim was a one-paragraph letter: https://www.nejm.org/doi/full/10.1056/NEJMc1700150

"Dreamland" covered this. A doctor did a data search of cases in his hospital system where narcotics were used for acute pain in a closely supervised inpatient setting for patients with no history of addiction. He saw almost no new addictions, thought that was interesting and fired off the letter. Pharma companies saw it and began touting it as a "study" that "proved" narcotics were safe for use for chronic pain in outpatient settings.

I will say, from personal experience, when I've been hospitalized and required IV opiates, they are not "fun." I did not really experience pleasure from getting them so much as a reduction in pain.

When I broke my arm in college (see above), it was a very different story. Their addictive potential felt a lot more real, for lack of a better way to put it. So, that initial study probably wasn't good justification for the rest of what happened in that book, but I don't think it was crazy or off the mark somehow. It just wasn't asking a question relevant to the outpatient use of opioids.

[peterb]

So, that initial study probably wasn't good justification for the rest of what happened in that book, but I don't think it was crazy or off the mark somehow. It just wasn't asking a question relevant to the outpatient use of opioids.

Exactly. Supervised, monitored inpatient use for acute pain is nothing like handing out bottles of pills to people complaining about their chronically sore backs.

But "Studies show that......!" and "Published in the New England Journal of Medicine!" are great selling tools.

[fly out]

'
That article hasn't been specifically discussed yet, but it is a review paper so it doesn't bring new evidence to the table, just discusses what is out there already.

Most importantly, he's kinda off base about one of his major arguments: that HCQ hasn't been tested in outpatients. (" To my knowledge, all of these reviews have omitted the two critical aspects of reasoning about these drugs: use of HCQ combined with AZ or with doxycycline, and use in the outpatient setting")

This study on exactly that was published a couple days ago in the New England Journal. This study on HCQ for patients with mild to moderate symptoms in China was published several weeks before that. There are more, but these two represent the highest quality I've read to date w/r/t study size and design.

Of the 5 outpatient studies he reviews that show support for its efficacy, 4 are pre-prints and/or not even submitted for peer review (take a look at the references section), and the only one that has finished peer review has a sample size of 22 patients, which is statistically meaningless. Compare that to the NEJM paper which was randomized, double blinded, and had 821 participants.

For these reasons, it's hard for me to take his review seriously. It's clear he was very selective in the articles he chose to review... he dug past a lot of articles showing no benefit from HCQ to find the ones that he cites in his paper.

Also, to put the cherry on this sundae, here's an important disclosure at the very top of the title page, worth reading given the discussion re: financial incentives in medical research.

To be fair to the good doctor, he couldn't have read the NEJM piece from two days ago unless it was given to him ahead of time. His submission was published ten days ago, or so.

That said, wouldn't both studies you mentioned fall outside the parameters of what he wanted to see? The NEJM study only listed hydroxychloroquine; did it include azithromycin or doxycycline? The China study was expressly limited to hospitalized persons, and it looks like that one was just using hydroxychloroquine, too.

I understand money has to come from somewhere, but I thought Dr. Boulware's disclosure (the NEJM piece) was at least mildly interesting:

Dr. Boulware reports grants from Jan and David Barcuski, grants from Alliance of Minnesota Chinese Organizations, grants from Minnesota Chinese Chamber of Commerce, grants from University of Minnesota Foundation, non-financial support from Rising Pharmaceuticals, during the conduct of the study.

though I'm not sure which way a Chinese connection cuts, if it does, at all.

It will be interesting to see how this all shakes out once we have the luxury of some distance in the rearview mirror.

[Glenn E. Meyer]

Anybody report this: https://www.politico.com/news/2020/0...nt-work-303275

Didn't do any good, didn't hurt anybody either.

[Nephrology]

Anybody report this: https://www.politico.com/news/2020/0...nt-work-303275

Didn't do any good, didn't hurt anybody either.

Haven't seen that but good find. That's maybe the biggest RCT I've seen to date. 11k participants randomized to a bunch of different Tx groups and 80% of their intend to treat population was retained thru end of trial. Solid.

[TheRoland]

I'm really really worried the dense states are going to see large second-spikes due to the protests, people riding public transit to them, people being forced into close proximity with each other. I'm worried enough to start trading stocks on this assumption (and that a second spike is going to cause the market to lose confidence again).

Does someone want to talk me into or out of this? Is there any evidence either way at this point?

[MickAK]

I'm really really worried the dense states are going to see large second-spikes due to the protests, people riding public transit to them, people being forced into close proximity with each other. I'm worried enough to start trading stocks on this assumption (and that a second spike is going to cause the market to lose confidence again).

Does someone want to talk me into or out of this? Is there any evidence either way at this point?

White Supremacy is a more urgent public health concern.
https://whdh.com/news/over-1000-heal...-as-an-excuse/

[TheRoland]

White Supremacy is a more urgent public health concern.
https://whdh.com/news/over-1000-heal...-as-an-excuse/

Yeah, a list of people to ignore, imho.

[blues]

White Supremacy is a more urgent public health concern.
https://whdh.com/news/over-1000-heal...-as-an-excuse/

Here is the ethically and medically sound solution to this dilemma: