His health, her health

Medications affect women differently than men but you wouldn’t know it from prescribed drugs.

Take the sleep drug Ambien, for example.  After the drug had been placed on the market, it was found to have a dramatically different effect on women. The U.S. Food and Drug Administration found that five times as many women were experiencing driving impairment eight hours after taking the drug. As a result, doctors now prescribe “sex-specific” Ambien which is a lower dose. In Canada the drug is sold under the name Sublinox. But sex-specific prescriptions are the exception rather than the rule.

Doctors prescribe the same drugs for men and women even though they have only been tested on men. Researchers have known about this weakness of drug trials for a long time. Dr. Marcia Stefanick, professor of medicine at Stanford University explains:

“Indeed, drug metabolism, tolerance, side effects and benefits differ significantly between the average man and woman for many widely prescribed medications, with women having a 50 to 70 per cent higher chance of adverse reaction (Scientific American, September, 2017).”

Despite knowing of the difference, few women are included in trials. In a review of 258 trials of cardiovascular treatments, only 27 per cent of the participants were women, and of those only one-third were reported by sex.

Despite years of “Red Dress” campaigns, most people and many physicians still think heart disease is a man’s disease. They are surprised to learn that heart disease is the number-one killer of women, far exceeding deaths from breast cancer. Physicians are less familiar with the symptoms of heart disease in women. In men, the main symptom is chest pain, whereas in women symptoms can include back pain, nausea, headache and dizziness. Women’s symptoms are seen as “atypical” because men don’t report them.

Chauvinistic blindness excludes half the population.

Heart disease also involves the build-up of plaque in the arteries. Men, and older women, tend to suffer from a blockage in one location. Younger women are more likely to have diffuse plaque along the entire artery with the same effect. Because a local block is not found in a younger woman, she could be diagnosed as “free from of heart disease” even though at risk of a fatal heart attack.

The other sex is sometimes overlooked in trials. Men are often neglected in studies for ailments thought to be unique to women. Osteoporosis, characterized by reduced bone strength, is considered a woman’s disease because white women are twice as likely to suffer a bone fracture as white men. As a result, fracture prevention trials include few men. But one-third of hip fractures are in men –and they have worse medical outcomes than women

Men are more susceptible to viral, bacterial, parasitic and fungal infections than women; the exception being sexually transmitted infections such as HIV and herpes which is more prevalent in women. However, women’s resistance to infection comes at a price. Women constitute 70 per cent of cases where a robust immune system attacks her own body in autoimmune diseases.

Professor Stefanick lauds the Canadian Institutes of Health Research for promoting the inclusion of sex and gender in drug trials and wishes the U.S.  Government would do the same. She adds:

“We need further mandates, through policy and funding restrictions, to ensure that female biology makes it into textbooks and testing protocols.”

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Doctors beware: this opioid is not listed

Doctors rely on Canada’s Controlled Drugs and Substances Act as a guide in prescribing drugs. Tramadol is not listed there but that could change soon.

image: Tramadol dropshipper

Tramadol is a sneaky drug, as Dr. David Juurlink discovered when a patient with a shoulder injury was prescribed tramadol. On the positive side, tramadol relieved the shoulder pain. Then problems starting showing up says Dr. Juurlink:

“The first sign of trouble arose three months later. His shoulder pain gone, the patient assumed he no longer needed tramadol. He was wrong. Shortly after stopping it, he developed debilitating insomnia, shakes and back pain – something he’d never experienced before. Irritable, exhausted and functioning poorly at work, he soon found the solution: All he needed to do was keep taking tramadol, and these problems went away (Globe and Mail, November 27, 2017).”

There are two outcomes of being hooked on drugs. One is a physically dependence, such as exhibited by the above patient. The other is addiction in which a patient’s health deteriorates and their behaviour is transformed –what we usually think of as addiction. This patient needed the drug for no other reason than to avoid the debilitating effects of not taking the drug.

The reasons why tramadol is not listed are complex. First, the way that it affects patients depends on their genetics. Tramadol acts as if it were two drugs. It relieves pain using the same mechanism as aspirin does but for some with a particular enzyme, it converts to an opioid. Only 6 per cent of Caucasians have the enzyme, whereas 30 per cent of those of East African or Middle Eastern decent will experience opioid conversion.

Tailor-made drugs, specific to a patient’s genetics, hold future promise. That would allow doctors would know in advance whether a patient has the enzyme or not. For now doctors roll the dice in prescribing tramadol.

Second, when Health Canada last reviewed tramadol in 2007, during the era of the Harper government, a libertarian regime affected policy. Manufacturers of tramadol lobbied Health Canada directly and indirectly to keep the drug off the list. Manufacturers peddled the “dual mechanism of action” of tramadol without disclosing just what that meant. Indirect lobbying came in form of financial support to at least one patient advocacy group who wanted to keep the drug freely available.

The Holy Grail of pain-killers would be one as effective as opioids without the side effect of addiction. Researchers have been looking or more than a century. The German drug company, Bayer, marketed a cough suppressant derived from morphine under the trademark Heroin in 1895. It was marketed as being non-addictive.

More recently, OxyContin was marketed as a pain-relief drug “without unacceptable side effects.” Doctors believed that they were prescribing a safe drug but OxyContin proved otherwise. Patients who took it for pain relief got hooked and when prescriptions ran out, they went to the streets in search of substitutes.

Under the Trudeau government, Health Canada is considering placement of tramadol under the Controlled Drugs and Substances Act –where it belongs. Whether it is listed or not will be a test of a government’s resolve to put the health of Canadians above commercial interests.

Legalize all drugs

Don’t use drugs. If these two statements seem contradictory, it’s understandable. Legalization is approval. And since drug abuse is a problem, why approve drug use?

The flaw in this argument is that drug abuse in not a legal problem, it’s a medical and social problem. It wastes lives and is a burden on our health care system; it destroys families; it consumes the time and resources of law enforcement agencies.

we want beer

Prohibition is a well-intentioned initiative but it doesn’t work. As we discovered in the case of alcohol prohibition, booze was simply driven into the hands of criminals and organized crime who waged war against rivals.

Warring cartels and gangs in Mexico alone killed 120,000 in the years 2006 to 2013. That’s forty per cent more deaths than all the deaths due to illegal drug use in the U.S. according to data from the Center for Disease Control.

Guns in Canada are a serious problem. In the same period (2006 – 2013) there were approximately 1500 gun homicides in Canada. Not exactly the carnage that Mexico is experiencing  but that’s not the point: just because guns result in death and injury, no sensible person would suggest making them illegal.

What does make sense is the regulation of guns. Gun owners must obtain a Possession and Acquisition Licence and renew it every five years. Education makes sense. As a general rule, applicants must have passed the Canadian Firearms Safety Course.

Tobacco in Canada is a serious problem. In the same period, 259,000 Canadians died due to tobacco-related diseases according to the Canadian Cancer Agency. Education has reduced the number of Canadians who smoke from fifty to less than fifteen per cent.

Politicians have agreed for decades that education is key to harm reduction. As one of the founding members of the Calgary chapter of the Alberta Legalization of Cannabis Committee in 1976, I received letters from all leaders.

In his letter, then leader of the opposition Progressive Conservative party Joe Clark wrote: “In my view, a drug education programme would be far more beneficial and economical in attacking the problem than using law enforcement agencies and the courts.”

NDP leader Ed Broadbent thought that marijuana should be removed from the Criminal Code and placed under the Food and Drug Act and added: “I would agree with your statement that it does not appear to have any worse impact than alcohol.”

Prime Minster Trudeau wrote that his Bill S-19, one that would remove marijuana from the Food and Drug Act, died on the order paper but his government was pursuing the bill. “[My government] is working to make certain the legislation we introduce strikes a proper balance between concerns over the personal and social effects of penal laws aimed at discouraging its use.”

Time has stood still for the last four decades. Regressive Canadian governments have preferred to pander to misconceptions such as the “war on drugs,” or “prohibition works.”

Meanwhile the U.S., a place we think of a bastion of conservative thought, has leapt ahead of Canada. Now some states, such as Washington, have legalized the sale of marijuana. I just returned from Seattle and didn’t notice any reefer madness in the streets.