Archives for August 2013

This may be the most delightful of all medical prescriptions: Chew a little raw garlic a couple of times a week and the risk of lung cancer drops by almost half. It drops by almost a third even if you’re a smoker.

News this good, not to mention this tasty, is rare in medicine, but that’s the conclusion of a large Chinese study published recently in Cancer Prevention Medicine.

The researchers compared 1,424 lung cancer patients with 4,543 healthy adults and asked them about their lifestyle and dietary choices. Granted, just asking people to recall their own behavior is hardly the ideal form of research. (Far more informative are studies that randomly divide people into two groups, give one group a treatment and the other group a placebo without revealing who’s getting what, and then compare the results.)

That said, the results from Jiangsu Center for Disease Control and Prevention in Nanjing are noteworthy, said John Milner, who has studied garlic chemistry for decades.

“This is additional evidence that garlic has some significant health benefits.” Milner, director of the Human Nutrition Center at the Agricultural Research Service at the United States Department of Agriculture, told me in a telephone conversation this week.

The new data from China fit with a longstanding body of research on garlic, which is high in sulphur-containing compounds, as a potential cancer-fighter. Sometimes called the “stinking rose,” garlic was first mentioned in the medical literature in 1550 B.C. in an Egyptian papyrus, then got a further whiff of credibility in 1858 when Louis Pasteur discovered that its juice kills bacteria.

Much of the biological action in garlic comes from its breakdown products, or metabolites, of allicin, which are released when raw garlic is chopped or crushed.

In the body, allicin and its breakdown products have numerous functions – reducing inflammation, combatting harmful oxygen molecules called free radicals, acting as a natural blood thinner, fighting bacteria, blocking cancer-causing agents (carcinogens), slowing down the rapid cell division that is the hallmark of cancer, enhancing DNA repair and triggering a phenomenon called apoptosis (cell death).

Interestingly, there are fewer health benefits from cooked garlic. However, “if you chop garlic and let it sit for 10 to 15 minutes, the active compounds are formed, then it doesn’t matter if you heat it,” Milner said. “Heating is only bad if you heat the [chopped] garlic right away.”

In 2009, researchers studying human urine samples found that consuming 3 to 5 grams a day blocked the creation of cancer-causing agents, carcinogens, called nitrosamines, which are found in some processed meats and are also formed in the body during normal metabolism.

Technically called allium sativum, garlic is in the class of plants that includes onions, chives, leeks and scallions, all of which have medicinal benefits like garlic, though these other plants have not been studied for their potential health effects as thoroughly as garlic.

According to the National Cancer Institute (part of the National Institutes of Health), preliminary studies suggest that eating garlic may reduce the risk of certain cancers, especially those on the gastrointestinal tract. These include cancers of the stomach, colon, esophagus and pancreas.

In a 2006 European study that involved people from 10 countries, higher intake of garlic and onions were linked with a lower risk of intestinal cancer. An older study (from 1994) called the Iowa Women’s Study had already showed that women who ate the most garlic had a 50 percent lower risk of colon cancer compared to those who ate the least.

Chinese studies in 1999, 2002 and 2005 have linked high consumption of allium-containing vegetables to lower risks of esophageal and stomach cancer, prostate cancer and stomach cancer, respectively. A 2005 San Francisco Bay-area study found that pancreatic cancer risk was 54 percent lower in people who ate larger amounts of garlic compared to those who ate less.

While these and other epidemiological studies comparing the dietary habits of large groups of people strongly suggest an anti-cancer effect from garlic and its vegetable cousins, proving that connection in interventional studies has been more difficult.

In one 2004 Chinese study, for instance, an extract of garlic (called allitridum) plus selenium seemed to reduce the risk of tumors in general and stomach cancer in particular. But a 2006 Chinese study interventional study found no such risk reduction in stomach cancer.

Complicating garlic research is the fact that some researchers use raw garlic while others various supplements or extracts; some supplements have not been thoroughly tested and may vary considerably in their content.

Ideally, said Milner, eating one-third of a garlic clove a day (about 1 to 3 grams) is a reasonable goal. “The bottom line,” he said, “is that, to get the benefits, that’s enough. You don’t have to go to exaggerated amounts.”

Although garlic is usually safe, it can interfere with certain medications, in particular anti-viral medications used for HIV/AIDS. Since garlic is also a natural blood thinner, pregnant women should probably not consume too much garlic, the National Cancer Institute website notes, nor should people taking prescription blood thinners and those about to undergo surgery.

(This post was originally published in WBUR’s CommonHealth blog, 8/16/13)

You may be in for a shock if you try to get a prescription for any controlled substance – from Ambien to opioid pain relievers – filled at Walgreens anywhere around the country.

Walgreens recently announced what it calls a new “Good Faith Dispensing” policy under which the pharmacy giant – the largest in the nation – is suddenly requiring its pharmacists to take “additional steps” to verify prescriptions for controlled substances.”

This process, the company says, “may, at times, require” the pharmacist to contact the prescribing doctor to make sure the diagnosis, the exact billing code, the expected length of therapy and “the previous medications/therapies tried and failed” are correct.

In plain English, this means that Walgreens pharmacists are going to call your doctor, or at least your doctor’s office, to see if your doctor did the right thing in giving you a prescription for pain relievers and other drugs. The policy is provoking distress and outrage among pain patients, physicians and others.

In a telephone conversation, a Walgreens spokesman denied that the aggressive new policy was specifically triggered by the Drug Enforcement Administration’s crackdown on the company in the wake of problems with infamous “pill mills” in Florida. Until recently, unscrupulous “patients” and unscrupulous doctors in Florida have colluded in diverting massive quantities of prescription pain relievers such as oxycodone (an ingredient in OxyContin) through fake clinics dubbed “pill mills.”

In June, Walgreens and the DEA announced an $80 million settlement to resolve the government’s charges that Walgreens failed to control the sales of opioid pain relievers in some of its stores.

The government said that distributors of pain relievers failed to monitor suspiciously large orders for opioids Necessary as that crackdown was, a presumably unintended result is that legitimate pain patients are finding it harder to get the medications they need.

Walgreens spokesman Michael Polzin told me that he was not sure precisely when the company’s “Dear Valued Prescriber” letter spelling out the new policy went out, adding that he thought it went out in April or early summer. (There is no date on the letter itself). The date of the DEA settlement was June 11, 2013.

Although pain patient advocates worry most about getting prescriptions for opioid pain relievers, Polzin confirmed that the letter actually stipulates new procedures for all controlled substances. In theory at least, that could make it harder for patients to get prescriptions for other drugs such as Restoril, Halcion, Sonata, Ambien and Lunesta.

Asked why Walgreens is taking this action now, Polzin said, “There’s been, as is well known, a sharp rise in the abuse of prescription painkillers in recent years and health care professionals of all practices are being asked to find better ways to make sure those medications are used for legitimate purposes.”

Asked specifically if the $80 million settlement imposed by the DEA triggered the company’s actions, Polzin said, “We actually imposed our Good Faith Dispensing policy before that settlement. We have done a number of things before reaching the agreement with the DEA to make sure we were fulfilling the obligations for dispensing controlled substances and making sure that our training and pharmacy staff were where they needed to be.”

He acknowledged that the new policy may mean that getting prescriptions filled “could take extra time – it does require us at times to get information from physicians’ offices.”

Whatever the motivation by Walgreens, the American Medical Association is furious. In a resolution in late June, an AMA committee chaired by Iowa dermatologist Marta van Beek called the Walgreens’ policy a direct “intrusion into medical practice.”

As the AMA committee put it, “pharmacists are not and under no circumstances should be required to confirm the appropriateness of a prescription; this decision is a purely medical one, completely in the purview of the treating physician.” The policy “will be very disruptive to physicians’ practices, interrupting visits and procedures and delaying other patients’ care.” The Walgreens policy may also seriously delay “delivery of medications to all patients.”

Van Beek added, in an email to me, “The physician-patient relationship is focused on the patient’s disease and how best to treat it in the context of the patient’s health and social factors. A pharmacy does not have this perspective.”

US Representative Michelle L. Grisham, a Democrat from New Mexico and a former secretary of health in that state, is also worried that the Walgreens’ policy “is endangering the health and safety of patients by delaying the filling of opiate prescriptions.” The policy may force patients “to go to multiple pharmacies to fill prescriptions, which could put patients in jeopardy with state Prescription Drug Monitoring Programs, she said in a letter to the New Mexico Board of Pharmacy.

In a telephone conversation, Grisham went further: Walgreens “policy is very over-reaching..[they] are vilifying the patient, which is outrageous.”

Pain patient Cindy Steinberg, national director of policy and advocacy at the Connecticut-based US Pain Foundation, acknowledges that “a pharmacist “is entitled to look for the authenticity of a prescription.” But, she told me, “this is now going over the line into judging the appropriateness of a prescription. That is outside pharmacy practice. They can’t question whether a physician can or should institute this therapy…“this is very harmful for people with pain who are simply trying to get their medications so they can have some quality of life.”

The new Walgreens policy is creating particular problems for pain patients in Florida. One South Florida chronic pain patient, Julee Payne, wrote me that she has filled her prescriptions with Walgreens for over 10 years. But now, she said, “we’re expected to drive around for hours to find a pharmacy who will/can fill our medications…”

The result of the new Walgreens policy, she said, is that pharmacists “have been given the absurd task of policing the doctors on top of everything else….It is truly a public health crisis here.”

(This post was originally published in WBUR’s CommonHealth blog, 8/12/13)