After Ketamine for pain, complaints of depression dropped in half & pain reports were lower

05/03/2017 — Nancy Sajben MD

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KPBS Radio highlighted a new study today by UCSD School of Pharmacy

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San Diego Scientists Find Further Evidence A Club Drug Could Treat Depression

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In a new analysis published Wednesday in the journal Scientific Reports, UC San Diego researchers said millions of FDA side effect records reveal that people who took ketamine for pain relief reported lower rates of depression.

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“The occurrence of complaints about depression dropped in half after ketamine administration,” said UC San Diego Skaggs School of Pharmacy professor Ruben Abagyan, who led the study.

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The researchers focussed on the FDA’s Adverse Effect Reporting System, a database that tracks negative side effects among people who take various drugs. But the researchers were not primarily interested in bad outcomes.

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Instead, they looked for a positive outcome: declining rates of depression among people taking drugs not typically thought of as antidepressants.

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They found signs that other common drugs — including Botox, a pain reliever called diclofenac and the antibiotic minocycline — also reduced depression among patients in the FDA database.

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[minocycline is a glial modulator and it can prevent CRPS from spreading.]

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University of Miami psychiatry professor Charles Nemeroff wrote that the study was, “very interesting.”

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“The findings are of considerable interest. However the interpretation of the findings are key,” he wrote, saying it will be important to understand whether ketamine is directly treating depression or simply relieving pain, which can indirectly help people experience less depression.

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The UC San Diego researchers said they controlled for this variable by comparing people who took ketamine with those who took other pain medications. They said they still found a larger drop in depression among those who took ketamine.

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This is the open source (free) article in Nature with brief excerpts below:

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Population scale data reveals the antidepressant effects of ketamine and other therapeutics approved for non-psychiatric indications

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.Isaac V. Cohen, Tigran Makints, Rabia Atayee, Ruben Abagyan

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We found that patients listed in the FAERS database who received ketamine in addition to other therapeutics had significantly lower frequency of reports of depression than patients who took any other combination of drugs for pain (LogOR −0.67 ± 0.034) (Fig. 1c). This reduction in depression is specific to ketamine and is known to be much more rapid than current antidepressants, making this observed effect very promising for treatment of patients with acute depressive or suicidal episodes. These patients cannot afford to wait up to six weeks for reductions in their depressive symptoms. Pain reports were also significantly lower for ketamine patients (LogOR −0.41 ± 0.019) (Fig. 1c).

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The analysis of the whole FAERS database revealed several other unintentional depression reducing drugs among antibiotics, cosmeceuticals and NSAIDS (Fig. 2). Our data supported previous studies that observed the psychiatric polypharmacology of minocycline [my emphasis], a tetracycline antibiotic14 (Fig. 2). The NSAID, diclofenac [that has highest incidence of heart attack and cardiac arrhythmia of any NSAID], was also observed to have some antidepressant properties (Fig. 2). It is theorized that both of these drugs may accomplish antidepressant effects through an anti-inflammatory mechanism. Because of the antidepressant activity of several NSAIDs, we further separated the non-ketamine pain cohort. Ketamine patients were then compared to patients who received any other combination of drugs for pain excluding NSAIDs. It was observed that depression event rates remained low (LogOR −0.56 ± 0.035) (Fig. 2)..The reduction of depression rates in ketamine patient records makes a case for study of ketamine as a psychiatric drug. These results imply that ketamine may be further explored as a monotherapy or adjunct therapy for depression. It should also be noted that FAERS data revealed that ketamine use [may] lead to renal side effects and awareness and caution in patients with renal or hepatic impairment may be warranted (Fig. 1a and b). [my emphasis].

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As an important side note, we also evaluated efficacy and side effects with the use of ketamine for pain management. We found that patients who were on ketamine had reduced opioid induced side effects including constipation (LogOR −0.17 ± 0.023), vomiting (LogOR −0.16 ± 0.025), and nausea (LogOR −0.45 ± 0.034) than patients who received any other combination of drugs for pain indications (Fig. 1d). Our data supports ketamine’s opioid-sparing properties and alludes to the fact that patients may receive benefits of improved pain, reduced requirement of opioids, and ultimately less opioid reduced side effects.

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The results of this study support previous small scale studies’ conclusions that ketamine is a good monotherapy or adjunct therapy for depression. In clinical practice ketamine would be especially useful for depression because of the quick onset of its action compared to existing first line therapies. Regardless of the causative mechanism ketamine appears to have therapeutic potential for TRD. Further, the potential to reduce many of the most complained side effects of opioid treatment makes ketamine adjunct therapy for pain seem desirable.

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Overall, this study demonstrates that the therapeutic potential of ketamine can be derived from appropriate statistical analysis of existing population scale data. This study also outlines a methodology for discovering off label pharmacology of existing approved drugs. This method can be applied to other indications and may reveal new important uses of already approved drugs, providing reliable justification for new indications without large investments in additional clinical trials.

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FDA Adverse Event Reporting System. The FAERS database was created to support FDA’s post marketing surveillance on drugs and biologic therapeutics. It contains adverse reaction and medication error reports sent to the FDA through MedWatch, the FDA Safety Information and Adverse Event Reporting Program. Reporting is voluntary and is done by patients, family members, legal representatives, doctors, pharmacists and other health- care providers. If any party reports an adverse effect to the manufacturer, the manufacturer is legally obligated to forward the report to the FDA. Data is available online in quarterly format for AERS from the first quarter of 2004 to the third quarter of 2012 and for FAERS from the fourth quarter of 2012 to the first quarter of 2016.

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The study used over 8 million adverse event reports from first quarter of 2004 to the first quarter of 2016. All the quarterly files from 2004 to 2016 were combined into a master file which was used as the primary source for analysis. . . .

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Out of 8 million reports, 279,853 reports were used for analysis of ketamine in Fig. 1. Two cohorts for ketamine (K) patients and pain (P) patients with 41,337 and 238,516 patients respectively....

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Posted in Adverse Effects, Chronic Pain, Depression, Glial Modulators, Ketamine, Major Depressive Disorder, Minocycline, Uncategorized. Tags: , , , , , , . Leave a Comment »

Naltrexone in Low Dose Reduces Pain & Depression

03/12/2017 — Nancy Sajben MD

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We’ve known LDN helps pain since the turn of the century. Stanford could really shake the research world if they trialed LDN for Major Depressive Disorder, not the depression that improves with less pain, or in Multiple Sclerosis clinics or the Parkinson’s or Inflammatory Bowel Disease clinics. Is it too much to ask for better quality clinical research, not just results of patients responding by click or touch on a computer touch pad?

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The astonishing promise of low dose naltrexone (LDN) research remains in its infancy since 1984, 33 years ago, when it was discovered to offer profound clinical relief for multiple sclerosis and other serious conditions. I have prescribed naltrexone in ultra low and low dose since 2003, and discussed its central anti-inflammatory glial modulating mechanisms in 2009:

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Low dose naltrexone, or LDN, has been prescribed “off label” for persons with many conditions including intractable pain, chronic fatigue syndrome, complex regional pain syndrome, RSD, Multiple Sclerosis, Parkinsons Disease, IBS, inflammatory bowel disease, autoimmune diseases and Crohn’s Disease to mention only a few. Low dose naltrexone is not a cure but may be potentially helpful for selected persons with these conditions. It appears to have little or no toxicity at this low dose – a few persons report transient insomnia, nausea or vivid dreams.

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The same year in 2009, soon after my post on LDN, Drs. Younger and Mackey of Stanford Pain Center reported a double blind study of low dose naltrexone in persons who had fibromyalgia more than 10 years and showed 30% improvement in pain and fatigue.

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In 2016, five Stanford authors including Dr. Mackey published a poster presentation. At least the 2009 study was double blind; not this one. It was open label.

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A novel glial cell inhibitor, low dose naltrexone, reduces pain and depression, and improves function in chronic pain: A CHOIR study

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Poster presented at: Annual Meeting of the American Pain Society; May 11-14, 2016; Austin, TX. Poster 418.

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Authors: K. Noon,  J. Sturgeon, M. Kao, B. Darnall, S. Mackey

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Stanford University Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford, CA

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Funding received from NIH and the Redlich Pain Endowment

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NIH funding should lead us forward, not back to a single open label study. One would hope Stanford would do the larger study they recommended 7 years ago. This adds to the CV of five researchers, but

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  • does it help millions with chronic intractable pain?

  • does it add to the growing body of clinical LDN experience worldwide?

  • when will the mechanism and uses of LDN, the TLR4 receptor and the powerful innate immune system be taught by healthcare providers in academia, in practice, and in pharmacies, not just in basic science?

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The poster highlights the Stanford CHOIR Information Registry (discussed below), but provides almost nothing new despite the computing power of CHOIR that likely cost small fortunes. Patients are asked to enter clinic data into a convenient handheld click- or touch-based input device. What could be easier? We look forward to better studies from Stanford’s CHOIR devices and we long for the days when doctors publish better data that addresses the disabling pain, depression and needs of millions of our patients with chronic intractable pain.

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Stanford’s CHOIR Information System

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“We modified and implemented an existing, web-based system that administers computer-adaptive PRO questionnaires, called the Collaborative Health Outcomes Information Registry (CHOIR).  Next, we developed a messaging interface to send PRO results from CHOIR to the UF Health Epic EHR.

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The CHOIR system was developed at Stanford University by a team of informaticists and physicians who provided a no-cost license for our implementation. CHOIR utilizes a client-server architecture with web-based clinician and patient interfaces that use open source technologies, including jQuery mobile and Google Web Toolkit. Users can access CHOIR via web browsers on desktop or mobile devices. The primary patient user function is the completion of computer-adaptive PRO assessments using a click- or touch-based input device ( Figure 1 ).  Clinical user functions include registering patients to complete a PRO assessment, reviewing individual and summary PRO assessment results, longitudinal outcomes tracking, and clinical decision support through the aggregation of PRO result sets.”

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.The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~

This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Posted in Chronic Pain, Depression, Glia, LDN, Low Dose Naltrexone LDN, Naltrexone, Pain. Tags: , , , , , . Leave a Comment »

Microbiome, Metabolome & Disease

01/18/2017 — Nancy Sajben MD

 

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Many of us have followed the research in this field for health, happiness and well-being. Today’s questions and answers from an expert on microbiota in Reddit Science is of great interest and something I wanted on these pages for future reference. I sifted through the pages to condense the questions, leaving answers intact. AMA is short for Ask Me Anything. Where Professor Barrett’s  responses to questions are clear, I have omitted the questions; where not clear, questions are abbreviated and/or added. I am sure we would all like much more information on inflammation and the inflammasome, the gut and brain and health. Support science. Be careful of low quality journals and quackery. She says even some yogurts have no bacteria.

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Science AMA Series: I’m Kim Barrett, Professor of Medicine at the University of California, San Diego and Editor of The Journal of Physiology. This week, we published an issue on the microbiota [editorial free], so I thought it would be a great opportunity to discuss how our microbes influence our well being. AMA!

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This is her main message, again and again:

[–]Kim_Barrett

Eat a well-balanced diet, including cultured/fermented foods, and avoid excessive fat and processed carbohydrates..

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[–]Kim_Barrett

Thanks to both. There is a lot of epidemiological evidence for the health benefits of all of these fermented foods, which may deliver bacteria similar to probiotics as well as beneficial metabolites that have greater bioavailabilty. These foods have been consumed by humans for millennia but were less prevalent in the diet as society discovered refrigeration etc. But studies to actually prove efficacy and mechanisms of action remain in their infancy. This is an area where the National Center for Complementary and Integrative Health is placing a lot of emphasis for research funding.

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Q Nose/sinuses:

[–]Kim_Barrett

Yes, this is a less appreciated area but rapidly growing area of study. I definitely would encourage you to look at our special issue of the Journal of Physiology, which has short reviews on the oral, skin and vaginal microbiota. Our external cavities all have their own distinctive microbiotas, but in aggregate they may encode many of the same sorts of metabolic capacities as seen in the gut. The specific populations may also depend on the type of environment – for example, the bugs on your forearm are different from those on your forehead. Lots more work to be done.

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there is not a simple way currently of knowing about our microbiota’s composition, but general indices of gut health may give some clues. Likewise, finding effective probiotics may be a bit of a case of trial-and-error, but there is good epidemiological evidence for a beneficial effect of fermented foods like Kombucha.

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Q on IBS:

[–]Kim_Barrett 

Serotonin is a major controller of gut motility and sensation, and alterations in serotonin signaling have been documented in irritable bowel syndrome. The cells that make serotonin in the gut have been shown to express receptors for short chain fatty acids (SCFAs), which are major products of bacterial metabolism of undigested carbohydrates. Finally, some gut bacteria metabolize the serotonin precursoe, tryptophan, which in turn has implications for the production of appropriate gut levels of serotonin.

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Q:  Sometimes, when I am constipated, I can perceive a certain taste and smell that arrives internally. Have direct nerve connections between the bowel and the brain been identified? What role to microbiota play in perception of satiety? What is the importance of the neurological phenomenon vs the blood chemistry in controlling weight gain or loss?

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[–]Kim_Barrett 

Lots of nerve connections between the brain and gut, and gut nerve endings have been shown to sense bacterial metabolites. To the extent that the microbiota and their metabolites control the secretion of GI hormones, they clearly participate in satiety perception, but this still needs further study. And weight gain/loss is such a complex phenomenon, also encompassing societal and behavioral aspects, that the relative contributions of the factors you mention have not been worked out by any means.

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Good and bad may be too simplistic. A “good” bacteria may be bad for you if in the wrong place. As for substrates and products, this is probably too big of a topic to tackle right now, but I would direct you to the work of Eugene Chang at the University of Chicago who has done a lot of work in this area. Gut permeability is also clearly important. We have done work to show that certain commensal and probiotic species can tighten the gut barrier so that pathogens and toxic metabolites are less able to penetrate and initiate inappropriate inflammatory reactions and a vicious cycle of further weakening of the gut barrier.

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Q   Strong evidence correlates aberrations in gut diversity with certain diseases. Phylogentitcally speaking, it seems to matter more that the microbiome is diverse and less important which species are specifically there. The hypothesis being that the gut microbial metabolome is relatively stable, regardless of specific species present. http://go.nature.com/2iQLOu1

Q1 – Have clinicians started to take the next step, looking at disease correlations with perturbation of the microbial metabolome?

Q2 – If so, what have they found? Do probiotics replace those missing metabolic pathways?

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[–]Kim_Barrett 

Absolutely agree with your comments about the metabolome. However, most of this work at present is still in preclinical models, although there has been a lot of attention to the way in which metabolic pathways change after bariatric surgery, for example.

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Q:

When I was very young, I had a few instances of food poisoning visiting family in Mexico, I even contacted tuberculosis. I, of course, was given many antibiotics. I’ve had a lot of digestive issues since then, it was always a problem. I’m 36 now, and adopted a very low carb diet 3 years ago. During the initial transition, I had, to put it succinctly, severe dhiarrea. Like stuff was probably dieing off. And then, 4 months in, I had more energy, metal alertness, and general feeling of being present. And I no longer had crippling depression. From a completely anecdotal standpoint, I think that changing my diet also drastically changed my gut biome, and that, in turn, actually effected my brain function. It seems like what you’re research has shown is that this isn’t some woo-woo thinking, but an actual thing?

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Q does Kefir boost gut bacteria?

[–]Kim_Barrett

Yes, along with other related foods.

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Q are we discovering new categories of bacteria in the body?

[–]Kim_Barrett 

This was a big sticking point in the field initially since many of the bacteria cannot be cultured. Now they are identified by sequencing. The estimate is that healthy individuals harbor at least 1000 different species. Not to mention viruses, fungi, protea….we’re just getting started, and as you imply, the bioinformatics challenges are huge.

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[–]Kim_Barrett 

There’s quite a bit of evidence that mixtures of different bacteria are more effective than single bacteria. Perhaps they have complementary metabolic functions, or mutually help each other to colonize the gut.

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Q  research of healthy bacteria for auto immune disease?  Crohn’s disease?

[–]Kim_Barrett

Others are exploring a role in asthma.

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Q: studies in which obese mice had received gut flora from lean mice and subsequently lost weight, and vice versa. Does this imply that a microbial treatment for obesity in humans could be developed, and if so, is there any interest in this?

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[–]Kim_Barrett 

A lot of people are looking for just such a treatment!

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please IGNORE THE ADS BELOW. They are not from me.

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Posted in Depression, Inflammasome, Inflammation, Metabolome, Microbiome, Uncategorized. Tags: , , , , . Leave a Comment »

Caffeine May Reduce Age-Related Inflammation, Stanford Aging Study

01/17/2017 — Nancy Sajben MD

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Caffeine may be able to reduce inflammation.

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Inflammatory immune molecules increase as we age and are associated with mortality from all causes, Alzheimer’s disease, stiffening of arteries, hypertension and cardiac disease. Inflammation kills. Yesterday Stanford and colleagues from University of Bordeaux published results of a long term aging study of 114 patients in Nature Medicine (paywall):

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Expression of specific inflammasome gene modules stratifies older individuals into two extreme clinical and immunological states

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For nonscientists, see below. Caffeine may block inflammation. Adenosine and adenine are known to stimulate the inflammasome. Caffeine blocks the effect of adenosine.

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“They found that older people between the ages of 60 and 89 tend to ramp up production of immune molecules in a complex called the inflammasome. That’s a clump of immune proteins inside cells that activate one of the immune system’s big guns, called interleukin 1 beta or IL-1B. It’s an important molecule for fighting off infection, but too much of it for too long has been linked with chronic diseases like heart disease, cancer, and Alzheimer’s disease.

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Among the older people in the study, 12 of them made much more of these inflammatory molecules, and 11 people made much less. The less-inflamed group was also healthier, with lower blood pressure, more flexible arteries, and more relatives who lived past age 90.

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They also had lower levels of the breakdown products of DNA and RNA circulating in their blood, including one molecule called adenine, and another called adenosine — which is adenine attached to a sugar molecule. These molecules are known to stimulate the inflammasome, and lower levels of them could explain why this group was less inflamed. In fact, treating cells with these breakdown products made them churn out more inflammatory molecules, and made mice more inflamed, with higher blood pressure.

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HIGHER BLOOD LEVELS OF CAFFEINE CORRELATED WITH LESS INFLAMMATION

That’s where the caffeine comes in. Caffeine is known to block the effects of adenosine in the brain — that’s how scientists think it keeps us awake. So, the researchers suspected that it’s possible that it could block the effects of adenine and adenosine on immune cells, too, and reduce their ability to cause inflammation. According to a questionnaire, people in the less inflamed group consumed more caffeinated beverages like coffee, soda, and tea. In fact, higher blood levels of caffeine and other caffeine breakdown products correlated with lower production of inflammatory molecules like IL-1B.

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When the scientists treated cells with adenine and another molecule known to trigger the inflammasome, the cells that were soaking in caffeine produced far lower levels of inflammatory molecules. The researchers still haven’t fully explained how caffeine is interfering with inflammation. And the results aren’t enough to base any behavioral recommendations off of; but it’s comforting news for those of us who were already reaching for that second hit of caffeine, anyways.”

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Many articles on pro-inflammatory cytokines IL-1β, IL-6, and TNF-α are found in the setting of chronic pain and in depression:

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IL-1β is an essential mediator of the antineurogenic and anhedonic effects of stress.

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Depressed rodents shown to have inflammation, published by Yale and NIMH a few years ago.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Posted in Addiction, Aging, Alzheimers Disease, Caffeine, Chronic Pain, Depression, IL-1B, Inflammasome, Inflammation, Uncategorized. Tags: , , , , , , . Leave a Comment »

Got no business feelin’ down – Music

12/03/2016 — Nancy Sajben MD

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I got no business feeling down. Music can be fun. Turn on the best. Find your self. Have some fun here. Stop that freekin gloom.

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It will take some work. Words have power.

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Music

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Y’all know the Abyssinian Baptist Gospel Choir don’t you? What do you think they’re singing about? There’s better ways to be happy than to allow the mind to sink back down to the world. It’s the spirit!

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The Beatles, “I Wanna Hold Your Hand. And when I touch You, I feel happy inside. It’s such a feelin that my love I can’t hide. Yeah you, you’ve got that something, I think you’ll understand.”

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Whatever that Infinite is, that Bliss, the only way to know It is to BE It. You already are. You, I, we are infinite. So make happy. You can’t destroy the ones you hate, we gotta love em. They are us. They are god too. You cannot divide infinite by 2, it’s still 2. It’s all Infinite. Just run from the danger gods.

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How to understand this? “The seeds of love I sow, ” Led Zeppelin, Physical Graffiti,”Let music be your master. Will you heed the Master’s call?“

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Ain’t no Judas. It’s all Love. Every last one. You don’t have to worry. It’s a movie. You are infinite, remember? It’s real and it’s a movie all at the same time. Step away for a bit and check out these lyrics I never heard til now.

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Love the Great Spirit, the Infinite, the Absolute, Truth, Consciousness. The world pulls us down. It succeeds! I got no business allowing that. I can do better. Just how to do that is this.

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Led Zeppelin, Physical Graffiti

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Houses Of The Holy  
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Let me take you to the movies. Can I take you to the show
Let me be yours ever truly. Can I make your garden grow
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From the houses of the holy, we can watch the white doves go
From the door comes Satan’s daughter, and it only goes to show. You know
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There’s an angel on my shoulder, In my hand a sword of gold
Let me wander in your garden. And the seeds of love I’ll sow. You know
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So the world is spinning faster. Are you dizzy when you’re stoned
Let the music be your master. Will you heed the master’s call
Oh… Satan and man
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Said there ain’t no use in cryin’ ‘Cause it’ll only drive you mad
Does it hurt to hear him lyin’? Was this the only world you had? oh-oh
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So let me take you, take you to the movie. Can I take you, baby, to the show
Why don’t you let me be yours ever truly.
Can I make your garden grow

you know.

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Kashmir
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Oh, let the sun beat down upon my face
And stars fill my dream
I’m a traveller of both time and space
To be where I have been
To sit with elders of the gentle race
This world has seldom seen
They talk of days for which they sit and wait
All will be revealed
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Talk in song from tongues of lilting grace
Sounds caress my ear
And not a word I heard could I relate
The story was quite clear.
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Ooh, baby, I been blind
Oh, yeah, mama, there ain’t no denyin’
Oh, ooh yes, I been blind
Mama, mama, ain’t no denyin’, no denyin’
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All I see turns to brown
As the sun burns the ground
And my eyes fill with sand
As I scan this razor line
Can I find, can I find where I’ve been
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Oh, pilot of the storm who leaves no trace
Like sorts inside a dream
Leave the path that led me to that place
Yellow desert stream
Like Shangri-la beneath the summer moon
I will return again
As the dust that floats finds you
Will move and search Kashmir
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Oh, father of the four winds fill my sails
Cross the sea of years
With no provision but an open face
Along the straits of fear
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Oh, when I want, when I’m on my way, yeah
And my feet wear my fickle way to stay
Ooh, yeah yeah, ooh, yeah yeah, but I’m down
Ooh, yeah yeah, ooh, yeah yeah, but I’m down, so down
Ooh, my baby, oh, my baby
Let me take you there
Come on, oh let me take you there
Let me take you there back to top
In The Light
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And if you feel that you can’t go on
And your will’s sinking low
Just believe and you can’t go wrong
In the light you will find the road
You’ll find the road
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Hey, ooh, did you ever believe
That I could leave you standin’ out in the cold
Hey, baby, I know how it feels
‘Cause I have slipped through
To the very depths of my soul
Oh, baby, I just want to show you what I’d give you
In case you ever been on the road
Now, listen, oh, as I was and would do for you, too
Honey, as you would do for me
I would share your load, let me share load
Ooh, let me share you load
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And if you feel that you can’t go on
In th light you will find the road
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Hey, oh the winds of change may blow around you
But that will always be so
Oh wo, when love is pain it can devour you
If you are ever alone
I’ll share your load, I will share your load
Baby, let me, oh let me, in the light
Everybody needs a light, oh yeah, oh baby
Everybody, everybody, everybody sure ’nuff they do
Light, light, light, in the light (Repeat)

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Be the witness. Watch the movie, don’t sink into it. It’s only the body. Step away for a few minutes. Be aware of love and consciousness of spirit. Expand consciousness as often as you can. Fill the heart with love. Practice this. Meditate from the heart. We get stuck but sometimes we need to break out some music. You are not the body or the mind. You don’t think God is fun? Infinite is more fun than imaginable, they say. You may have evolved in taste for music, Infinite Bliss has infinitely better, sages say.

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please ignore the ads below. They are not from me.

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Posted in Anxiety, Depression, Music, Uncategorized. Tags: , , . Leave a Comment »

Ketamine in Bipolar Depression – A Review

09/08/2016 — Nancy Sajben MD

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An excellent review of Ketamine, a rapid-acting antidepressant and anti-suicidal agent, in Bipolar Depression

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Efficacy of Ketamine in Bipolar Depression: Systematic Review and Meta-analysis. 

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Parsaik AK1, Singh B, Khosh-Chashm D, Mascarenhas SS.

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OBJECTIVE: To consolidate the evidence from the literature to evaluate the role of ketamine in the treatment of bipolar depression.

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METHODS: Major databases, including MEDLINE, EMBASE, Cochrane, and Scopus, were searched through October 2014, for studies reporting the role of ketamine in the treatment of bipolar depression. Only randomized controlled trials were included in the meta-analysis. We calculated standardized mean differences (SMDs) with SE for each study included in the meta-analysis. A random effect model was used to calculate the pooled SMDs. Heterogeneity was assessed using the Cochran Q test and I statistic.

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RESULTS: Of the 721 articles that were screened, 5 studies that enrolled a total of 125 subjects with bipolar depression (mean age, 44.6+/-4.3y and 65.6% females) were included in the systematic review; 3 randomized controlled trials (69 subjects) were included in the meta-analysis. The meta-analysis showed significant improvement in depression among patients receiving a single dose of intravenous ketamine compared with those who received placebo (SMD=-1.01; 95% confidence interval, -1.37, -0.66; P<0.0001). The maximum improvement was observed 40 minutes after the ketamine infusion. No heterogeneity was observed between the studies (Cochran Q test P=0.38, I=0%). The 2 studies that were excluded from the meta-analysis also showed significant improvement in depression after ketamine therapy. Individual studies also reported improvement in anhedonia and suicidal ideation after ketamine therapy. None of the subjects had serious side effects, and the side effects were similar between the ketamine and placebo groups.

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CONCLUSIONS: This study suggests that ketamine is effective in treatment-resistant bipolar depression and may reduce suicidal ideation and anhedonia.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

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Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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The advertising below is not recommended by me.

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Posted in Bipolar Disorder, Depression, Ketamine, Suicidal Ideation, Uncategorized. Tags: , , , . Leave a Comment »

Veterans Suicides 20 per day – MD not paid in 12 months for 5 approved visits

07/21/2016 — Nancy Sajben MD

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VA Conducts Nation’s Largest Analysis of Veteran Suicide

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Read the report all you want, but for 12 months I’m not reimbursed. And no explanation why. No wonder they can’t get doctors.

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Yet another call just now from TriWest asking me to treat a veteran. VA crisis lines leave vets in limbo. Calls go to voice mail. Veterans have killed themselves just after calls to crisis lines. A lot of these suicides are due to PTSD. Veterans cannot get the help they need.

 

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I believe it is TriWest who won the contract to schedule suicidal veterans who have Treatment Resistant Depression or PTSD or Bipolar Depression. I treat that. It works except in the most extreme cases, in minutes to just a couple days. It’s simple and safe for outpatient use. It has been tested at NIMH and Yale since 1991. The VA-UCSD psychiatrist referred him and then continued care.

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I will not see one more veteran until I am reimbursed for the 5 pre-approved visits for a veteran I treated 12 months ago. He was better in a few days, the first time in decades he had relief of depression. If you cannot pay me who can relieve treatment resistant Major Depression in 2 days, then honey, no wonder you can’t find docs to help. They limited me to their chosen codes for billing. I spoke to psychiatrists who work with veterans and they have never heard of those codes. I guess they just mean loud and clear: NO PAY. Fine. It was a pay cut to offer and took weeks of paper forms, months of approval – you have to really want to do it. With frequent help from a very experienced clerk and a doggedly informed veteran who knew all the ropes, it took months for paperwork to get rushed through. Plenty of doctors just graduating this month don’t know how many months paperwork takes and they won’t get paid.

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San Diego VA has the worst reputation in the nation. I understand it is the San Diego VA that has the worst lag time delays of several months before veterans can even be seen. Worst in the country. Correct me if I’m wrong. And we have a lot more veterans because warm sunny weather is easier on their bones. Is that any excuse to dis-incentivise any doctor by not paying for services?

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The new veterans suicide hotline does not even return all calls. Public Radio just had an expose’ on this one or two weeks ago.

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Twenty veterans take their life daily.

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Only 30% of people with depression respond to antidepressants.

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Based on publications from major academic centers, treatment resistant depression, it seems, is diagnosed after failing as few as 3 or 4 antidepressants.

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Compare any antidepressant to ketamine with potential relief in hours to a couple days.

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It’s not like this is new. In 1991 ketamine was first studied at NIH for depression. Yale has carried the work forward with them. But people live at home and it has to be cost effective. It is unnecessary and/or unaffordable for most people including taxparers to be paying for IV infusions when many or most patients do well on sublingual or nasal use. It is the #1 drug of abuse in China, so don’t just offer it to any person who needs it. Make sure you understand how important glial modulators are in depression. See Yale with NIMH publication on inflammation in depression, I posted on these pages about 3 or 4 years ago when it came out.

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Yale with NIMH had published that ketamine rapidly creates synapses.

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And Yale has published:


Activation of a ventral hippocampus–medial prefrontal cortex pathway is both necessary and sufficient for an antidepressant response to ketamine

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In January 2012, I posted detailed information:

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Depression PTSD – Ketamine Rapid Relief

 

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  • PTSD has a more direct link to suicide than previously thought, a current Texas A&M University study concludes – references below.

  • A high lifetime risk of suicide occurs in women who have been sexually and physically abused as young girls.

  • More than 300,000 veterans have been diagnosed with PTSD or major depression – many not yet diagnosed.

  • Risk of suicide is the highest during the first month of standard antidepressant therapy, and a significant number of patients do not have adequate improvement even after months, resulting in harm to personal and professional lives.

  • Patients are at suicide risk upon discharge from psychiatric hospitals.

  • Significant predictors of both suicide attempts and preoccupation with suicide are guilt and anger and impulsive behaviors.

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  • Ketamine is the most important breakthrough in treatment of major depression with rapid and lasting effects.

  • Ketmine can help immediately, unlike all other antidepressants that may require weeks or months to work, if they help at all. See NPR report here – that appeared soon after I posted this (skip to their last section). It is FDA approved and legal. NPR again reports ketamine’s rapid relief of depression.

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    • The medical literature on ketamine use is profoundly important. There are over 6,800 medical publications. Ketamine has potent healing powers. Karl Jansen, psychiatrist in London, believes that “ketamine has potent healing powers when used as an adjunct to psychotherapy.” There is nothing like it; however, treatment for serious depression still requires team support, not medication only.

    •  The World Health Organization reports that disability to due depression is second only to heart disease.

    • Suicide is a catastrophic medical emergency. I cannot stress this enough. Depression is treatable.

    • Your death is unnecessary. It would be a terrible loss to all who love you.

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Please read that entire post January 2012 before you call to ask questions. The calls are very time consuming.

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There is no reason to restrict life and death matters to one drug, and then make it dependent upon only IV infusions. What kind of life is vegetating in depression for decades? It is a short acting drug. I have posted on why ketamine should never be used alone, but must be used with other glial modulators.

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Most troubling:

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Compounded Medications are Not Covered by Any Insurance

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Most people cannot afford compounded medications, especially if disabled due to Major Depression or PTSD or pain – same medications work on mood and pain.

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TAKE ACTION

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Healthy people can get back their lives. These simple steps can be taught across the nation. Millions are needlessly disabled, especially our young adults who are most vulnerable to these disorders, and several hundred thousand of our young veterans.

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An entire nation can get and breathe relief.

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DO THIS:

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Call your favorite politician and relevant organizations who care about healthcare and veterans to STOP the collusion and restraint of trade since all insurers began refusing to cover compounded medications. All these new $100,000 per year medications are paid for by the taxpayers and your insurance deductible that goes up every year. How long will you be able to afford medical care? How long can this restraint of trade be practiced under our noses unless we take action?

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Get this on the Democratic platform this presidential year. It’s a scam perpetuated by multibillion dollar pharma and their mighty rich contributions to congress who are killing affordable medical care.

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Affordable medical care

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These medications must be compounded. How many can afford $200 to $300 or more cash out of pocket just for medications? Or will this become another safe old drug that is bought by a financier, patented, and now they charge $100,000 a year? You know who pays for everything and it ain’t the 1%.

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Posted in Compounded Medicine, Compounding Pharmacy, Depression, Ketamine, PTSD, San Diego Veterans Association, Suicide, Uncategorized. Tags: , , , , , , , , . Leave a Comment »
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