Month: May 2014

Every pharmaceutical product that comes into direct contact with your blood is tested via a process that involves kidnapping horseshoe crabs, forcefully bleeding them, dropping them off somewhere far away, and then mixing their blood with your future medicine.  I have so many thoughts on this.

One, I miss you, Mitch Hedberg.

Two, we are going through a lot of trouble to not kill the crabs (although up to 30% of the crabs die before being released, and those that survive seem to be less fertile).  This either a sign of a great yet extremely specific compassion, or because we’re concerned about depopulation and this is easier than domesticating them.

Three, can horseshoe crabs feel pain or fear?  If they can, catch, bleed, and release seems less humane than a clean kill and draining all their blood.  Human pain has two components: nociception, which is the peripheral nervous system “ouch”, and your brain’s interpretation and reaction to that pain. That’s why the same sensation can have a very different emotional component depending on the source.  Horseshoe crabs have a  nervous system, so they can feel nociception, but with such limited brains and no endocrine system at all it’s unlikely they’re feeling pain by this definition.  Certainly less than the bunny rabbits that previously filled this role.  Probably little enough that I’m willing for them endure it to lessen human suffering.  But not so little there’s no room for improvement.  Which pharmaceutical companies are working on.  Not so much because this method is creepy, but because it is expensive.

Fourth, this sounds a lot like human descriptions of alien abductions, and would answer the nagging question “why do aliens smart enough to traverse light years want to anal probe so many humans?.” Maybe our anal secretions contained a key element of their biotech development process.  Maybe they happened to create a synthetic version right around the time camera phones came into vogue.

When people visit the crisis chat I volunteer at, I have three options:

1. Listen, no follow up
2. Listen, refer to specialist for concrete help (example: a woman being abused by her husband comes in to chat.  I validate her feelings and ideally help her move to a mental/emotional state where she is emotionally ready to leave.  I then refer her to the National Domestic Violence Hotline for help with the specifics of actually leaving).
3. Listen, call for emergency government interference. There are two circumstances I must do this: someone under 18 is being neglected or abused by a guardian (-> call Child Protective Services or equivalent), or I believe someone is likely to attempt suicide in the next 24 hours (-> call local 911 for an emergency rescue, high likelihood they are involuntarily committed to a psychiatric hospital).

Since I started I’ve called CPS twice and watched other people call two or three times, and never seen a 911 call.  However, I’ve talked to a lot of visitors who are really scared of me calling 911.  I have complicated feelings about this.

I believe people have a right to commit suicide.  I believe my visitors when they say that psych wards are stressful and leave them worse off than they were before.   Active rescues take away people’s power, and when so much of suicide is driven by a feeling of powerlessness, that’s dangerous.   I spoke to a woman with sensory integration disorder for whom a psych ward was pretty much hell on Earth.  If a person is depressed over money, an expensive hospital stay and days of missed work will make it worse.  

I also believe active rescue is really beneficial for some people, and we cannot perfectly predict who falls in that category.  I think it’s safe to say that people coming to crisis chat are more likely to benefit from/want a rescue than the general suicidal population, and I am ultimately willing to tolerate a certain number of unwanted active rescues in exchange for a certain number of wanted ones.

A non-trivial number of people use my chat service rather than the phone line specifically because they (correctly) believe it is harder for us to find their physical location, so they can reach out without fear of the police knocking down their door.  The fact that these people exist indicates to me that this is a good service to provide.  There is a big gap being suicidal thoughts and suicidal acts, and having place to bring light to those thoughts without bringing your world down around you can be the first step towards letting them go.

Thus far my compromise is that if a visitor is voicing concern about me calling 911 on them and telling me they do not want to be committed, I tell them how to avoid having me call.  They can tell me about their wish to die as much as they want, they can even tell me their plan, as long as they also tell me they don’t plan on acting on them in the next 24 hours.  Is it possible people will lie to me?  Yes.  And I would be sad if I found out there was a suicide I could have prevented.  But I would also be sad if an unwanted rescue kept someone from reaching out later.  And I suspect that the truly imminently suicidal are less likely to lie about it/be able to lie about it.  For one, lying is mentally taxing, and the very depressed don’t have the space cycles.  For two, lying requires planning, and the biggest risk for suicide isn’t depression, it’s impulsivity.  My hope is that the same impulsivity that causes suicide will cause people to tell me about it.  I also hope, but will never have the data to back this up, that I’ll be able to recognize impulsivity and make a different deal with the person.  I don’t know what I’d do in that case, I just have this gut feeling that all the people who’ve asked me this so far needed a sense of control more than they needed a rescue, and I’d act differently if I didn’t think that was the case.

Jezebel has a post up discussing the link between Accutane and suicide.  I link to the Jezebel post and not the new article because I find the comments interesting.

First, some background.  Accutane (generic name: Izotretinoin) is mostly an anti-acne medication, although it’s occasionally used for other skin disorders and cancers.  Depending on who you ask, it’s either a form of vitamin A or a close relative of vitamin A.  Vitamin A is fat soluble, which means if you take too much it will kill you (the livers of many arctic mammals are toxic for this reason).  One to two courses of Accutane (generally lasting 8-10 months) is usually enough to permanently cure severe acne.

Izotretinoin is a notorious teratogen, meaning it can cause serious birth defects if taken during pregnancy.  The cause appears to be that izotretinoin serves as a signalling molecule in a certain stage of pregnancy, but this is not definite.  In America, the relevant legal authority has responded with the iPLEDGE system.  Only prescribers registered with iPLEDGE can prescribe accutane. They must register recipients (with a detailed sexual and menstrual history) in the system and certify that they’ve been  warned about the risk of birth defects, and promised to take two forms of birth control.  Prescriptions must be picked up in a seven day window, lost prescriptions cannot be replaced, a prescription must be for exactly 30 days.  Recipients must take a blood (not urine) test for pregnancy every month before getting their prescription.  They recently relaxed the latter requirement for men and women of non-child-bearing age to pledge to take birth control, but still require a blood test.

This program represents some of the worst government interventions in health to me.  It imposes huge burdens of time, money, and privacy.  It infantilizes women by requiring a pregnancy test even if they report no sexual activity, yet takes their word on the whole birth control thing.  It very nearly requires hormonal birth control, and while I recognize hormonal birth control as a life changing intervention for many people, I think the dangers are understudied and under reported and dislike anything that dismisses its costs.  The timing restrictions seem to be designed to force users to adhere to pregnancy tests, which are predicated on the idea that you can’t trust women to notice they’re pregnant.  And of course, you have to do all this for people without working uteruses.  It’s also considerably more work than you need to do to take thalidomide, an even more notorious teratogen, which means the decision to impose iPLEDGE is being made based on something other than strict rational consideration of costs and benefits.

No one is quite sure how izotretinoin works.  It may induce cell death in the sebaceous glands.  It may act as an anti-microbial.  It may affect the expression of hundreds of genes.  It has shown promise as a cancer treatment, which means it probably inhibits cell growth.

Some people report that Accutane has psychological side effects, including suicide.  This is really tricky.

A lot of Accutane users are teenagers, who are already an emotionally chaotic group.  You can compensate for differing risk with a control group, but a higher variance is still more likely to lead to a false report of differing means.

Second, suicidality and depression are not as linked as you would think.  People at the absolute pit of depression are often too overwhelmed and apathetic to kill themselves. Suicide risk actually increases when treatment starts working (which may be why anti-depressants are linked to suicide in teenagers, and is definitely why mixed states are so dangerous).  Severe acne is socially isolating, which can lead to depression.  It’s entirely possible that getting better frees up enough emotional energy to feel bad, or that the first set back after an improvement feels unmanageable, and so while the drug has no direct psychoactive effects, it looks like it does through its effects on the skin.

On the other hand, it’s a known biohazard with no accepted explanation for why it works, and almost any disruption in physical systems can manifest as depression and anxiety.  The weird thing would be if it didn’t.  The Jezebel comment thread is full of people saying it induced terrifying psychosis in them.  It’s also full of people saying it saved their lives by clearing up their acne.  A 24 mouse study showed some increase in depression-like behavior in mice following injection.   An even smaller study showed that Accutane reduced cell growth in certain regions of the brain, which is terrifying for a drug we give to teenagers but hard to draw concrete conclusions from.

So what do you do, as a potential patient or parent of same, in the absence of good evidence?  Clearly you need to watch new patients closely for behavioral changes and discontinue if they occur, but what about the risk of subtle long term damage?    I don’t know how to weigh that.