206. Socially-Acceptable Addiction

If I could buy stock in caffeine, I'd do it; caffeine's PR on such a rise lately:

1. increased athletic performance with increased adrenaline and access to body fat (= energy)

2. increased memory and general cognitive function

3. decreased risk of neurodegenerative diseases such as Alzheimer's and Parkinson's

4. decreased risk of some types of cancer, diabetes, some liver disease, kidney stones, strokes

These findings are based on association studies, as in let's study people with higher intake of caffeine (read coffee drinkers) and look at their health and athletic/academic performance.  But is it the caffeine, or the coffee, or some other yet to be identified factor?

All I know is that when I am driving long distance or need to be alert for a long afternoon clinic or night call, I pop a 200mg caffeine pill.  One of my partners apparently favors the 188mg caffeine Java Monster, about the same as coffee, which can range from 100 to 300 for a 12 oz cup, compared with 25-50 for tea or 40 for a Diet Pepper or Diet Coke (from caffeineinformer.com).

Spoiler alert: those who find that caffeine has lingering effects (say more than 4-6 hours), may be "slow metabolizers," due to a variant of the CYP1A2 gene, which increases risk of heart attack and/or hpertension with more than two cups of coffee daily. 

205. At A Shower?

I met Melinda for an IUD removal, which appeared to have migrated and penetrated the uterine wall, causing pain.  Though usually simple--just a gentle tug, this malpositioned IUD could be a problem. It seemed to come out easy enough but she experienced moderate discomfort. But it was out.

Then the retrospectively questionable decision to insert a new one at the same visit--she did need contraception, after all.  This insertion was painful and a week of persistent pain led to the IUD removal.

Unexpectedly the pain continued.  Blood tests did not show any infection, nor did an ultrasound reveal any abnormality. The patient requested increasing amounts of narcotics, as many as 70 tablets in one month.  With no explanation for the pain and with a history of opioid addiction, we decided to limit narcotics, first to 40 per month, then 30, and so on.

That's when she came and said her purse, with all the pills in it, had been stolen while at a friend's baby shower.  We've heard stories of pills being lost when a patient stood over a toilet while shaking a few out of the vial, and of pills stolen from a locked car or from a high alcohol density weekend party. But at a shower?

Whatever, during these tapering down or in some cases steady state prescriptions, we make it very clear that no early refills will be made no matter what.  We call that a pain contract.