Does Oxygen Addiction Exist?

Ok, I know, the joke’s on me. We’re ALL addicted to oxygen, after all it’s in 21% of the air we breathe (if this is not the case, please check your location, you may be on the wrong planet). We all need oxygen physiologically, but I’m talking about psychologically. There are those patients that know, I mean absolutely know, that oxygen seems to make their dyspnea better, even though a check of their pulse oximetry shows an oxygen saturation of one-hundred percent even when exercising. So back to my question, does this mean that they are psychologically addicted to oxygen, or does the supplemental oxygen actually fulfill an as yet unknown physiologic purpose?

Ever since two studies in the early 80’s (one which showed an  overall increased survival with oxygen use, and another which showed a benefit with continuous oxygen over nocturnal use), supplemental use of oxygen for people with low oxygen levels has been considered standard of care. The current cutoff for an acceptable level of oxygen in a stable patient is, in general, eighty-nine percent (though there are always exceptions, let’s be clear, that I am talking about ambulatory oxygen in otherwise stable patients, and not about a hospitalized patient who is having a heart attack). For the most part, insurance companies will not pay for ambulatory oxygen therapy unless it is documented that their oxygen hits the magic number of 88, as we know that’s when the hemoglobin saturation curve starts to fall down a steep cliff. Or perhaps it’s because that’s when the Dr. Brown’s Delorean takes off. Either, one, I can’t quite remember.

Anyway, as I was saying, there is no known benefit to using oxygen when the measured levels are normal. And come to think of it, I don’t know of any data showing beneficial effects of its use in those with COPD whose oxygen saturation drops only with exertion (a common scenario where it is prescribed). Yet, many patient often insist on the continuation of oxygen even after it is explained that it is no longer medically necessary. To date I know of no study that shows beneficial effects of adding ambulatory oxygen to people with normal oxygen levels. One study compared forced air with oxygen in people with normal oxygen levels and found no reductions of subjective dysnea. Currently, the LOTT study is underway to see if ambulatory oxygen may be beneficial in patients with COPD and low-normal levels of oxygen. In addition, there are possible negative effects of oxygen, including the possibility of carbon dioxide retention, potential oxygen toxicity, and the hazards of transporting  and storing the stuff. Not to mention the dangers of  having inflammable substance being used by a smoker.

However, in my experience, patients who really feel that the oxygen is helping them with dyspnea do not care about these ideas, and are resentful about their physician talking about discontinuing it. Given that there is no data to continue the use of supplemental oxygen in those with normal oxygen levels, does their insistence in fact represent a form of addiction? I often see patients who refuse oxygen because of their misconception that their body will ‘get used to it’ and that they will not be able to get off of it. Thus far, I have brushed aside these concerns as there is no known physiologic basis for this. I wonder if perhaps I should consider the possiblity that their bodies might not get used to it, but their brains might.

.

EMR and the Loss of Eloquence

Much has been made of the downside of the increasing use of EMR systems by physicians. But I am not going to  dwell on those pervasive complaints concerning the cost and complexity of setting up the systems. Nor shall I rehash the well known issue of what I call “doc blocking”. . . wherein a computer (or other entity) stands between the patient and physician, slowing the exchange of information to however many words can be typed per minute. No there’s another more pressing issue to me personally that is rarely discussed in regards to use of the EMR. The loss of eloquence. Continue reading “EMR and the Loss of Eloquence”

Healthcare Armageddon 5: The Crux of the Problem

There’s a central theme running through many of these “Truth About Health Care” posts that I write. Whether it comes to medical centers putting out press releases that are nothing more than thinly veiled advertising, or drug companies trying to get physicians to write more prescriptions, it comes down to the fact that there’s a whole lot of competing interests out there trying to get a bigger slice of a shrinking money-pie. And the pie is about to shrink a whole lot faster. . . Continue reading “Healthcare Armageddon 5: The Crux of the Problem”

The Medical Press Release

Pass the pills please!

 You may have noticed the rash of medical news spewing from your favorite news outlets with greater frequency. As a medical professional you probably cringe as you envision the calls that are about to flood your office, “Doctor Smith, I heard a report on the news that this drug you prescribed to help me quit smoking is bad for my health!” or,   “I want a referral to The Hoffenheimer Institute to get peduncular ray beam therapy for my hypertension, they are reporting great results!” And, like me, you probably curse the media, as the stream of bogusness is regurgitated in high def.  My advice? Don’t hate the game, hate the players. Continue reading “The Medical Press Release”

Update: Lunch money Pharma spends on physicians

This post at KevinMD has blown up and is generating significant interest.

Since writing it I was contacted by CNN, they talked about wanting to do a series on America’s addiction to medications and what sounded to me like the various excesses of drug companies to try to get people to take those medications. They wanted me to comment on the various excesses of Pharma from a physician’s perspective. They were interested in hearing about all the things the drug companies give us, specifically,  free stuff, give-aways, trips,  golf outings. . . you get the point. I explained that I had no experience with such things, nor did I know of anybody who had, and probably was not the right person to talk to.  

I feel like in this discussion, we private practice physicians are guppies in a big ocean. The occasional office lunch amounts to essentially (excuse the pun) small potatoes compared to the influence that pharma has had on the opinion makers, and subsequently, in the drafting of practice guidelines (such as recent lipid guidelines or the use of activated protein C in sepsis). In this, the influence is insidious; it exists largely in rooms that are closed to the rest of us. The influence is not nearly as extroverted and obvious as CNN (and the rest of us) would like to see.  However, I agree with many of you that having drug reps bringing lunch into the office at the very least gives the impression of influence, and may not be a practice that we as physicians can defend much longer.  In retrospect, I wished I had agreed to the interview with CNN, only for the sweet irony of my interview being followed by a commercial featuring two elderly people sitting in bathtubs on top of a hill.  .  .

Healthcare Armageddon 3: Washington Argues Over Grandma’s New Shoes.

It started with The House of Representatives’ symbolic gesture of their disdain of all things Obama-care. It continues with the current bickering over fiscal policy in Washington D.C. Thus goes a debate that is destined to lead the country nowhere because it does not deal with the core of the problem. Continue reading “Healthcare Armageddon 3: Washington Argues Over Grandma’s New Shoes.”