The People's Pharmacy

This week, we start the show with an interview with epidemiologist Thomas Farley, MD, MPH. His essay in JAMA Health Forum (Aug. 8, 2025) describes why older Americans are dying of falls at an alarming rate.  Once you have a chance to hear why this problem is worse in the US than in comparable countries, we will welcome your calls and stories. Prescriptions for medicines that make people drowsy or unsteady play a major role. Are you taking any? You can call in between 7 and 8 am EDT on Saturday, October 4, 2025, at 888-472-3366. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on October 6, 2025. The Epidemic of Deaths from Falls: Dr. Thomas Farley wrote in JAMA Health Forum that falls kill more Americans over 65 than breast or prostate cancer. If you add up deaths due to car crashes, overdoses and other unintentional injuries in older people, the total is still below the number of deaths from falls. That toll was more than 41,000 in 2023. It has tripled over the past three decades. Why are elderly Americans (particularly those 85 and older) so much more vulnerable to dying because of a fall? Perhaps older people everywhere suffer the same fate. Dr. Farley considered that as a possible explanation. But in other high-income countries that might serve for comparison, the rate of deaths from falls has actually dropped over the past 30 years. One difference that might help us understand what is going on is the rate of prescriptions. After all, older people have always contended with vision problems, physical frailty, cognitive impairment or clutter that is a trip hazard. Those things probably haven’t changed much since the year 2000. Today, though, older people are taking more medications. Older Americans take far more than those living elsewhere. Which Drugs Increase the Risk of Falls? Not all drugs increase the risk for falls. From 2017 to 2020, Dr. Farley points out, 90% of seniors were taking prescription meds, and 45% were taking drugs considered “potentially inappropriate.” Many of those could be termed Fall-Risk Increasing Drugs, or FRIDs. Are you taking any? Any medicine that interferes with balance or causes drowsiness is probably a FRID. Dr. Farley points to four categories in particular: opioids to treat pain, benzodiazepines for anxiety, antidepressants and gabapentinoids used off label to treat pain. (These are gabapentin, aka Neurontin, and pregabalin, known by the brand name Lyrica.) Other medicines, such as beta-blockers for heart conditions or anticholinergic drugs like diphenhydramine, can also cause problems. The overwhelming majority of older folks injured during a fall were taking one or more FRID at the time. Some of the medicines we are discussing are also covered by the American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults.  Any prescriber caring for people over 65 should be able to check whether the drug they are contemplating is on the Beers list. They may also want to consider whether there might be a less risky alternative. If you are accompanying an older relative, you could ask about that. Occasionally older patients are reticent about asking questions for fear of offending the prescriber. Beyond the Usual Suspects: It is hardly surprising that opioids would be related to a risk of falls. There are, however, other medicines that might be a problem in some circumstances. Blood pressure pills may cause dizziness, especially when a person first stands up. Certainly high blood pressure needs to be treated, but perhaps patients should consider trade-offs in terms of how aggressively to pursue perfect blood pressure numbers. Another medication that has been associated with falls, surprisingly, is the combination of atorvastatin to lower cholesterol and insulin for diabetes (Gerontology, Sep. 2, 2025). Call in Your Questions About FRIDs: Listen to Dr. Farley describe the problem. Then we welcome your calls. Have you taken a medicine that makes you drowsy or unsteady? Have you or an older relative taken a tumble you suspect was related to a medication? We want to hear about it. We spoke earlier with Dr. Farley. After we listen to his interview, Joe and Terry will try to answer your questions about medicines that might increase the risk for falls. Are there alternatives? What can you do? The show airs live from 7 to 8 am EDT on Saturday, Oct. 4, 2025. Give us a call to ask a question or share a story: 888-472-3366 This Week’s Guest: Thomas A. Farley, MD, MPH, has been a public health educator, researcher, and practitioner for more than three decades. Dr. Farley is a Professor of community health at Tulane University and has held positions in health agencies at the federal, state, and big city level. He is the author of Prescription for a Healthy Nation, Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives, and Prevention of Diseases in Populations: From Biology to Policy. Dr. Farley writes a newsletter on Substack called Healthscaping. https://medium.com/@DrTomFarley/about The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Thomas A. Farley, MD, MPH Listen to the Podcast: The podcast of this program will be available Monday, Oct. 6, 2025, after broadcast on Oct. 4. You can stream the show from this site and download the podcast for free. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1447: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:05-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Falls send a lot of people to the ER. In fact, more older Americans die from falls than from breast or prostate cancer. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:35-00:44 The number of deaths from falls in the U.S. has been increasing dramatically in recent decades. That’s not true of other developed countries. What makes us so vulnerable? Joe 00:45-00:53 Our guest today blames overuse of prescription drugs. Many of the pills Americans take make them unsteady on their feet. Terry 00:53-01:01 Has your medicine ever made you dizzy? Our lines are open for your stories and questions at 888-472-3366. Joe 01:01-01:07 Coming up on The People’s Pharmacy, the surprising risks in your medicine cabinet. Terry 01:15-02:26 In The People’s Pharmacy health headlines. When COVID first appeared, one of the novel symptoms that people reported was a loss of the ability to smell. Now research indicates that this problem can last for years. The study, called RECOVER, included 1,393 people who said they had trouble detecting odors. In addition, 1,563 were included who did not report that problem. Nearly all of the volunteers had a documented COVID-19 infection. The researchers tested participants’ ability to smell. 80% of those reporting olfactory difficulties had tests confirming the problem. Somewhat surprisingly, 66% of those who did not report trouble smelling also had some abnormalities in their sense of smell. Of those, 8% were severely impaired. Not being able to smell is bad enough. The investigators also report a link between an impaired sense of smell and cognitive difficulties or brain fog. Scientists suggest that these deficits could have a profound impact on people’s well-being. Joe 02:26-03:23 The FDA first approved the anticoagulant heparin in 1939. It was originally used to prevent blood clots. A new study of COVID patients demonstrates that heparin can prevent severe complications from SARS-CoV-2. 238 patients with COVID were assigned to receive inhaled heparin. Another 215 received standard of care and 25 got placebo. In-hospital death was far higher in the control group. Heparin is not just an anticoagulant. It also has antiviral and anti-inflammatory activity. Administering it in inhaled form can prevent lung injury and blood clots in the lungs. The researchers suspect that heparin could be beneficial against other serious lung infections, such as pneumonia or influenza. Terry 03:24-04:59 It may sometimes seem that people who have heart attacks or strokes are struck down out of the blue. A new study suggests that instead, nearly everyone who experiences a cardiovascular event had at least one suboptimal risk factor beforehand. The research included more than 9 million adults in Korea. A routine screening in 2009 recorded blood pressure, cholesterol, blood glucose, and smoking history. The scientists also checked prescription records for medicines used to treat these problems. When researchers checked participants’ health records after 13 years, they were able to see who had developed cardiovascular complications and who had not. They also studied nearly 7,000 American adults participating in the multi-ethnic study of atherosclerosis. These middle-aged to older individuals did not have heart disease when the study began. They, too, had their blood sugar, blood pressure, and cholesterol measured, and they reported if they were smokers. Nearly 18 years later, the investigators determined who suffered heart attacks, strokes, heart failure, or cardiovascular death. In both Korea and America, 96% of those who experienced complications had blood pressure above 120 in the initial screening. Even though this wasn’t technically hypertension, it was considered non-optimal. High cholesterol and high blood sugar were also common. Most people had multiple risk factors. Joe 05:00-05:35 The CDC is reporting an alarming rise in drug-resistant bacteria called NDM-CRE. This group of germs has surged in recent years and can cause pneumonia, urinary tract infections, sepsis, and wound infections. These bacteria are highly resistant to existing antibiotics. That makes treatment very challenging. Experts recommend testing and preventive strategies such as adherence to disposable gowns, gloves, and masks when interacting with patients. Terry 05:36-06:20 People at high risk for cardiovascular disease are sometimes encouraged to take aspirin as a preventive. A new study investigated whether the PREVENT risk calculator can determine who might benefit from aspirin for prevention. The vast majority of those who reported taking aspirin to prevent heart attacks did not qualify based on the PREVENT Risk Calculator. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. I’m a medical anthropologist. Joe 06:20-06:42 And I’m Joe Graedon. I’m a pharmacologist. Today, our lines are open for your calls and questions. Have you had a bad fall while taking a medicine that made you dizzy or drowsy? We want to hear your story. Our lines are open at 888-472-3366. Terry 06:42-06:49 Today’s topic is about avoiding falls and becoming aware of which drugs might increase the risk of falls. Joe 06:49-07:07 To start off, we’re talking with Dr. Thomas Farley, professor of community health at Tulane University. Dr. Farley wrote an alarming analysis in JAMA Health Forum in August titled, Risky Prescribing and the Epidemic of Deaths from Falls. Terry 07:08-07:12 Welcome to the People’s Pharmacy, Dr. Thomas Farley. Dr. Thomas Farley 07:12-07:13 Thank you. It’s good to be here. Joe 07:14-07:34 Dr. Farley, we saw your opinion piece in JAMA Health Forum a little while ago, and it really got our attention. It was titled Risky Prescribing and the Epidemic of Deaths from Falls. Tell us a little bit about what prompted this really important article. Dr. Thomas Farley 07:35-08:20 Well, so I’m an epidemiologist and a doctor who works in public health and was writing a textbook for public health students on the roughly 30 leading causes of death in America. And one of those is falls in older adults. And as part of my routine research for the textbook, I looked at trends in falls. And I was shocked to see that over roughly the past 30 years that the mortality rate from falls in the United States has roughly tripled. We now have about 45,000 people dying per year from falls over the age of 65. And I found that that increase had not been seen in other countries around the world. The U.S. is an outlier of this. So I said this is an important problem that people need to understand what’s behind it and also to take seriously. Terry 08:22-08:53 And, Dr. Farley, we want to ask you what the reasons might be. What you wrote was, in 2023, more than 41,000 individuals older than 65 years died from falls. Among older adults, the number of deaths from falls is more than from breast or prostate cancer and is more than from car crashes, drug overdoses, and all other unintentional injuries combined. What the heck is going on? Dr. Thomas Farley 08:54-09:43 That was exactly the question I had. What the heck is going on? Why are we seeing this tripling of falls to where now this is really an important cause of death in America today? You know, older adults have always fallen. They’ve always been at risk for the falls. But we’re seeing, why would we be seeing this increase? And so the next thing I did was to say, well, what are the things that put people at greater risk for having a serious fatal fall? And there are things like having a physical disability, having vision problems, maybe having cognitive problems like early dementia, living alone, having a cluttered household, using alcohol. But none of those things have any reason to think that they would have tripled in the past 30 years. On the other hand, there have been big changes in prescribing a prescription drug to older adults. So that’s what led me to really look into what has happened with the prescription drugs in the past 30 years. Joe 09:44-10:54 So let’s drill down on the medications, if you don’t mind. You know, there are some drugs that are highly sedating, you know, the anti-anxiety agents, what we call the psychotropics, the drugs for schizophrenia, for example, or severe depression. But there are lots of other medications that can make people feel dizzy. And I think that a lot of doctors just sort of pass over that pretty quickly without really asking people, “is this medicine making you feel dizzy?” And I’m particularly thinking about high blood pressure because the guidelines now say 120 over 80. Doctor, you’ve got to get everybody. I don’t care how old they are. Everybody needs to be under 120 over 80. And yet that may take three, four, or five different blood pressure medications to achieve that goal. And that can lead to something called orthostatic hypotension and dizziness. So if you could drill down a little deeper on the blood pressure problem. Dr. Thomas Farley 10:54-12:01 If I could, first I’ll talk about the drugs that affect the brain in other ways that you mentioned. Really, any drug that makes you drowsy or clumsy, sedating, is going to increase your risk of falls. Those are things that the drugs that I worry about the most. But then, as you say, there are other drugs that affect your heart and cardiovascular system, which may cause people to just have less blood flow to the brain over a very short period of time, and they can have a fall from that. As I look at the data, I have to say I’m more concerned about the first category, the central nervous system active drugs, than I am about the blood pressure drugs. Blood pressure absolutely is a serious problem, increases your risk of heart disease and stroke and kidney failure. People with hypertension need to be on medications, but there are safer high blood pressure drugs than there are less safe high blood pressure drugs. And so it is fair for people who are older adults who are on a high blood pressure medication to talk to their doctor, say, is this one of those high blood pressure meds that’s going to increase my risk of falls? Is this one that is safer? Terry 12:02-12:38 Now, Dr. Farley, in the article in JAMA Health Forum, you do talk about categories of medications that might make people drowsy or woozy. Benzodiazepines, for example. And when we write about benzodiazepines, which we do from time to time, we usually say this category of drugs is generally considered inappropriate for older adults. Are doctors paying attention or are they still prescribing benzos for older people? Dr. Thomas Farley 12:39-13:22 They’re still prescribing benzos for older people. From what I could find, there’s not as much research on this as I would like to see. But I found one study that looked at people over the age of 85 who were seen in an outpatient setting, 20% of them were giving prescriptions for benzos. That’s absolutely a very high-risk drug for them, and that’s not appropriate. I mean, overall, there was a study done, published in JAMA Internal Medicine, that showed more than 90% of older adults are taking prescription drugs, and 45% are taking prescription drugs that are considered to be potentially inappropriate. So there’s an awful lot of prescribing going on out there on drugs that are potentially quite risky, benzos being one of them that make me worry a lot, but others as well. Joe 13:23-14:16 We’re talking about diazepam, Valium, alprazolam, Xanax. These are drugs that a lot of people take for anxiety. But there are also problems for some people with antidepressants that can make them feel dizzy as well. And millions of people are taking antidepressants on a regular basis. I’m also wondering about antihistamines because, you know, people, if they have stuffy nose or allergies, are likely to take over-the-counter drugs. And some of them, like diphenhydramine, Benadryl, can make people very woozy. And now all the PM pain meds, you know, the Aleve PM and the Advil PM and the Tylenol PM, they all contain diphenhydramine. And for some people, they may have a little wooziness if they have to get up in the middle of the night. Dr. Thomas Farley 14:18-14:39 Yeah. So I think of antihistamines in two categories. There’s kind of the older ones, as you mentioned, diphenhydramine, that absolutely make people that are sedating and make people clumsy so they could increase the risk of falls. The newer ones are probably less likely to do that. And I don’t have data out there as to which ones are prescribed more these days or whether there’s an increase in one category or the other. But that’s absolutely something that I would be concerned about. Joe 14:41-15:40 I have a letter that we received from one of our readers. She says, a few years ago, my cardiologist put me on spironolactone to lower my blood pressure from 140 over 80. Shortly thereafter, I got up from bed for the bathroom. I blacked out in the bathroom, fell, and fractured two vertebrae. I was given a walker and kept on spironolactone. Later, I was using the walker to get to the bathroom in the middle of the night. I blacked out again, fell onto the walker and cut both knees. That resulted in a three-week stay in a rehab facility. My cardiologist never mentioned that spironolactone might make me faint or fall. I’m no longer on any blood pressure medication, but due to the fractures, I am four inches shorter and my life has been changed forever. I think we sometimes forget that, you know, dizziness sounds like such a mild side effect, but it can have devastating consequences. Dr. Thomas Farley 15:41-16:05 Yeah. You know, for women in particular, a fall, even a small fall can lead to a hip fracture and hip fractures absolutely can be fatal on older adults. And so, you know, I, I, there definitely are some antihypertensives that are going to increase the risk of falls more than others. And so, again, I’m a big believer that we should treat people with hypertension. I don’t want anybody to get that impression. Joe 16:06-16:07 Right. Dr. Thomas Farley 16:06-16:15 But I do think that older adults need to be having a serious conversation with their physician about, are they on an antihypertensive that is going to be safe from a false perspective? Joe 16:15-16:42 We just have a minute left, but it seems like very rarely do health professionals, especially family practice doctors or interns, actually check people for their potential for dizziness. It might happen at physical therapy. It might happen at health coaches. But shouldn’t doctors be checking for dizziness every time an older person comes in who’s taking many medications? Dr. Thomas Farley 16:43-17:31 They should be assessing the risk of falls more broadly. And dizziness would be part of that, but also the other things, are they particularly physically frail, do they have vision problems? And look, there’s a falls risk checklist that they can use. And they ought to be far more careful with patients that are at risk of falls than those that have a lower risk of falls. I think more generally, this data says to me that not just individual doctors, but health systems as a group ought to be looking at this in the same way that they looked at opioids in the past and say, you know, we need to be pulling data on our providers and see who’s prescribing these fall risk increasing drugs or FRIDs a lot. And if so, have some conversations with them about how to get patients onto either drugs that are safer or to see whether they need to be on the drugs at all. Terry 17:32-17:37 Dr. Thomas Farley, thank you very much for talking with us on The People’s Pharmacy today. Dr. Thomas Farley 17:38-39 Thanks for having me. Terry 17:39-17:47 You’ve been listening to epidemiologist and health educator, Dr. Thomas Farley of Tulane University. You can find a link to his paper on our website. Joe 17:48-17:59 Our phone lines are open for your stories, comments, and questions. That number, 888-472-3366. Terry 18:00-18:03 You could also put a comment on Facebook or at People’s Pharmacy. Joe 18:04-18:15 Again, that number, 888-472-3366. We invite your questions about medications that might increase the risk for falls. Terry 18:16-18:54 Again, that phone number for you, 888-472-3366. You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Welcome back to the people’s pharmacy I’m Terry Graedon. Joe 18:54-19:12 And I’m Joe Graedon. Terry 19:12-19:23 Today, we’re talking about FRIDs, F-R-I-D. Is that acronym new to you? It was for us. It means fall-risk-increasing-drugs. Joe 19:24-19:48 We invite you to share your story about a medicine that might have made you feel, you know, woozy or unsteady. Our number, 888-472-3366. Again, if you’d like to join our conversation. We are live in the studio, 888-472-3366. Terry 19:49-20:38 And Joe, we have a comment from Jeannie. She says, I’m 80 plus years old. And at this point, I’m taking no prescription drugs because every one of them has side effects. I have high blood pressure, 142 over 70. And my doctor wanted me to take losartan. After reading the side effects, I decided the answer would be no, because it can cause dizziness. It can also lower your heart rate, and mine’s already low. I average 40 beats a minute, and when I’m asleep, sometimes it’s 30 beats a minute. Taking Losartan means I could fall and maybe break a hip. Some seniors who break their hips have died within a year because of the stress on their bodies. Why would I want to trade one problem for another problem? Very good point. We do need to point out, you have to do the balancing act, right? Joe 20:38-21:25 You do have to do the balancing act. It is critical to keep your blood pressure under control. We don’t want anybody allowing blood pressure to skyrocket. But sometimes trying to get everybody down to below 120 over 80 can lead to dizziness, especially something called orthostatic hypotension. It’s when you stand up suddenly and then all of a sudden you get dizzy and then you may fall. And that’s because of the blood pressure medication. So as Dr. Farley said, you want to make sure you talk to your doctor about drugs that don’t make you feel dizzy. Again, our phone lines are open. 888-472-3366 is the number to call if you have a story to share. Terry 21:26-21:30 And we go to Arlington, Texas to talk to Ann. Ann, your question, please. Caller 21:33-21:48 Hi, this is Ann. I was wondering if I only take Synthroid in the morning before I eat, but I’m dizzy right when I get up, and then I’m kind of dizzy until I eat more during the day. How do I figure out what’s making me dizzy? Joe 21:50-21:58 Good question, Ann. Well, first, are you taking any other medications besides Synthroid, which is a thyroid medication, right, Ann? Caller 21:59-22:09 Yes. Just later in the day, I take hydroxychloroquine and some supplements, calcium and that kind of thing. Terry 22:10-22:26 Usually, we don’t think of supplements as causing dizziness. And generally speaking, Ann, I wouldn’t expect Synthroid to cause much dizziness either. This sounds like you may need to have a more in-depth conversation with your doctor. Joe 22:26-23:16 You know, I’d have to look up hydroxychloroquine, Terry, because, you know, it is a drug that is prescribed. It’s an old-fashioned medication. It’s sometimes used for arthritis symptoms, for example, or other autoimmune conditions. And so it’s not clear to me if that could be a contributor. But you definitely want to be very careful when you get up in the morning and so that you don’t, you know, on your way to the bathroom, for example, have a fall. So that’s a critical issue to bring up to your doctor whenever you get a chance. Okay. Thank you so much for your call. Bye bye. Terry, it looks like you’ve got Bert in Clearwater, Florida. Terry 23:16-23:19 Let’s go to Bert and find out what’s on his mind. Joe 23:21-23:21 Hi, Bert. Terry 23:21-23:22 Hey, Bert. Joe 23:22-23:22 Are you there? Caller 23:24-23:25 Hello, yes. Joe 23:26-23:26 Go ahead, please. Caller 23:27-23:50 I’m here. What’s your question? I was just calling in to say that with respect to dizziness, I’ve had some problems with taking Flomax and drugs for a similar kind of problem. And that I find that, you know, like I’m sitting on a couch or something like that, I’ll get up and I’ll be busy and have to put a hand out and steady myself. Terry 23:51-23:52 That’s, yes. Caller 23:52-23:58 For a few seconds or whatever until that goes away. And then it’ll go away and then I go ahead with what I’m doing. Joe 23:59-24:26 Bert, you’re describing a classic case of orthostatic hypotension. That’s the doctor’s term for stand up, oops, feeling dizzy. And what that means, quite honestly, is that you’re going to have to get up from the couch cautiously. So don’t ever stand up suddenly and start walking because you might end up on the floor. Terry 24:27-24:30 Bert, did we interrupt you before you were finished with your story? Caller 24:31-24:34 No, no. I think I got everything out. Joe 24:35-24:56 Okay. Well, excellent. Be careful. And we do understand that sometimes Flowmax is essential to help you not have to get up three, four, five times in the middle of the night to go to the bathroom. That’s when it’s especially important to be careful if you do get up to go. So thanks for the call. Let’s just give the phone number again, Tara. Terry 24:57-25:13 Absolutely. 888-472-3366. That’s our number. We’d love to talk with you and hear about your experience. And let’s talk to Janet in Pittsboro, North Carolina. Janet, tell us your story, please. Caller 25:13-25:14 How are you? Joe 25:14-25:15 We’re doing well. Caller 25:15-25:40 I am with uh, prescribed [muffled], which is also called sertraline, to help me sleep. I have a problem with insomnia. And the prescription is 50-milligram tablets. And it says take three to four tablets by mouth at bedtime as needed. I cannot. That’s an overdose to me. Terry 25:40-25:40 Yeah. Caller 25:41-26:14 But not too long ago, I took two. And right before that, I took one 5-milligram diazepam. And I fell. And I had fallen last October a year ago, almost exactly a year ago. And formaldehyde dust left in my house by a contractor, and I broke my femur. And that was a disaster. I mean, I was in ICU for 10 days, but that didn’t involve a drug. That involved me trying to clean up this dust. Terry 26:14-26:14 Uh-huh. Caller 26:15-26:23 But now, just the other day, well, September the 9th, I think, I fell again, but I was dizzy when I got up. Terry 26:24-26:52 I understand, Janet. We actually would like to make some comments on what you’ve told us. And we’d like to remind everybody that when you want to talk to us on the show, you need to turn off your radio because otherwise it will be distracting for everyone. So, Janet, I’m going to hang up here and we’re going to make some comments about the diphenhydramine and the sertraline that you have been taking. Joe 26:52-26:56 I thought I also heard her say something about diazepam. Terry 26:57-26:59 I didn’t catch that, but it might have been there. Joe 27:00-27:04 I thought I heard that. And that would be, of course, a benzodiazepine. Terry 27:05-27:14 Sertraline is one of the medications that Dr. Farley was talking about that put older people, and it sounds like Janet might be an older person. Joe 27:14-27:15 It does sound that way. Terry 27:15-27:34 Put older people at risk for falls. And, Joe, we were talking about drugs that are prescribed. Sertraline is a prescribed antidepressant. Obviously, Janet’s doctor is prescribing it for her sleep. That’s an off-label indication. Joe 27:34-27:41 I’m having a hard time understanding that. And she said three or four pills, and I’m thinking, what? Oh, whoa, whoa, whoa, whoa. Terry 27:42-27:45 Yeah, that doesn’t sound like a good idea. Joe 27:45-27:46 Well, first of all. Terry 27:46-27:53 But diphenhydramine, Joe, in combination with sertraline or even by itself, tell me about diphenhydramine. Joe 27:53-27:59 Well, of course, we’re talking about Benadryl. We’re talking about the PM in Tylenol PM. Terry 27:59-28:12 And a lot of people who have trouble sleeping will take this medication, which is over the counter. You can take it every day without even telling your doctor. But we’d like to suggest you need to tell your doctor. Joe 28:12-28:28 And we’d also like to suggest that if you have to get up in the middle of the night to go to the bathroom, it would not be a good idea to take any of those PM pain medicines because they could make you woozy, you know, at three in the morning when you get up. Terry 28:28-28:39 And sertraline as a sleeping pill, if you’re susceptible to falls, is a bad idea. Get your doctor to give you something better. Joe 28:39-28:45 Let’s talk about the “Beers” list. And we’re not talking about drinking beer. Terry 28:46-28:54 No, we’re not. We’re talking about a gentleman whose last name was Beers who was concerned about this type of problem. Joe 28:54-29:01 It was spelled B-E-E-R-S, Dr. Beers. And before we do that, Terry, what’s the phone number? Terry 29:02-29:12 The number is 888-472-3366. And Joe, tell me more about Dr. Beers and his list. Joe 29:12-29:26 Well, he created a list many decades ago, and he said to his colleagues, doctors, don’t prescribe drugs on my Beers list because it will make them vulnerable to lots of problems. Terry 29:27-29:48 So the drugs that Dr. Beers put on his list are drugs that are potentially inappropriate for older people. And sometimes referred to as PIP, Potentially Inappropriate Prescriptions. But basically, we’re talking about older people because they’re more vulnerable to problems with certain drugs. Joe 29:48-29:55 Well, what’s become very popular these days is a category of drugs called gabapentinoids. Terry 29:55-30:01 And we’ve got a comment on that, Joe, from Facebook. Would you like to hear it first? And then you can launch into your… Joe 30:01-30:02 I would like to hear it. Terry 30:02-30:28 Okay. Mary Jo wrote, I’m a paramedic. I have a question about Neurontin. People are prescribed this all the time for their peripheral neuropathy, which makes them a fall risk anyway. But when elderly people consume it, they have a bigger risk of falling. And I can’t read the rest of Mary Jo’s comment, sorry to say. So now you get to carry on about Neurontin. Joe 30:28-30:34 Mary Jo is a paramedic. So she is likely to be in that emergency. Terry 30:34-30:37 She gets called. When somebody falls. Joe 30:37-31:17 When the ambulance comes, that’s Mary Jo. And, you know, the gabapentinoids, and that’s gabapentin, it’s pregabalin, Lyrica. She mentioned Neurontin. And these drugs are now being prescribed so widely for pain, especially for nerve pain. So gabapentin is the number five most prescribed drugs in America today. You know, so many people are in pain and they can’t take opioids because their doctors are afraid of them or they’re afraid of them. And as a result, they’re put on gabapentin. And it can make people vulnerable to falls. Terry 31:17-31:19 It can definitely do that. Joe 31:19-31:43 That number again, 888-472-3366. If you’d like to join our conversation, are you taking one, two, three, maybe four blood pressure medications simultaneously? How does that affect your level of dizziness? We’d love to hear from you. Again, that number, 888-472-3366. Terry 31:44-31:49 And we go to Peggy in Auburn. Peggy is, where is Auburn exactly? Caller 31:50-31:53 It’s in the southeast corner of Nebraska. Terry 31:53-31:54 Wonderful. Joe 31:54-31:56 Right next to Iowa and Kansas. Terry 31:56-31:57 Okay. Joe 31:58-31:59 Terry, where did your mom grow up? Terry 31:59-32:07 In the western corner of Nebraska. We’re not going to get into geography. We don’t have time for geography, but I appreciate that. Caller 32:07-32:28 Now, your story, please. I am taking two blood pressure medications. And at the time, amlodipine and my doctor prescribed hydrochlorothiazide. And that made me dizzy. And I passed out. I walked outside. It was sunny. It was warm. Went to the ground. Joe 32:29-32:29 Oh, my. Caller 32:29-32:37 Fell to the ground. I called him and told him he changed the medication to metoprolol. Okay. Joe 32:38-32:40 Metoprolol, right. A beta blocker. Caller 32:40-32:40 Metoprolol, yes. Joe 32:41-32:46 And were you able to get up and manage to not break any bones on that fall? Caller 32:47-32:51 I did not break any bones. I’m 59 years old. Okay. Terry 32:52-33:16 So the people who are most likely to break bones are the really older people, you know, 80 and older. So we’re glad you didn’t break anything, and we’re glad that you realized that the drugs causing your problem were your blood pressure medicines, and you got your doctor to change the prescription. Good work, Peggy. Thanks for calling. Joe 33:18-33:19 We appreciate it. Terry 33:20-33:22 And, Joe, we’re getting close to our break, aren’t we? Joe 33:22-33:40 Oh, we got lots of time. Okay. I think it’s been so long since we’ve done a live show, we kind of have forgotten the time cues. Al, we’re still good, right? Yeah, we still have two minutes. Okay. So shall we go to Herb? Terry 33:40-33:41 Sure. Joe 33:41-33:46 In Research Triangle Park, North Carolina. We can just squeeze Herb in. Terry 33:46-33:48 I think we have enough time to talk to Herb. Joe 33:48-33:49 Herb, what’s the story? Caller 33:51-33:52 Hi. Terry 33:52-33:52 Hi. Caller 33:52-35:19 Terry and Joe. Good conversation. I don’t know what to say. Here it is. I have a 97-year-old mother who has no issues other than she is not 120 over 80. Oh, my. So she has been prescribed amlodipine, the sort of those kind of things. I have been fighting this battle for some time. So what I would like to say is that your audience, don’t give up the fight. Don’t give up the fight. What I did was I said, look, when she goes into to see the doctor, she’s excited because she gets the white coat syndrome. So what I do is I have her and me to take her blood pressure in an ambulatory way throughout the week, not just there. So that would be my suggestion to people. At 97, she does use a walker. I will say that. But I think sometimes trying to do good does not always end up being good for a 97-year-old mother. And I thank you all so much every week for what you do, and I also do your subscription as well. Herb, thank you so much for that call. Terry 35:20-35:38 And thank you for watching out for your 97-year-old mother. The fact that she uses a walker is very smart. And the fact that you are taking her blood pressure, making a record of it so that you can show the doctor what her blood pressure is like at home, that makes a lot of sense. Joe 35:38-37:00 Well, you know, this idea of white coat hypertension is something that I think a lot of people have to struggle with because, you know, they have to drive to get to the doctor’s office. If there’s traffic, it can be very anxiety producing. And then the question becomes one of how well is your blood pressure taken at the doctor’s office? When we come back after the break, we’re going to ask you to give us a call about how your blood pressure has been taken. So there are some guidelines from the American Heart Association. You’re supposed to, number one, be allowed to rest quietly for about five or 10 minutes when you get to the doctor’s office. You’re encouraged to go to the bathroom and pee. And then when you get into the office, they need to make sure that they take it correctly, that you’re not sitting on the exam table with your arm dangling down, that you’re in a chair with your arm supported. Has that happened to you? I’m curious. Have you been encouraged to follow those guidelines or did they just take your blood pressure as soon as you walk in the door? Give us a call. Tell us about your experience with white coat hypertension. Our lines are open at 888-472-3366. You can send us something through Facebook. Terry 37:00-37:14 That’s right. Facebook or at People’s Pharmacy. And that’s how we got Mary Jo’s comment. And, you know, when we come back from our short break, we will talk more about drugs that increase the risk of falls, but we’ll especially get to the blood pressure. Joe 37:15-37:20 888-472-3366 is the number to call. Terry 37:38-37:41 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:51-37:53 Welcome back to the people’s pharmacy I’m Joe Graedon. Terry 37:54-38:12 And I’m Terry Graedon. Joe 38:13-38:23 Have you ever been warned about drug-induced falls? Has your doctor evaluated you for such a risk, and how would they even do that? Terry 38:24-38:40 I’m not sure how they would do that, but there are some tests that they use to see how people can get up out of a chair and that sort of thing. So there may be assessments. Joe 38:36-38:38 Well, you know, physical therapists do this all the time. Terry 38:39-38:41 That’s true. They check your balance. Joe 38:41-39:03 And doctors should be trained so that they do know how to test a, not just an older person, anybody for a fall risk, especially if they’re taking more than one or two medications. And I suspect that if you were to ask a lot of nurses these days, when a patient comes in, How many drugs are they taking? I bet the average is more than two. Terry 39:04-39:21 Especially if someone is struggling with high blood pressure. Now, I love the idea that Herb suggested a few minutes ago that you should take your blood pressure at home and keep a record of it. So you know what it’s like throughout the day and you can share that with your doctor. That’s important. Joe 39:21-39:31 And, you know, does a 97-year-old woman need a whole bunch of medications to get her blood pressure under 120 over 80? Terry 39:32-39:43 The idea is that you’re going to increase longevity. But once you get to 97, I don’t know that you’re aiming for greatly increased longevity. She’s already there. Joe 39:43-39:45 The risk of a fall. Terry 39:45-39:47 Is significant. Joe 39:47-40:11 And worrisome. I remember my mom went in to see Dr. Bob Gutman, who was an internist, and he said, Helen, I could get your blood pressure down to 120 over 80, but you’ll feel bad. And are you willing to take the risk for a stroke and let it be a little higher? And she said, yes, Dr. Gutman, I’m willing. And she lived to 92 and died from a medical mistake. Terry 40:12-40:18 But she chose not to have a fall because the idea of a fall frightened her. Joe 40:18-40:21 It sure did. You have a story from Jane. Terry 40:22-41:32 I do have a story from Jane, and then we’ll go to the calls. Jane said, I worry about how often doctors put people on blood pressure drugs based on one reading at the clinic. Way too often that reading was gotten by totally incorrect methodology. Like many people, I have white coat hypertension. And Joe, when we’re done with Jane, we’ll ask you to explain that. I now take a chart of at-home readings covering the last 10 days to two weeks of several readings a day. Even though these are perfectly fine numbers, I still have to fend off the doctor wanting to start me on meds based on the somewhat high reading at the office. Also, in the last 20 years, my pressure has been taken correctly only two or three times. I wonder how many people are dutifully taking their medication every day based on a single reading done improperly at the doctor’s office and therefore are perpetually experiencing low blood pressure or maybe dizziness at home. I suspect a fair number of falls, appearances of cognitive decline, etc. are the result of this unfortunate dogma. So we appreciate Jane’s comments. Joe 41:32-42:04 We surely do. And this idea of white coat hypertension has been controversial for decades. There are some people who say, oh, that’s all nonsense. If somebody has 130 over 90 in the doctor’s office, they have to be treated, even if their blood pressure is 120 over 80 at home. I think that thinking is starting to disappear. I hope it is, because a lot of times these days, people are not getting their blood pressure taken correctly. Terry 42:04-42:11 Let’s talk to Patricia in Wilmington. She’s got a story about a drug we haven’t mentioned yet. Patricia, welcome to the People’s Pharmacy. Caller 42:13-43:04 Thank you. Hi. Yes, first time caller. My husband is 86 and he takes many drugs for a variety of issues. But one of the drugs that he’s been prescribed over the years is Viagra. And I’m not sure why 86, you still need to be taking Viagra, but that’s a whole nother story. Sometimes he’ll take more than what’s prescribed because he’s not getting the effects that he wants. So he’ll take two or three. And that’s caused him to get dizzy and lightheaded. And so I plan to go to his doctor with him the next visit to have a discussion about does he really need to continue to have the Viagra and also the importance of taking just the prescribed amount Terry 43:04-43:24 and not what you think you need. Such a great comment. And I don’t think people actually appreciate that Viagra can make you dizzy, especially in combination with other medications or if you take more than the prescribed amount. So, Patricia, we really appreciate this comment. Joe 43:25-43:39 That voluntary dose increase of two or three Viagras would definitely be problematic. The dose is 100 milligrams. So if he were taking 200 or 300 milligrams, whoa. Terry 43:39-43:44 And, of course, falling would be the least romantic thing you can possibly think of. Joe 43:45-43:50 Exactly. So, yes, definitely discuss with his doctor this potential problem. Terry 43:51-43:56 And we’ve got a call from Ken in Medville or Meadville, Pennsylvania. Joe 43:57-43:58 I bet it’s Meadville. Terry 43:59-43:59 Is that right, Ken? Caller 44:01-44:03 Yes, yes, you are, Joe. Meadville. Joe 44:04-44:11 I grew up in Pennsylvania. I went to Penn State, and there were a bunch of kids there from Meadville, Pennsylvania. What’s the story? Caller 44:12-45:07 Well, I’m 79, and I’m on a medication called nadolol, 20 milligrams. I guess that’s a beta blocker, but it can be used for blood pressure, too. I missed the first few minutes of the show. I was wondering if that was one of the ones on the Beers list. And I’m having severe balance issues. I wouldn’t call it dizziness, but I can’t seem to walk down the sidewalk when I’m out walking straight. I kind of wander back and forth. I can’t stand on one foot. I’ve always been athletic. I still can play table tennis quite actively. Joe 45:09-46:24 Well, let’s start at the beginning. You’re taking a beta blocker, as you have pointed out, nadolol. And to be honest with you, physicians have generally moved away from beta blockers for high blood pressure as the first line approach. In fact, I can’t say off the top of my head if nadolol is on the Beers list, but I can say quite confidently that most physicians would not start with a drug like nadolol to control blood pressure. And so even if you’re not quote unquote dizzy, if you’re unsteady on your feet, it is absolutely time to be in touch with your doctor and say, let’s try something else. And that something else might be a drug like a diuretic. It might be a medication like an ACE inhibitor. But you definitely need to talk to your doctor because if you’re feeling unsteady, if the possibility is when you’re walking on the sidewalk or someplace else and you fall, it could be a disaster. So Ken, thank you so much for calling and please do follow up with your physician as soon Terry 46:24-46:32 as possible. Shall we go to Richmond, Virginia and talk to Ann? Absolutely. And our numbers are Joe 46:32-47:08 888-472-3366. We just have a few minutes before we have to sign off. We’d love to hear from you, especially about how your blood pressure has been taken in the doctor’s office. Has it been done correctly? Has it been taken by a nurse, a doctor, or a technician? Did your arm get supported at chest or heart height? Because a lot of times your arm will be dangling or it’s not supported that can affect your blood pressure reading. But where are we going to? Richmond, did you say, Terry? Terry 47:08-47:14 Yes, we’re talking to Ann. She’s been waiting to make her comment or ask her question. Go ahead, please, Ann. Caller 47:16-47:38 Hi. I have eye issues. I have glaucoma and other eye issues and have been treated with lots of different meds. But the longest one is Latanoprost and also dorzolamide, timolol. I wonder if there are any eye meds that I should be careful of for dizziness because I’m dizzy. Joe 47:38-47:55 You know, and that’s a brilliant question. And thank you so much for asking about eye meds. Because I think a lot of times people assume, oh, well, if I just put a drop in my eye, it’s just going to stay in my eye. It won’t have an impact on the rest of my body. Terry 47:55-48:03 But timolol, for example, we know for sure that it can have an impact. And it’s possible that Latanoprost also does. Joe 48:03-48:24 Well, timolol is a beta blocker, and we just ended up talking about beta blockers. And so you should definitely talk to your doctor about this if you are feeling somewhat dizzy as a result of your eye drops. So, you know, when you put eye drops in your eyes, they don’t just stay there. They circulate through the rest of your body. Terry 48:24-48:28 Now, of course, you do need to treat your glaucoma. Joe 48:28-48:28 Absolutely. Terry 48:28-48:46 So you and your doctor are going to have to come up with a regimen that will work for the glaucoma and not put you at risk of a fall. So good luck with that, Ann. We sure hope you come up with something helpful. And Joe, did you want to talk to Eric in Charleston, West Virginia? Joe 48:46-48:54 Absolutely. Eric, welcome to the People’s Pharmacy. What’s this about blood pressure cuffs? Well, good morning. Caller 48:55-49:37 Yes. I have two items, actually. The cuff was interesting because at one point I went to my GP and the nurse came out and took my blood pressure and it was way up, way too high. And then the doctor came in and said, hmm, we used the wrong cuff. Your arm happens to be a little larger than usual and therefore we need to give you a big cuff. And so we took it and it came back 10 points lower than when it was. So it seemed to be very important to pick the right cuff, especially if your arm is larger than normal. Terry 49:38-50:16 Absolutely, Eric. And the same thing holds true. If your arm is extra small, you need the right size cuff. Because if your arm is extra small and they use an ordinary cuff, your blood pressure reading is going to be a little bit too low. And Joe, we got a Facebook comment from Karen who says, I think something needs to be said about the devices being used to check blood pressure nowadays. I’m 65. I’ve had great blood pressure around 120 over 70 my whole life. But about 15 years ago, I noticed that my blood pressure registers higher in the doctor’s office. And it probably has something to do with the cuff. Joe 50:16-50:55 Well, the cuff is one of those things that is often not even considered. I mean, because if you’re the patient and you walk into the doctor’s office, they slap the cuff on your arm. They never measure your arm. So if you have a very small arm or a very large arm, I mean, imagine a guy six feet, four inches tall, weighs 250 pounds, lifts weights. He’s going to have a gigantic bicep. And if they use a standard cuff on him, it will be an inaccurate reading. When’s the last time you ever had your arm measured before you had your blood pressure taken? Terry 50:55-51:01 Well, let’s talk to Phil in Clearwater, Florida, because he’s got some stories to tell. Hey, Phil. Joe 51:03-51:05 Hello. How are you today? We’re doing well. What’s up? Caller 51:06-52:03 Well, I just want to give comments. I concur with you that a lot of physicians or their staff do not let you take time. And like sometimes I go to the doctor’s office and, you know, I’ve showered and got ready and I ran in there. And, you know, then they take you back and boom, they take your blood pressure right away and it’s elevated. And then they say, well, I’ll take it again. The doctor takes it like at the end of the exam and it’s back to normal. Same thing happened to my wife. She went there and I swear they want to put a diagnosis of hypertension in your chart so that they can charge more to the insurance company. But I don’t know if that’s true or not. That’s my hypothesis. But I just think you need to take control of your own body, your own medication, and tell them, no, I want you to wait five or ten minutes. Let me relax here a second. So it’s stressful enough going to the physicians anyway. But on top of that, I think they’re not always doing it correctly. So I concur with what you said. Joe 52:03-52:22 And there’s one other thing, Phil. You should never talk when you’re having your blood pressure taken. Because if the technician or the nurse starts to ask you questions like, how are you doing? Or what’s going on in your life? Or some other medical question, talking will raise your blood pressure. Terry 52:23-52:47 Joe, in fact, we got a Facebook comment from Renee who says, for white coat hypertension syndrome, show the nurse a note that says, no talking until after I weigh, relax, and they take my blood pressure. They rush you and they want to ask you all kinds of questions and show their incompetence before taking my vitals. Thanks for that, Renee. Yes. Joe 52:47-52:53 And always go to the bathroom. You’re supposed to urinate before you have your blood pressure taken. Terry 52:53-52:58 I don’t believe I have ever been asked if I needed to use the facilities. Joe 52:59-53:01 I’ve never had that happen to me either. Terry 53:01-53:04 Do we have time to talk to Johnny in Fort Worth or? Joe 53:04-53:07 Very briefly, Johnny. Terry 53:07-53:08 We’re almost out of time. Joe 53:08-53:11 We have just a minute or two left. Go ahead, quickly. Caller 53:12-53:43 Hi. Hi. I take a hormone drug. I have prostate cancer. And I also take four pills a day. I’ve lost four pills a day, but I’ve noticed that when I’m driving, sometimes I have an urge. I get anxious. And I’m just trying to figure out what’s going on. I don’t. My blood pressure usually runs by 140 over something. But that’s my issue. And I’m trying to think. I’ve been trying to work with my oncologist, trying to figure out what’s going on. Thank you. Joe 53:43-54:07 You will need to work with your oncologist because, obviously, it’s critical that you keep your prostate cancer under control with your meds. But you don’t want to be dizzy while you’re driving. So that’s a critical point to bring up to your doctor. Well, Terry, we are just about out of time. I am so grateful for all of the calls we’ve had from all over the country. Terry 54:07-54:54 And, Joe, we have one more comment. I think we have time for it. Jan says she’s a nurse in the emergency department. A woman brought her mother in because she was dizzy and nearly falling. Her doctor had prescribed a benzodiazepine, Librium, the day before her visit to the ED. Remember, Jan’s a nurse. She says, I informed the ED physician that her symptoms started right after she took the first dose. And the physician said it couldn’t be the medication because the dose was too low. He told her to call her doctor the next business day, which was two days from when we saw her. Her daughter was afraid to leave the patient alone at home, of course. Providers need to improve the medication reviews when patients’ experience falls. Joe 54:55-55:08 Absolutely. And that is very good advice from a nurse. Thank you so much for that, Jan. Well, that is all the time we have today. Thank you so much for listening and sharing your stories today on The People’s Pharmacy. Terry 55:09-55:20 Absolutely. And The People’s Pharmacy is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 55:20-55:35 Lynn Siegel produced today’s show. Pamela Alberta provided technical assistance. Al Wodarski, the great Al Wodarski, engineered. Dave Graedon edits our interviews. And the People’s Pharmacy theme music is by B.J. Liederman. Terry 55:35-55:53 We would like to thank today’s guest, Dr. Thomas Farley, who is professor of community health at Tulane University. You can find a link to his article in our show notes. It’s the article titled Risky Prescribing and the Epidemic of Deaths from Falls. Terry 56:08-56:31 Today’s show is number 1,447. You can find it online at peoplespharmacy.com. You can subscribe to our podcast through your favorite podcast provider. We post the show on our website on Monday morning. That’s where you can share your thoughts about this show. And you can email us your comments, radio at peoplespharmacy.com. Joe 56:31-57:07 If you go to peoplespharmacy.com, you can sign up for our free online newsletter. It’s an easy way to stay on top of the breaking health news. By subscribing to our newsletter, you’ll also have regular access to our weekly podcast and find out ahead of time which topics we’ll be covering. And speaking of the podcast, Terry, we would be so grateful if our listeners would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. And when you go to the YouTube channel, in about a week or two, you can see Dr. Farley and The People’s Pharmacy. In Durham, North Carolina, I’m Joe Graedon. Terry 57:07-57:24 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 57:29 – 57:37 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 57:38 – 57:45 All you have to do is go to peoplespharmacy.com/donate. Joe 57:45-57:56 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

Are you concerned about your bone health? Do you worry about osteoporosis? According to the CDC, more than 10 million Americans have low bone density that makes them more vulnerable to fractures. For many older people, a fracture can be devastating, reducing mobility and possibly even leading to death. What does the latest medical science tell us about how you can maintain strong bones? At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Sept. 27, 2025, at 7 am EDT on your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Sept. 29, 2025. Strong Bones: You may have seen Halloween skeletons or even chewed the meat off a bone that you then dropped on a plate with a clatter. No wonder we usually think of bones as hard, unchanging objects. Dead bones are. But living bones are quite different. Strong bones are constantly undergoing change. Scientists call it remodeling. One set of specialized cells, osteoclasts, breaks bone tissue down and recycles it. Another set, the osteoblasts, builds bone back. Ideally, their activities are in balance. But if the osteoclasts start to get ahead, as they tend to do while we age, that can weaken bone. The result is low bone mass, known as osteopenia, or even serious bone loss called osteoporosis. This puts a person at risk for fractures. Who Gets Osteoporosis? Osteoporosis may have been less common a hundred years ago or more, when many people had to do manual labor that put stress on their bones. That helps for strong bones, so today’s sedentary lifestyles can undermine bone health. Although we think of osteoporosis as typically affecting postmenopausal women, men can lose bone mass too. Medications may contribute to the risk for bone loss. Steroids such as prednisone or methylprednisolone are especially risky if taken for a long period of time. Androgen deprivation therapy for prostate cancer is a risk factor specifically for men. Diagnosing Osteoporosis: Doctors assess bone mineral density with imaging called dual-energy X-ray absorptiometry, or DEXA for short. Then they compare the results on the scan to the results they would expect from a 30-year-old person. Results more than 2.5 standard deviations from that could result in a diagnosis of osteoporosis. A person who experiences a fracture without trauma, such as falling from standing height, is also suspected and often diagnosed with osteoporosis. Non-Drug Approaches to Strong Bones: People who want to keep strong bones need to focus on exercise. High intensity exercise can be helpful, but brisk walking may be enough. Tai chi and yoga are also popular. If you have been diagnosed with osteoporosis, be sure to check in with your doctor before you start a new exercise program. Building balance and core strength without increasing your risk of a fall (and thus a fracture) would be ideal. Our guest expert, Dr. Kendall Moseley, says the jury is still out on technology such as vibrating platforms, weighted vests or vibrating belts. More studies should show how valuable these could be. Following a diet that supplies adequate protein, vitamin D and calcium is also crucial. If you must take a calcium supplement, calcium citrate may be well tolerated and absorbed. How Do Doctors Treat Osteoporosis? Physicians prescribe several different types of medications to help curb bone less and perhaps even build it back. Some of the oldest and least expensive are the bisphosphonates such as alendronate (Fosamax). These slow bone break down and give the osteoblasts a chance to catch up. They can be hard on the digestive tract, though, and they have been associated with a few rare but alarming side effects: jawbone deterioration and atypical thigh bone fracture. Most people seem to do well on them. Doctors generally prescribe them for up to five years. Did You Forget Evista? Another type of osteoporosis medicine is called raloxifene (Evista). It is appropriate only for women, because it is an estrogen modulator. It acts like estrogen in the bones and reduces bone loss. In the breast and uterus, it opposes estrogen activity. Raloxifene does double duty in reducing the risk of breast cancer as well as osteoporosis. Like all drugs, though, it has some worrisome side effects. It can increase the risk of blood clots that cause deep vein thromboses and strokes. What About Prolia? Denosumab (Prolia) is a monoclonal antibody that also interferes with osteoclasts. That is how it improves bone density. One thing to keep in mind about Prolia is that stopping it requires careful planning and backup medication. Otherwise, a patient can lose all the bone that was built rather quickly and may suffer debilitating fracture. This Week’s Guest: Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. In addition, Dr. Moseley is Medical Director of the Johns Hopkins Metabolic Bone & Osteoporosis Center. Kendall Moseley, MD, is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Listen to the Podcast: The podcast of this program will be available Monday, Sept. 29, 2025, after broadcast on Sept. 27. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss the pros and cons of estrogen for strong bones. You’ll also learn about a drug that builds bone, teriparatide (Forteo). And you’ll hear about the importance of preventing falls and how to do that. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1446: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy. Joe 00:06-00:13 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Joe 00:14-00:27 Hypertension is often called the silent killer, but osteoporosis might be considered a silent and deadly disorder. This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 If an older person breaks a hip, the consequences can be disastrous. They often lose mobility and they may even die. Joe 00:42-00:50 The focus for osteoporosis is usually on older women, but we should remember that men can also lose bone and become vulnerable. Terry 00:51-00:57 There are drugs that hurt bone health as well as help build it back. What about supplements or exercise? Joe 00:57-01:06 Coming up on The People’s Pharmacy, the science of strong bones, lifestyle, medication, and movement. Terry 01:14-02:32 In The People’s Pharmacy health headlines, semaglutide has gotten a lot of attention over the past few years. If you don’t recognize this generic drug name, you probably do recognize the brand names. Ozempic for type 2 diabetes and Wegovy for weight loss. Both these medications are self-administered injections, but not everyone is enthusiastic about needles. There’s also an oral form of semaglutide called Rybelsus. The FDA has approved it for treating type 2 diabetes six years ago, and so far it has mostly gone under the radar. A new study published in the New England Journal of Medicine demonstrated that oral semaglutide at 25 mg a day helped people without diabetes lose significantly more weight than placebo. The randomized trial included more than 300 volunteers and lasted approximately a year and a half. This could be good news for people who have trouble accessing injectable semaglutide or keeping it cold. People taking semaglutide reported improved quality of life. They were also more likely to report side effects, especially digestive distress. Joe 02:34-04:17 Aspirin has been available for well over 100 years, but the active ingredient has been used by native healers for thousands of years. In 1991, a research article in the New England Journal of Medicine reported that regular aspirin users were 40 to 50 percent less likely to die of colon cancer. Now, 34 years later, another research paper in the New England Journal of Medicine reports that people taking aspirin had a significantly lower chance of colorectal cancer recurrence. Swedish scientists recruited patients after they’d had their tumors removed. The particular hotspot mutation called PIK3CA. The aspirin dose was 160 milligrams, or roughly half a standard strength tablet daily, for three years. 626 patients were randomly assigned to receive either aspirin or placebo. 7.7% of people taking aspirin experienced a recurrence of their colorectal cancer, whereas 14.1% of those on placebo had a recurrence. That was about a 50% relative risk reduction. 43% of the participants taking aspirin experienced a non-severe side effect compared to 35% of those on placebo. Serious adverse events occurred in 17% of aspirin takers compared to 12% of placebo recipients. The authors conclude that low-dose aspirin represents an effective, low-cost treatment approach to prevent colorectal cancer recurrence in high-risk, genetically selected patients. Terry 04:17-04:58 Nutrition experts have praised the Mediterranean diet as a way to reduce cardiovascular risk. It’s also been considered as a way to lower the likelihood of developing dementia and a natural approach to calming inflammation. Now, dermatologists have announced the results of a study showing that four months on a Mediterranean diet can reduce the severity of psoriasis symptoms. Almost half of the participants following a Mediterranean diet reduced their psoriasis score by 75 percent, and none of those on the control diet did so. The researchers conclude that this dietary strategy could be helpful along with medical treatment. Joe 04:59-05:41 A new study of acupuncture for chronic low back pain called Back in Action produced positive results. 800 patients were randomized to receive either standard acupuncture of 8 to 15 treatment sessions, enhanced acupuncture, which included 4 to 6 maintenance sessions beyond the standard, or usual medical care alone. Those in the acupuncture groups had significantly greater reductions in their pain-related disability than those in the usual care group. The authors conclude that, quote, these findings support acupuncture needling as an effective and safe treatment option for older adults with chronic low back pain. Terry 05:42-06:05 Do cocoa flavanols normalize blood pressure? In the COSMOS study, people with systolic blood pressure under 120 were significantly less likely to develop hypertension if they were taking cocoa flavanols than if they took placebo pills. People whose blood pressure started higher did not get the same benefit. And that’s the health news from the People’s Pharmacy this week. Terry 06:14-06:17 Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. According to the CDC, over 10 million Americans over 50 have osteoporosis. That means their bones have become fragile and more vulnerable to fracture. Terry 06:30-06:40 More than 40 million Americans have low bone mass or osteopenia. What can be done to prevent fractures, disability, and death from weakened bones? Joe 06:41-07:00 To find out, we’re talking with Dr. Kendall Moseley. She is Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. She also serves as medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 07:01-07:04 Welcome to the People’s Pharmacy, Dr. Kendall Moseley. Dr. Kendall Moseley 07:05-07:10 Thank you so much for having me today. I’m very excited to chat with you both about a topic that’s near and dear to my heart. Joe 07:11-07:48 Well, it’s near and dear to our hearts as well, Dr. Moseley, but I suspect that there’s a tremendous amount of confusion when it comes to bones because we’ve all seen skeletons. We’ve all had interactions with bones, perhaps in food. And it just always seems as if bones are so solid. And yet, in reality, bones are constantly breaking down and building up. It’s a very dynamic process. Could you just give us a quick overview on bone physiology? Dr. Kendall Moseley 07:49-09:21 Absolutely. And I think you’ve highlighted something I always try to stress when I talk to groups of people is that bones are not these inanimate objects. I mean, we’re not these walking, kind of lumbering rocks moving down the street. In fact, we have this very important scaffold underneath our skin that enables us to walk and roll and twist and bend. And without a very strong scaffold, we’re kind of in trouble. So you’re right. Bones are dynamic. Our bones are always building up and they’re always breaking down. And it’s that process of kind of building up and breaking down that allows us to be flexible, right? If we didn’t have remodeling of our bones, we’d be very stiff and brittle. But it’s that balance, that key balance of how our bones build up and how they break down that really dictates how strong our bones can be. Clearly, you would prefer a lot more building up than breaking down. And at different parts in our life cycle or different times in our life cycle, we have different balances in that building up and breaking down. If you really want to get into the nitty gritty of the pathophysiology, which I think is important to understand because there are two very different types of cells that treatments for bone disease sometimes impact, we really boils down to these cells, one of which is called the osteoclast. It’s kind of like a little Pac-Man cell that’s responsible for breaking down our bone if it’s an area of injury or a little micro fracture. So that osteoclast will come in and kind of carve out a pit of bone so that the osteoblast, B as in build, can come in and fill in new bone. Again, to rejuvenate that area and to keep your bones flexible. Terry 09:22-09:34 And I’m assuming that as we get older, there are more osteoclasts or they’re moving faster than the osteoblasts building our bones back. Am I wrong? Dr. Kendall Moseley 09:35-10:58 No, I think that that’s a wonderful way to think about it. You know, the life cycle is complicated. You know, when I meet patients for the first time, and again, I’m in a metabolic bone clinic, so I see patients who generally come already with a diagnosis of osteoporosis or low bone density. And when we’re sitting there talking to one another, we say, gosh, why aren’t your bones perfect? And believe it or not, what we do is we go all the way back to childhood because changes happen throughout the life cycle to bones. We build or gain bone. We’re building more bone than we’re breaking down until about the third decade of life. So those osteoblasts are overtaking the osteoclast to give us nice, strong skeletons. So you might imagine how early childhood insults could impact the bones. In midlife, we have kind of a steady state where the blasts in the clasps are kind of remodeling at a usual rate, generally in balance with one another. At around the time of menopause that women go through, there is a steep decline in bone density, which is driven primarily by those osteoclasts, those Pac-Man cells that break down bone at a much more rapid rate than the osteoblasts are able to keep up with. And men have an inflection point later on in life. They don’t go through a menopause per se, but about the time, about 70 years of age or so, again, that imbalance starts to shift, which favors the osteoclast or bone breakdown, where again, it’s kind of like a tortoise and the hare story that the tortoise is no longer keeping up with the hare and the bones will break down. Joe 10:59-11:46 Dr. Moseley, I’m curious as to how things have changed, because I suspect that our ancestors, and when I say our ancestors, I’m not talking about Neanderthals. I’m talking more about our grandparents and our great-grandparents. they were probably spending a lot more time outdoors. You know, farmers and just workers and, you know, both men and women were just physically more active than we are today. Today, I think we spend a lot of time sitting. And I’m curious as to how our lifestyles have affected bone health over the last, let us say, 50 to 100 years. Dr. Kendall Moseley 11:47-13:01 Now, I think that that is a fair assessment. We know that activity movement is critical for bone health. You know, in fact, when we talk about the tenets of therapy for osteoporosis and low bone density, one of the things we always have to discuss in clinic is how can we get you more active? What kinds of exercises should you be doing? Because movement really stimulates those bones to kind of rebuild, grow, remodel. And so absolutely, you know, back in the days when we were out and about, you know, in the farms or, you know, pushing things, you know, down the street. I think we did have a lot more activity related to our bones. I will also counter, though, you know, we didn’t live as long back in the day. And so that graph that I just kind of talked about with this aging process kind of inevitably causing slow and steady bone loss as we get older, a lot of the implications for weakened bone really don’t occur until that later stage in life where women are postmenopausal or men are older. And so did we really see the full effects of osteoporosis and bone loss, you know, in prior generations when perhaps they didn’t live to be the older ages where the fracture started to manifest or people passed earlier from other conditions that we didn’t have treatments for? Terry 13:01-13:19 Dr. Moseley, I want to just revisit something you said a few minutes ago and really bring it back up because a lot of people think of osteoporosis as a women’s problem. And you mentioned men get osteoporosis too. Tell us a bit more about that. Dr. Kendall Moseley 13:20-14:28 Terry, thank you for bringing that up. It is a very important point. And oftentimes, you know, my practice is a lot of women in my practice, and oftentimes women will bring their significant others or their spouses and they listen to my spiel and they kind of turn to their spouse or significant other and they say, well, gosh, Maybe that means we need to screen you as well. And it’s true. So men do get osteoporosis. It is a misconception that this is a woman’s disease. Statistically speaking, about 10 million Americans in the United States have osteoporosis greater than the age of 50. About 8 million of those individuals being women, 2 million being men, although even that statistic I counter. One big point is that we really under-diagnose osteoporosis. We don’t name it when we see it, and secondly it relies upon screening for osteoporosis and as we’ve just said men really we don’t see this as a man’s disease so are we screening men to even be able to make the diagnosis in that portion of the population so absolutely bones thin at different times in our lives but there are still other factors other disease states other medications that can threaten a man’s Joe 14:28-14:56 skeleton just as easily as it can a woman’s well you mentioned medications and of course a lot of men who are diagnosed with prostate cancer are given hormone suppressing drugs, what we call antiandrogens. And I suspect that has a profound impact on bone strength and not just in men, in women too, because testosterone people think, oh, that’s a man’s hormone, but it’s responsible for bone strength in both men and women. Dr. Kendall Moseley 14:57-16:11 Right, right. No, absolutely. So one of the biggest offenders and we, you know, the term is iatrogenic, meaning sadly, we as doctors do this to patients, I mean, deliberately, because oftentimes we’re treating another disease state and we have no choice, but we do give patients oftentimes medications that have side effects that directly hurt the bone. One of those medications, in fact, is androgen deprivation therapy. So on prostate cancer with a goal to get testosterone levels to zero, we give them these hormone blockers. And it’s kind of like a menopause for men that they go through when we have that low testosterone. We know testosterone is converted into estrogen. So that causes low estrogen in men, which can hurt the bones. Women, there’s a corollary with breast cancer. So our breast cancer survivors, we treat with drugs such as aromatase inhibitors, where again, we render estrogen levels to zero. And we see oftentimes a significant amount of bone loss associated with those medications as well. Probably the worst drug that we use, but oftentimes very, very necessary for patients with chronic inflammation or autoimmune disease would be things like steroids. So steroids, I always refer to as somewhat dirty drugs. You know, if you need them, you need them, just like anti-cancer therapies. But those medications as well can really thin bones through a number of different mechanisms. Joe 16:12-16:36 So the anti-estrogens for breast cancer, the anti-androgens for prostate cancer, and the corticosteroids that are used for so many different conditions, including autoimmune disease and asthma and COPD, all of those medications can have a profound effect. Should everybody who’s taking one of those medications get a bone scan? Dr. Kendall Moseley 16:37-18:07 In my humble opinion, absolutely. And I think most guidelines would agree. I, you know, it depends on timing. So the low hanging fruit, the easy answer would be with your anti-estrogen medications and your anti-testosterone medications. And certainly if you know an individual is going to be treated with those drugs, it’s usually for a longer period of time. So anti-estrogen medications upwards of five to 10 years in many breast cancer survivors. Anti-androgen medications oftentimes not as long, but sometimes two years or more. And in those patients, you absolutely do want to get a screening bone density test and anticipate that in fact those medications are going to thin the bones and ideally jump ahead of that problem. And again, we have interventions we can use pharmacologically and lifestyle-wise to anticipate the bone loss and obviously treat it before it becomes a problem. Steroids are a little bit trickier. Steroids in general, we say that if a patient is going to be on a dose of prednisone or an equivalent of 5 milligrams or more for 3 months or more continuously, that would be a dose at which you certainly would want to get a screening bone mineral density test, potentially treat to prevent bone loss, depending on what that screening bone mineral density test shows, and then follow the patient more closely. We’re not as worried about the inhaled steroids. We’re not as worried about steroid injections that patients oftentimes will get for joint pains and arthritis. It really is the systemic steroids that cause the most problems. Terry 18:08-18:15 You’re listening to Dr. Kendall Moseley, Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 18:16-18:21 After the break, we’ll learn the difference between osteopenia and osteoporosis. Terry 18:21-18:24 If you break a bone, does that mean you have osteoporosis? Joe 18:25-18:27 What are the options for treating osteoporosis? Terry 18:28-18:30 Exercise might be helpful. Which ones are best? Joe 18:31-18:33 Should you be wearing a weighted vest? Terry 18:39-18:42 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 18:51-18:54 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 18:55-19:13 And I’m Terry Graedon. Joe 19:13-19:21 Today, we are talking about bones. How would you know if your bones are strong or vulnerable to breakage? Terry 19:21-19:27 What options are available to maintain bone health? Are some exercises better than others? Joe 19:27-19:52 We’re talking with Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins. She’s also Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Terry 19:53-20:17 Dr. Moseley, I think there are a lot of kind of long, complicated words that we need to deal with in this interview that people may have heard or maybe not have heard, but are not completely certain what does it mean. So let’s start with the difference between osteopenia and osteoporosis. Dr. Kendall Moseley 20:18-24:09 Right. I think that’s a great question. There’s a lot of big words in the bone field, and those would be the big ones that patients bring to the office. So we have to think about bone density and bone health and bone strength along a spectrum. So, you know, spectrums are uncomfortable for a lot of people. We like to have our bins, our diagnoses. And so in the bone world, we divide things into normal. We say osteopenia, although we are getting away from that term. We more so use low bone density and then frank osteoporosis. And the World Health Organization would define those three terms based on a T-score. And what is a T-score? So To make a diagnosis, to screen for osteoporosis, we use a very specialized scan called a DEXA scan. It’s a dual energy X-ray absorptiometry scan. You can see why we call it DEXA. And it’s basically a fancy X-ray. And it’s a 2D interpretation of bone quantity, usually looking at the spine, looking at the hip. And it’s two different locations in the hip. It’s the total hip and the femoral neck. And sometimes we even look at a forearm in certain circumstances and disease states. And it’s that fancy x-ray, again, that we use to follow osteoporosis, but more importantly, to diagnose it in those in whom we’re worried that they have thinner bones. That T-score is really just a standard deviation. And the standard deviation is that individual’s bone compared to that of a 30-year-old, which seems very unfair. But as I said earlier in the segment, we really gain bone until about the age of 30. So we’re kind of comparing that patient to what their ideal should have been back in the day. A T-score, anything between 0 and negative 1 is considered normal, so normal bone density. Anything between negative 1 and negative 2.5 or 2.4, excuse me, is considered low bone density or osteopenia. And anything less than or equal to a negative 2.5, again, negative 2.5 standard deviations from normal is considered osteoporosis. And that’s what spits out on the reports, and that’s oftentimes what patients bring to the clinic. Although it’s very, very important to insert a big caveat here. People with low bone density or osteopenia can still fracture. In fact, the majority of fractures, which is the take-home message, we’re trying to prevent broken bones, the majority of people who fracture actually are in the osteopenia or low bone density range as compared to the osteoporosis range bone density. So if someone comes to clinic and maybe that DEXA scan says the T-score is a negative 1.5 or it’s a negative 1.8, which technically, again, is osteopenia or low bone density. If that same patient has also had a fracture, a fragility fracture, that patient has osteoporosis. So it doesn’t matter to me what this screening scan shows. If that bone has broken in a fragility manner, and gosh, I get that question all the time, too, so I’m going to beat you to it. What is a fragility fracture? This is a fracture of the spine, hip, pelvis, wrist, upper arm from standing height or less. So slipping outside on an icy street and bracing your fall with your wrist, if you break that wrist, that is a fragility fracture. Stepping out of the bathtub and maybe the floor is a little bit slippery and you come down hard on your hip and you have a hip fracture, that is osteoporosis. Falling out of a two-story building or a motor vehicle accident and you break your pelvis, that’s just lucky, you know, walked away with just one broken bone. So, again, fragility fractures, no matter what that bone density test is showing, whatever that score says, if you have a fragility fracture, you have a diagnosis of osteoporosis, that should be treated. It’s akin to having a heart attack, right? I don’t need a cath if you’ve had a heart attack to tell me you have cardiovascular disease and we have to take that seriously. Joe 24:09-24:51 I’ve got a question for you because our grandson, who’s seven, was running the other day at camp and he tripped and he fell and he broke his arm. That happens a lot to kids. You know, they fall off the jungle gym or they fall off their bicycle and they land and out goes their arm and boom, they’ve broken it. Now, they don’t have osteoporosis. Why would a woman who falls in a similar situation, maybe while riding a bicycle, why would she be automatically defined as osteoporotic? Dr. Kendall Moseley 24:53-26:07 Well, a woman who falls off a bicycle, that’s considered traumatic, right? So maybe it’s less than standing height because she’s sitting down on a bicycle, but she’s fallen off of a moving object going presumably at a fairly rapid speed and you get entangled in the wheels, etc. So I would probably talk through the logistics of that particular fall, and I would probably walk away saying that was more traumatic than atraumatic. Getting back to kiddos, they’re a different bird. So again, falling off of a jungle gym, that’s from a height higher than standing height. Kiddos also have just very different bones. So their bones are kind of built to be a little bit more flexible. They’re a little bit more rubbery. They remodel at a faster rate. And so they do oftentimes get these fractures, you know, tripping, falling, bonking their heads. We had that a couple of weeks ago in our household. We know those fractures heal very rapidly. Where we start to worry in kiddos, and this is probably beyond even the scope of our discussion today, is when there are multiple fractures, low trauma fractures, you know, situations in which it doesn’t make sense that that arm or that leg breaks. And then there’s a whole host of genetic conditions that oftentimes we will screen for to make sure that, in fact, that child doesn’t have a metabolic disease. Terry 26:07-26:42 Well, I think it’s important for parents to realize that a situation like that requires extra attention. But we’re not going to follow through on that any further. What I’d like to do is go back to your idea that a fracture might institute treatment. And what I mostly hear from people my age, women my age, is that they have been told by their doctor that they have to take a drug because of the osteoporosis. Joe 26:42-26:47 And a lot of them don’t want to take a drug. Or the osteopenia in some cases. Terry 26:47-27:08 Or the osteopenia. And the most popular drugs are the bisphosphonates like alendronate, which used to be called Fosamax. So what options are there for treating osteoporosis? Is bisphosphonates where you start? Or are there other things people can do? Dr. Kendall Moseley 27:10-29:57 Now, when I talk to patients, I always break it down into, gosh, what are things that you can leave here with? What is your to-do list going to look like? And that can be things like calcium, vitamin D, exercise, protein, other healthy lifestyle interventions, and we can get into that absolutely. And then there’s things that maybe I need to do, you know, when the prescription pad may need to come out. When we think about osteoporosis and how we treat osteoporosis, again, we love our bins in medicine. It helps to organize our thoughts and kind of talk to people about how we’re thinking about their disease state. And osteoporosis is no different. We think about it on a spectrum. So is the osteoporosis mild? You know, in a mild case of osteoporosis, maybe just low bone density, no prior fractures. We sometimes use a tool called a FRAX calculator that comes up in the guidelines. If we’re seeing signals that things are generally fairly positive, we might just recommend lifestyle interventions, calcium, vitamin D, some good exercise, protein, et cetera. As we move further down into the different bins, we get into different categories. So moderate osteoporosis or low bone density, where again, the DEXA scan is giving us data, we don’t like to see the numbers are decreasing. There’s maybe an increased falls happening at home. The FRAX calculations are more elevated. That might be a category in which, in addition to lifestyle interventions, we might recommend medical therapy, usually something more mild. You know, if we think about it as a swimming pool, we start in the shallow end and get a little bit deeper. That might be an oral bisphosphonate. For women, we use things called selective estrogen receptor modulators, which act on the estrogen receptors within the bone. As we wade deeper into the pool, we get into the more, you know, severe osteoporosis or, excuse me, high-risk osteoporosis or severe osteoporosis. In those categories, that’s when we start using, again, in addition to lifestyle interventions, the calcium, the vitamin D, and the exercise, that might be a place at which we do start to recommend more intense pharmacotherapy. That might still just be an oral but it may be an infusion, it may be an injection, depending on the case. What I think, though, doesn’t always matter. I think everything comes down to forming a relationship with a patient and talking through what the patient’s concerns are about their bones, what their concerns are about the logistics of a medication. Because if I think you need a daily injection, but you don’t want to do anything, there’s no point in us kind of not reaching any sort of conclusion in terms of treatment. If you’re in a very high-risk fracture category, we might want to start with a bone-building drug. But if you tell me all you’re willing to do is an oral pill once a week, I’d rather not let perfect be the enemy of good. And we might start with something milder, despite what I think. Joe 29:57-30:24 Dr. Moseley, you’ve mentioned exercise a couple of times, and we’ve gotten all kinds of recommendations with regard to exercise. You know, it has to be bouncy exercise. You have to jump up and down. You have to stress your bones. And then we’ve heard from other experts who say, you know, if you do Tai Chi, it’ll actually be good for your bones. Terry 30:24-30:24 Or yoga. Joe 30:25-30:37 Or yoga will be helpful. And so there’s just a lot of confusion around the best kind of exercise or it’s just exercise in general. Walking, will that be helpful? Dr. Kendall Moseley 30:39-32:45 Yes, yes, and yes. So my take home with patients is always just keep moving. Just keep moving. We all have physical limitations, right? There are patients who can’t, you know, run. They can barely walk. Oftentimes they’ll come in in a wheelchair and a walker, but it’s important that they move their bodies. Walking counts in terms of exercise. There are two, you know, big picture issues when we think about exercise and bone or movement and bone. And the first is, yes, is there a way that we can kind of physically tax or stress bone in a way that promotes healthy bone remodeling and bone building. And there are data in individuals who use high-intensity exercise. There was a trial called the LIFTMORE trial looking at women and men, older women and men, with supervised high-intensity exercise about three times per week and showing, in fact, there was benefit to the bone. And this is heavy weights. This isn’t just your little two or three pounders that you’re using, but in fact, supervise, you know, high weight, high intensity exercise, and they gained bone. Is that possible for all patients, to all patients have access to that sort of exercise and gyms and equipment, et cetera? Not necessarily. So the second thing we need to think about with exercise and the importance of exercise is, gosh, how do we keep you upright and fracture free by virtue of the fact you’re not falling? So if we can strengthen individuals, lower body strength, core strength, and you can get that just through walking or through yoga or through Pilates, you know, really making sure that you have a sense of self in space, keeping you from falling, that’s a victory in and of itself as well when it comes to bone strength. So, yes, I mean, would we love everybody out there lifting, you know, 30-pound weights and a supervised setting and potentially gaining some bone? That would be lovely. But I think realistically speaking, we all bring different limitations to a clinical setting. And just moving, again, just getting those legs working, just getting a sense of balance, sending people to physical therapy for balance training and core and posture, that can be just as important as getting them into a gym. Terry 32:45-33:30 Dr. Moseley, there’s something else I’d like to ask you about while we’re on this topic of physically stimulating our bones. Something that’s gotten some buzz is vibration. And there are people who have purchased pads that they stand on that vibrate to try to help their osteoporosis. there is also a device that I saw, I think it has been cleared or approved, I’m not sure which, by the FDA. You wear it like a fanny pack. It’s a belt called an Osteoboost and it vibrates for half an hour a day, provided you wear it that long. Are these devices of any use? Dr. Kendall Moseley 33:32-35:28 I think the jury’s still out. I get those questions all the time in clinic because, Again, I’m very encouraged that patients want to feel empowered with their health and they want to do things other than just take a pill or do an injection. I think it’s important. It’s a partnership that way. What can you do? What do I need to do to strengthen your bones? So vibration plates and these vibratory belts that are out there now, I think they’re trying to get at the pathophysiology of bone remodeling, which is, again, stressing bone, targeting mechanoreceptors that live in the bone that cause release or non-release of hormones that could be detrimental to bone remodeling and bone strength. And I think there’s promise there in the idea that it’s targeting, again, these mechanoreceptors in the bone. What we don’t have with either the vibratory plates or the belt are fracture data. So there are some data potentially showing stability of bone density with the use of these different devices. There are some data potentially showing some improvement in bone density. With the belt, it was only tested in individuals with low bone density or osteopenia. We don’t know in an osteoporosis population. The vibratory plate data is kind of all over the place. But what we don’t have with those devices is fracture prevention data. And that’s always hard to get. Even in the drug trials, you need thousands and thousands of study subjects to determine if that intervention is going to reduce fracture risk. So we may never have that information. So what I tell patients when they bring those, you know, pamphlets to the office or that printout or that clipping from a newspaper article is they say, I don’t think that these devices are going to hurt you at all. I think, in fact, they potentially could be beneficial to you. And how can we work those devices into our treatment plan so that, Again, you are doing things at home that may be beneficial to your bone, but I’m also keeping tabs on your bone density. And we, again, can decide together if we need to ratchet up your treatment plan to the point where we need pharmacotherapy. Joe 35:28-35:38 Dr. Moseley, I’ve been seeing a lot lately about weighted vests or sort of backpacks that are supposed to be good for you. Any thoughts about that? Dr. Kendall Moseley 35:39-36:37 Weighted vests are going to fall into the vibratory plate category and even these belts. And it’s the idea that you want to put deliberate strain on your bones to encourage them to remodel more actively. And again, this is a space where we maybe have some data showing stability of bone density, maybe a little bit of improvement in bone density. We do not have fracture data showing that weighted vests are beneficial to bone health. My challenge I have with them is depending on the vest, and there’s so many different types out there, they sometimes can cause low back pain. They can cause posture problems. We certainly don’t want anyone falling over from their weighted vest. So if there’s any hint that the vest might cause instability in the patient, I tend to be against them. But gosh, if it’s one more tool hanging by the front door that encourages someone to go outside and take a walk with their weighted vest on, by all means, I’m very optimistic that this could be something, again, to motivate people to take their bones into their own hands. Terry 36:38-37:03 You’re listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is also Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 37:04-37:08 After the break, we’ll learn about raloxifene as a treatment for osteoporosis. Terry 37:09-37:12 It might reduce the risk of breast cancer as well as of bone fractures. Joe 37:13-37:20 What other drugs do doctors prescribe for osteoporosis? And what are their pros and cons? Terry 37:20-37:24 Are there problems in stopping certain bone-building drugs? Joe 37:24-37:27 Dr. Moseley will share her pillars of treatment. Terry 37:40-37:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Joe 37:53-37:56 Welcome back to The People’s Pharmacy. I’m Joe Graedon. Terry 37:56-38:13 And I’m Terry Graedon. Joe 38:13-38:23 There are now numerous medications to improve bone health, but they all have some side effects. Which are the safest and most effective? Terry 38:23-38:41 The FDA first approved a drug called raloxifene in 1997 to prevent postmenopausal osteoporosis. The brand name was Evista. Although other osteoporosis medications approved around the same time are still in wide use, raloxifene has almost disappeared. Joe 38:42-38:52 Why don’t doctors consider raloxifene for osteoporosis? This medication has another important benefit that has seemingly been forgotten. Terry 38:52-39:18 Today’s guest is Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is Clinical Director of the Division of Diabetes, Endocrinology, and Metabolism and Medical Director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 39:20-40:00 Dr. Moseley, we’d like to talk about treatment first and some of the medications that you do prescribe. And I’m just curious about a drug that seems to have been forgotten. I mean, it never really gained much popularity, but it’s, I think, kind of an interesting medication called raloxifene because it has both, I’ll call it pro-estrogen and anti-estrogen activity, which seems like an oxymoron. Like, how could that possibly be? But could you just give us a quick overview of a drug that seems to have gotten kind of dusty in the dustbin of history? Dr. Kendall Moseley 40:02-43:08 Sure. I don’t think of it that way as a dusty drug. We actually use a fair amount of it in our clinics because it has a role in osteoporosis care. So raloxifene is what we call a SERM. It’s a selective estrogen receptor modulator. And as you indicated, it has stimulatory properties at the level of the bone and actually inhibitory properties to tissue such as the breast and the uterus. So raloxifene is actually similar to a drug called tamoxifen that many women and men have heard of it that’s used as an anti-breast cancer medication in that patient population. So raloxifene, for starters, because it’s a selective estrogen receptor modulator, is not to be used in men. It is solely to be used in women. And we generally, as I was talking about those bins of risk, the low, the moderate, the high risk, and very high risk, we generally reserve that medication for individuals in a low to moderate risk category. And that’s because we have data showing that raloxifene, in fact, does reduce the risk of vertebral compression fractures. And again, we look at different types of bones and different fractures. We don’t have as much data demonstrating that raloxifene actually reduces the risk of hip fracture. And so when we have patients who maybe have low risk or moderate risk osteoporosis, it’s spine predominant, we see that that’s the lowest site. Oftentimes we will use raloxifene. It’s a daily pill. It’s easy to take. It’s easy to stop. It has a relatively low side effect profile. So probably the first thing I warn women is beware, your hot flashes may come back once you start this medication. Some run for the hills when I bring that up. Others say no problem. It doesn’t typically last forever, but certainly for the first few weeks or so, those hot flashes can come back. The other side effect that’s certainly more serious than the hot flashes would be that it can increase the risk of blood clots and stroke as a result. So if there’s a patient who has a history of blood clots or a clotting disorder or pulmonary embolus, again, that would not be a medication of choice. The reason it is appealing to a lot of women and certainly even our use in clinic is it doesn’t necessarily come with the more scary side effect profile that some of the other drugs have. So, again, you can start it and stop it at any time without any ramifications, no rebound bone loss. You can take it indefinitely as long as the patient is tolerating it without concern for jaw necrosis or atypical femur fractures that, again, come up with some of our other drugs. So it’s fairly easy to use. It’s inexpensive. We don’t typically have to fight the insurance companies too terribly hard to get it prescribed. So that’s helpful. And we actually wind up using raloxifene a fair amount for, again, those patients who come in and they acknowledge that their bones are less than perfect. They’re concerned about their bone health, but perhaps they’re similarly concerned about medication side effects. And again, in the interest of not letting perfect be the enemy of good, if what we decide upon is raloxifene, this daily pill that may not have that hip fracture prevention data, it’s certainly better than nothing. So again, in our bone clinics, we do use it. Joe 43:08-43:51 And the thing that I think a lot of women find very attractive about raloxifene is that it It has a breast cancer prevention piece as well as, as you pointed out, a vertebral fracture prevention piece. So it’s sort of a double benefit. But let’s move on, Terry, to some of the other medications because, as you’ve already mentioned, there are some pretty serious side effects. And you mentioned atypical femur fracture. We want to talk about the tooth problem. And we want to talk about some of the newer drugs that are injectable that once you get them, it may be in your body for six months or longer. Terry 43:51-44:04 But let’s take that one at a time. So let’s start with those bisphosphonates that Joe was alluding to. What drugs are we talking about? When do you use them? What do people need to know about them? Dr. Kendall Moseley 44:06-47:19 Right. So we can start, I guess, with the bisphosphonate category. And bisphosphonates are probably the old guard of the osteoporosis regimen. I mean, they started, you know, greater than two decades ago with use of these. And probably the one most people have heard about is alendronate. Alendronate is a once-a-week pill that’s a little bit challenging to take. You take it first thing in the morning, full glass of water, nothing else to eat or drink for an hour, no going back to bed. And these medications, the way that they work in the bisphosphonate category is they are drugs that effectively get incorporated into the bone, into the hydroxyapatite matrix of the skeleton. And once these drugs are incorporated into the bone and they come in proximity of those Pac-Man cells, see here those cells come back again. When those Pac-Man cells come along and encounter these bisphosphonates, they effectively render the Pac-Man cells, the osteoclast, useless. So they can’t break down bone anymore. they’re incorporated into the skeleton, so they do have a lasting effect. And when I talk to patients about these, we kind of think about it like coats of paint, right? So with each year that you’re on these drugs, you kind of paint the wall once again and once again and once again, and the paint can accumulate, which is why there can be concern about long-term use of these medications. And I’m going to throw five years out there, but there’s no rule that five years is a maximum amount of use you can do these. But after about five years of use, we do start to consider a pause in therapy in the appropriate patient because of these layers of pain and this, you know, potential paralysis of the Pac-Man cell and paralysis of a bone remodeling process can cause adynamic and potentially more brittle bone. You know, if your bones are frozen and they can’t rebuild and remodel themselves, we worry that that’s not healthy either for the skeleton because we do start to encounter very rarely atypical femur fractures where kind of there’s a hip fracture that happens below the, you know, kind of along the thigh, which is not anticipated, or we can see jaw complications with jaw erosion, that things can get infected, all stemming from this idea that brittle old bone can’t rebuild, remodel, and heal itself as easier as, you know, refreshed bone. There’s an IV formulation of that pill now called zoledronic acid. It’s administered once a year. So in patients who really aren’t good at swallowing pills, patients who have esophageal disorders, history of ulcers, which can be a side effect of the alendronate therapy or the oral bisphosphonates, this once a year drug can be quite helpful. It’s given through the vein over about 30 minutes. That one, typically three to five, although again, with an asterisk in the appropriate patient, sometimes we go shorter versus longer. But that drug two, similar side effect profile with rare risk, again, of these atypical femur fractures and jaw necrosis. But I always like to pause there and say, you know, these are rare side effects and we have to always consider the alternative, which are what are our real concerns about you breaking your hip or breaking your spine or losing bone in the context of that new steroid that you’ve been prescribed. So it’s always a balance talking about side effects of medicine, which they all have, and the benefit of the drug at the end of the day and reducing fracture risk. Oftentimes we have to 50 to 60 percent. Terry 47:19-47:32 And I’m supposing that there’s no really good way to predict ahead of time who might be at higher risk for one of those really awful side effects like an atypical femur fracture. Dr. Kendall Moseley 47:33-49:37 Yes, I mean, I wish I had a crystal ball. I mean, we do know that there are certain individuals at higher risk for the more rare but real side effects. So jaw necrosis, in general, the risk will be higher in, let’s say, cancer patients. So they get bisphosphonates at much higher doses, much more frequent doses. But even in osteoporosis patients, and it would typically be in the setting of what we consider to be invasive dental work. So this is if you are having an extraction, you’re having an implant, you’re having a bone graft where there’s kind of deliberate invasion of the jaw bone itself that can become subsequently infected. and the concern is that bone once infected can’t heal itself well and can, you know, erode over time. We get questions a lot about things like root canals or what about, you know, braces. Sometimes our orthodontists are worried about braces or bridges, caps. Those are not invasive. We’re not getting into the jaw in those contexts. So again, we’re less worried about that and the jaw necrosis complication. Atypical femur fracture is something that typically we have observed, and it’s been really since the onset of alendronate. Women used to get a prescription for alendronate in one hand and hormones in the other hand, and it was see “see you again never.” So we’ve learned now that with longstanding bisphosphonate use, we can see these atypical femur fractures. And that’s why I gave that five-year number a little bit ago, which is where after about five years of use, We don’t see a precipitous increase in atypical femur fractures, but we certainly start to consider, is this medication actually necessary? Because that long-term use can be a problem. We see increased risk in individuals on bisphosphonates who’ve also been treated with long-term steroids. Both conditions can cause this adynamic or frozen bone. And we know that Asian women are at higher risk for atypical femur fractures. So that’s something that we always want to consider when meeting with the patient, again, on that yearly basis to decide whether or not it’s appropriate to continue therapy versus discontinue the therapy. Terry 49:38-50:12 Now, Dr. Moseley, let’s assume that your patient has been on a bisphosphonate for five years, has stopped, comes back to you in a year or two, and you say, that osteoporosis, it’s still a problem. We’re going to move on to the next category of drugs. You have those bone-building drugs, but there’s a problem with them as well. You mentioned before that raloxifene, the SERM, is easy to stop, but some of these bone-building drugs, they could be hard to stop. Dr. Kendall Moseley 50:13-50:25 Well, I want to kind of push back a little bit on the bone-building. I think the drug you may be referring to is denosumab, which actually is a drug, which is an anti-breakdown drug, first and foremost. Joe 50:26-50:42 And Dr. Moseley, a lot of people are not familiar with generic names like Alendronate or Denosumab. So we’re talking about Fosamax in the case of the bisphosphonates, and Prolia is the brand name for Denosumab. Terry 50:42-50:46 Or is it pronounced Prolia [pro-LEE-ya]? I’m never sure exactly how, and I’ve heard it both ways. Dr. Kendall Moseley 50:47-52:44 I’ve heard it in both scenarios as well. You could probably use them interchangeably. And I’m glad you said that too. The academician in me has been taught never to use the trade names. But no, the denosumab, the prolia, or prolia, however you’d like to inflect that, that’s the one that’s an anti-breakdown drug that has more anabolic properties. So if you want to gain bone, oftentimes we do see more improvements statistically at the spine and the hip with that every six-month injection. But indeed, and I’m glad you brought this up, Terry, because it’s important, that drug, once you start it, it can be challenging to stop. That drug works very differently from the bisphosphonates. It is what’s called a RANK ligand inhibitor, which basically interferes with how the osteoclast and the osteoblast communicate with one another. But it’s a monoclonal antibody, meaning it doesn’t get permanently incorporated into the skeleton. Rather, it’s given every six months because it’s almost as though the clock strikes midnight when you stop it. And all of these cells, all of these osteoclasts that have been kind of paused for the duration of the use of the medication, if you stop it abruptly, they wake up and have a party and can actually break down your bone at a very rapid rate to the point at which we’ve even seen spontaneous vertebral compression fractures in patients who stop their medication without talking with their doctor first. So that drug gets every six months. It is not impossible to stop. In fact, we’re looking as a society at different transition mechanisms, usually, and almost, actually, I’ll say almost always with the use of a bisphosphonate to try to prevent this rebound effect of the drugs to see if patients can stop the medication. but it can be very challenging. So that drug is not for those who come to see me and don’t want to take anything or those who oftentimes have a difficult time making it to their clinic appointments. That is a drug for individuals highly committed to their bone health and very dedicated to a treatment course of 5, 10 or even beyond that years. Joe 52:45-53:28 Dr. Moseley, what about estrogen? I mean, estrogen, it seems like a roller coaster ride. Back in the, oh, I’d say 1970s, 1980s, Premarin was the number one most prescribed drug in America. Just about every woman who was going through menopause was put on Premarin. It’ll take away your hot flashes. It’ll build your bones. It’ll make you feel sexy. I mean, it’s the greatest. And then of course along came the women’s health initiative and then oh my goodness no estrogen it’s too dangerous and now it seems like estrogen is coming back again tell us a little bit about estrogen and bones. Dr. Kendall Moseley 53:29-55:08 Yes, well I mean, that’s uh, you’re right it’s a very very hot topic now and I think we’re all kind of re-evaluating how we think about estrogen not just for bone health but also women as they’re going through the perimenopause, you know, did we kind of throw the baby out with the bathwater, so to speak? We love estrogen for bones. You know, as I described earlier, women lose a tremendous amount of bone density through their perimenopause due almost entirely to this decline in estrogen. It’s like we take the brake off of the osteoclasts and they wake up and they break down a lot of bones. So we absolutely like estrogen for bones. What’s happened though, is that estrogen is really not first-line treatment for osteoporosis or low bone density, in part due to the fact that we do have these data potentially in older women showing increased cardiovascular risk, increased cancer risk. So we don’t typically use it as a first-line drug to treat osteoporosis or prevent bone loss. But if we do see women who are on estrogen for other purposes, maybe they’re on it for vasomotor symptomatology or mood or difficulty with sleeping, We certainly will keep those women off on their hormones, excuse me, and potentially add additional therapy down the road for bone health if we feel that it’s warranted. So we’re probably going to see that pendulum continue to swing back. There is a committee being formed as we speak to reevaluate this exact question about the role of menopause hormone therapy and osteoporosis treatment to see, again, if maybe we got a little bit ahead of ourselves and underestimated the importance of estrogen and bone health, particularly in younger women. as they go through the early stages of their menopause. Terry 55:09-55:21 Dr. Moseley, unfortunately, I don’t have these generic names on the tip of my tongue, but drugs like Forteo, for example, now, is that a drug that is meant to build back bone? Dr. Kendall Moseley 55:22-57:04 Absolutely. I’m glad we’re spending some time on this because it’s a very important category of medications, these anabolic or bone-building drugs that we use in these high-risk fracture individuals. So very low bone density, multiple fractures, oftentimes failing other drugs, where we have to turn to this category of bone building drugs. And there’s a few, luckily, in that category now. So starting with your self-injection medications for up until about two years, we’ve got abaloparatide and teriparatide, also known as Tymlos and Forteo. And these are subcutaneous injections that patients, in fact, give themselves. And sometimes we see those eyebrows shoot straight up when that seems to be a tall ask for the patient. But it’s a self-injection for up to two years. It’s actually parathyroid hormone, interestingly enough. So we’re harnessing the body’s own hormone, giving it back to patients in a pulsatile fashion, which can increase bone density. And then the other drug that’s slightly newer approved in 2019 called romosozumab or Evenity, which are subcutaneous injections administered monthly in a healthcare setting for up to one year, so 12 sets of injections. It should be noted that all of the bone-building drugs, the abalaparatide, the teriparatide, and the romosozumab, after that one- to two-year treatment duration have to be followed by an anti-breakdown drug. If they’re not followed by an anti-breakdown drug, either an oral bisphosphonate, an IV bisphosphonate, or denosumab, in fact, those patients very sadly can lose whatever bone they’ve gained while on treatment back down to baseline, which is always a very, very sad day when we see those patients in clinic because it’s a wasted opportunity to build good bone. Joe 57:05-57:40 Dr. Moseley, there’s one important area that we have not talked about, and that is fall prevention. You know, we talk a lot about exercise. We talk about other lifestyle changes, but avoiding a fall may be the most important thing of all in preventing a fracture of the hip or even a fracture of arms or legs or goodness knows what else. So how can not just women, but older men avoid a fall that could lead to a fracture? Dr. Kendall Moseley 57:41-59:36 Right. No, I think that’s a tremendous question. In fact, every clinic visit, when I see patients, we go through, have you had any falls this year? The first step is assessing the home. And I think the majority of falls happen in the home and it might be a throw rug. It may be furniture that’s too close together. It may be, you know, plastic toys from the grandchildren underfoot, pets. I’m not saying get rid of the grandchildren or the pets, but we do have to be conscientious about our home environment to make sure there’s grab bars on the shower. Make sure that the impediments to just walking aren’t challenging. Some people choose to move to single-story homes, you know, if stairs become too difficult. I think that’s also something to consider. But then there’s also the strengthening itself, the balance and the posture. So oftentimes we fall when we become unstable. Sometimes we don’t have a choice. There’s neuropathy, excuse me, that sets in due to nerve conditions, diabetes, et cetera. Sometimes there’s low vision that we have very little control over. But those things that we can modify, lower body strengthening, posture, core strength, which certainly over time become weaker, people become more stooped. all of those things lead to increased risk of falls. And then finally, we have to really, as clinicians especially, reevaluate those medication lists. I think geriatricians or, you know, boneheads, people across the board agree that a lot of times falls happen because of the medicines we put people on. And this can be anything from anti-diabetes medications, which can cause dips in blood sugar and cause some dizziness, to different types of nerve medications that may cause dizziness over treatment of blood pressure, where blood pressure is quite low. I see many, many falls in the context of maybe overly aggressive medication regimens, or maybe patients just aren’t talking about how they feel dizzy every single time they stand up after that new blood pressure medicine was added. But we really owe it to our patients to make sure that every drug on that medication list needs to be there, particularly as it pertains to fall safety. Terry 59:37-59:51 Dr. Moseley, we have only two minutes left of time. So I am going to ask you to summarize, please, your pillars of treatment, the things that we all need to take away from our conversation today? Dr. Kendall Moseley 59:52-01:00:03 Oh, so many pillars and so little time. So we started with lifestyle. It absolutely is important that patients really follow as healthy a lifestyle as possible. Calcium is important for bone… Terry 01:00:03-01:00:04 How much? Dr. Kendall Moseley 01:00:03-01:00:09 I know there’s a lot of debate. So calcium, the recommendation… Joe 01:00:07-01:00:09 How much and what kind? Dr. Kendall Moseley 01:00:09-01:01:27 So exactly. So the boneheads and even the cardiologists agree that calcium for those with established bone disease, again, this is not a healthy community dwelling population, but those who make it into a bone clinic who are at risk for fracture, 1200 milligrams a day, ideally through diet, ideally, but there are dietary restrictions. So if you have to take a supplement, calcium citrate is the supplement of choice. It’s better absorbed. You don’t have to take it with a meal. And in fact, it does not require an acidic environment for absorption. Vitamin D, very important. Ideally, we’re shooting for a blood level anywhere between 20 to 30 nanograms per milliliter, depending on what guidelines you look at. And for some patients, that might mean 1,000 units a day. For others, 5,000 units a day. For others, prescription strength. So that’s something to work on with their physician. Exercise so resistance training and walking counts about 150 minutes per week as high intensity is tolerated and then finally protein we really protein is having its moment so we want to aim for 0.5 grams of protein at least per pound of body weight because we know we lose muscle as we get older and that’s critical for bone health so lifestyle factors and then obviously the pharmacologic strategies as we discussed earlier if absolutely necessary. Terry 01:01:28-01:01:33 Dr. Kendall Moseley, thank you so much for talking with us on The People’s Pharmacy today. Dr. Kendall Moseley 01:01:34-01:01:42 Thank you so much for having me. And it’s always a joy to talk to people who are interested in bones. And hopefully people walk away with a few little lessons themselves today. Terry 01:01:43-01:02:08 You’ve been listening to Dr. Kendall Moseley, Associate Professor of Clinical Medicine in the Division of Diabetes, Endocrinology, and Metabolism at Johns Hopkins University School of Medicine. Dr. Moseley is clinical director of the Division of Diabetes Endocrinology and Metabolism. She’s also medical director of the Johns Hopkins Metabolic Bone and Osteoporosis Center. Joe 01:02:09-01:02:18 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:02:18-01:02:25 This show is a co-production of North Carolina Public Radio, WUNC with the People’s Pharmacy. Joe 01:02:26-01:02:55 Today’s show is number 1446. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview and let us know what you do to keep your bones strong. You can also reach us through email. We’re radio at peoplespharmacy.com. Terry 01:02:56-01:03:19 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, you can hear how estrogen might be used to make bones stronger. What about other drugs that build bone? What practical steps could you take to prevent falls and avoid breaks? Joe 01:03:19-01:03:43 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We’d be grateful if you would consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:03:43-01:04:21 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:04:22-01:04:31 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in. Terry 01:04:32-01:04:36 All you have to do is go to peoplespharmacy.com/donate. Joe 01:04:37-01:04:50 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

The statistics are shocking. At any given time, nearly one fourth of American adults are experiencing low back pain. Even worse, roughly one-third of the population will have to deal with chronic pain at some point in their lives. How does the brain react to pain? What can people with chronic pain do to alleviate their suffering? Our guest is a nationally recognized pain expert with a number of suggestions. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Sept. 20, 2025, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Sept. 22, 2025. Chronic Pain: We are all familiar with the instantaneous pain of having your hand contact a hot pan. In that case, pain serves its most important function, warning us not to do that again! Many people have known the pain of a sprained ankle or a twisted knee. In most cases, we recover from such mishaps in time, and the pain becomes a memory. But sometimes, the brain circuits get stuck, so to speak, and we end up with ongoing chronic pain. That can last and cause suffering well after the original stimulus has disappeared. There is no evidence that suffering is good for the soul. The Experience of Pain Is Personal: It is critical to remember that pain is subjective. The nerves may carry a sensation of “heat” from that hot pan or “pressure” if you slam your thumb in the door. It isn’t pain until the brain interprets it. And brain interpretations can and do vary from one person to the next. Past experience and levels of social support as well as expectations of relief influence the ways that people feel pain in response to injury. Personalizing Treatment of Chronic Pain: If the experience of pain, especially chronic pain, is highly individual, shouldn’t treatments be individualized as well? Every pain patient deserves an individualized assessment, with particular attention to red flags that might be warning of an imminent medical emergency. Ruling that out must not invalidate the patient’s experience. Then the patient and provider can proceed to work on a multi-modal approach to pain control. How Will the New FDA Opioid Guidelines Affect Patient Care? The FDA recently issued new guidelines on the use of opioid (narcotic) pain relievers.  The agency will require much clearer warnings about the risks of such medications, especially when used for longer periods of time. Prescribers will be reminded to use the lowest effective dose for the shortest time needed. They will also be reminded that these drugs should never be stopped suddenly, because that could trigger withdrawal symptoms. Should people be avoiding opioids? Dr. Mackey thinks the new guidelines are in line with precautions that responsible prescribers are already observing. What Non-Drug Approaches Can Help Chronic Pain? We asked Dr. Mackey when non-pharmacologic approaches are appropriate, and he responded that they are always appropriate, sometimes in conjunction with rather than instead of medication. There are at least six categories of tools for pain, including medical interventions (surgery, for example), mind-body approaches such as mindfulness-based stress reduction (MBSR), physical therapy, nutraceuticals, complementary and alternative therapies (such as acupuncture) and medications. Each of these categories might have only a small effect by itself but taken together they can provide substantial relief. What About Drugs? There are probably a couple of hundred drugs that could be helpful, only a handful of which are opioids. So even for people who don’t tolerate opioids, there are plenty of tools to help alleviate pain. Dr. Mackey does prescribe opioids, but he also prescribes medicines such as topiramate, duloxetine, ketamine and low-dose naltrexone, among other medications. Keeping in mind that everyone is different, these will be used in a variety of methods and combinations, depending on patient response. How Can Patients Find a Pain Doctor? In some parts of the country, especially rural areas, it may be difficult to find a healthcare provider skilled at treating chronic pain. Dr. Mackey suggests utilizing the resources of the American Academy of Pain Medicine. Another resource, possibly more for providers than patients is Doximity. This Week’s Guest: Sean Mackey, MD, PhD, is a pain management specialist and anesthesiologist. He holds the titles of Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine (Adult Pain) and, by courtesy, of Neurology and Neurological Sciences, all at the Stanford University Medical School. Dr. Mackey is Chief of Stanford’s Division of Pain Medicine and a past President of the American Academy of Pain Medicine. His website is https://seanmackey.people.stanford.edu/research Sean Mackey, MD, PhD, Stanford University Division of Pain Medicine Listen to the Podcast: The podcast of this program will be available Monday, Sept. 22, 2025, after broadcast on Sept. 20. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll learn what is happening in the brain when we feel pain. We also discuss the anger and depression that so often accompanies chronic pain (and may unwittingly exacerbate it). You’ll also hear about two drugs often used to treat pain. The gabapentinoids gabapentin and pregabalin can be helpful in some situations. What side effects should patients be warned about? Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Watch the Video: Here is a clip from our interview with Dr. Mackey.   Transcript for Show 1445: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon.   Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy.   Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. The CDC estimates that almost one in four American adults suffers chronic pain. Are there successful treatment strategies? This is The People’s Pharmacy with Terry and Joe Graedon.   Terry 00:34-00:43 The experience of pain is deeply personal. Shouldn’t treatment strategies be personalized as well? What works for one person might not help someone else.   Joe 00:44-00:53 We’re honored to be speaking with one of the country’s leading pain experts. Dr. Sean Mackey is Chief of Stanford’s Division of Pain Medicine.   Terry 00:54-00:59 Dr. Mackey will offer insights into the multimodal approaches his patients have found helpful.   Joe 00:59-01:07 Coming up on The People’s Pharmacy, your brain on pain. Why chronic pain changes everything.   Terry 01:14-02:01 In The People’s Pharmacy health headlines, daylight savings time will come to an end on November 2nd, But scientists don’t agree on the health implications of turning the clocks back an hour. A Stanford University study published in the Proceedings of the National Academy of Sciences suggests that going back and forth between standard time and daylight savings time disrupts circadian rhythms. The researchers found evidence that this increases the risk for obesity and stroke. They calculated that sticking with standard time year-round would prevent 300,000 strokes each year and cut down on obesity. People who usually stay up late suffer greater biological consequences from shifts in time regimens.   Joe 02:02-02:59 Previous research blamed changing clocks for higher rates of car crashes and heart attacks. That may have inspired the Stanford scientists. However, researchers at Duke University have just published their analysis of data from 168,870 patients over the course of a decade. The study in JAMA Network Open found no differences in heart attack rates in the weeks before and after changes to daylight savings time. In addition, they found no increase in stroke or mortality. These dueling findings could leave policymakers in a quandary. Should we stop switching times twice a year because of the possible risks involved? Or is it actually relatively safe to switch into and out of daylight savings time? Clearly, the answer is the common and extremely unsatisfying conclusion. More research is needed.   Terry 03:00-04:10 Another topic that has been controversial for decades is hormone replacement therapy to relieve menopausal symptoms. HRT is unquestionably effective, but the Women’s Health Initiative raised serious doubts about its safety over 20 years ago. Instead of reducing the risk of coronary heart disease, as expected, HRT actually appeared to increase heart risks. A new analysis of these data, published in JAMA Internal Medicine, found that women in their 50s did well on hormone replacement therapy, But women in their 70s appeared to have an increased risk of atherosclerotic coronary vascular disease if they were taking estrogen, alone or with progestin. The authors conclude, the findings support guideline recommendations for treatment of vasomotor symptoms with hormone therapy in women aged 50 to 59 years. caution if initiating hormone therapy in women aged 60 to 69 years, and avoidance of hormone therapy in women 70 years and over.   Joe 04:11-05:05 The FDA has announced that it will be cracking down on direct-to-consumer prescription drug advertising. The Commissioner of the Food and Drug Administration, Dr. Marty McCary, offered a viewpoint in JAMA outlining the new approach. The agency will be rolling back a 1997 loophole that allowed pharmaceutical manufacturers to shorten the length of cautions and side effects in ads or commercials. The FDA will now require much more complete disclosures of risks. That could make advertising prohibitively expensive and less appealing. Commissioner McCary concluded, quote, we will no longer tolerate deceptive practices that distort the patient-doctor relationship and waste billions of dollars in health care resources that could be better spent lowering drug prices for Americans.   Terry 05:06-06:17 Israeli scientists have been studying a green Mediterranean diet for years. This eating pattern follows the Mediterranean approach of lots of vegetables, fruits, and whole grains, and very little meat, sugar, or processed foods. In addition, a green Mediterranean diet includes green tea and a green smoothie containing the water plant mankai every day. The study examined the status of approximately 90 proteins found in the blood. Two, in particular, were lower in people whose brains were functioning well. They’re called galactin-9 and decorin. Following a green Mediterranean diet seems to lower the levels of these proteins and might help slow cognitive aging. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon.   Joe 06:17-06:28 And I’m Joe Graedon. Have you ever burned yourself on a hot frying pan or hurt your back lifting something too heavy? Describing your pain level to someone else can be difficult.   Terry 06:28-06:36 Acute pain like that is something almost everyone has to deal with. Chronic pain, on the other hand, can be far more challenging.   Joe 06:36-06:55 To help us better understand the nature of pain and how to treat it, we turn to Dr. Sean Mackey, a pain management specialist. He holds the title of Redlich Professor at Stanford University Medical School, where he’s also Professor of Anesthesiology, Perioperative, and Pain Medicine, and by courtesy, of Neurology and Neurological Sciences.   Terry 06:56-07:02 Welcome back to The People’s Pharmacy, Dr. Sean Mackey.   Dr. Sean Mackey 07:03-07:22 Hey, it’s great to be back. I heard a lot of wonderful comments about the last show, and it always makes me feel good when the information that you folks are putting out there related to pain is making an impact in everyone’s lives. So thanks for all you’re doing and appreciate the opportunity to come back.   Joe 07:22-07:52 And thank you for your work, Dr. Mackey. We are so grateful to be able to speak with you again about pain. And, you know, pain, it’s such a personal thing. And it’s so hard to measure. So many times, you know, if a doctor is asking you, well, what’s your pain level on a scale of one to 10? And of course, that’s somewhat qualitative. And it’s hard for one person’s pain to compare to another person’s pain. It’s totally qualitative.   Terry 07:53-07:59 And it also depends on what your experience of pain may have been in the past.   Joe 07:59-08:49 Yeah, I do have a quick story to tell you about a dear friend of mine who recently had to undergo a medical procedure. And it was supposed to be, you know, kind of a minor procedure, no surgery involved, a little lidocaine, no big deal. He said it was the most excruciating pain of his life. This is a big guy. He’s like 6’4″, probably weighs about 230 pounds, lifts weights, does all kinds of stuff. And it was like, I couldn’t bear it. I was screaming inside. And some of those screams came out. So tell us about this thing about personal pain and how variable it is from one person to another.   Dr. Sean Mackey 08:49-11:24 Yeah, I think you hit it. You hit it perfectly. And therein lies the challenge we have with understanding, getting our heads wrapped around this concept of pain, because we all believe we know what it is because we base it on our own personal experiences. But the problem is that our personal experiences don’t translate to anybody else. And it’s getting back to what you said, this nature that pain is an individual and subjective experience. And that’s counter to everything that our beliefs are, our eyes see, and what we understand, meaning we all expect that there to be this direct one-to-one link between the amount of tissue damage and the amount of pain that somebody experiences. And that model, that mechanistic model was put forward by Rene Descartes back in the 17th century. And while he is a really smart guy. He gave us Cartesian geometry. He gave us some modern philosophical beliefs. He was completely wrong when it came to pain.   You have to think about pain in the context of how you would think about love. Like, how much do you love your child on a scale of zero to 10? How much do you love your dog? And then, you know, but it’s such a silly thing. Nobody, how many times have you ever been ask, hey, how much love do you feel? Nobody would ever ask that. But that is the same concept that we have to do when we’re talking about pain.   And the message that I would give people is pain is individual. And it is encapsulating all our prior life experiences, all of our thoughts, our moods, our emotions, everything we’re bringing into that experience right now. And whatever that person is experiencing, just accept it. We put a pain scale to it, which is probably more to get a sense of how much impact the pain is having, how much distress they’re having, than it meaning something really objective. And that is one of the key messages also, that this individual variability, we have to take care and not putting it onto others, particularly when making policy decisions and making broad statements about what somebody should be taking or not taking, what treatment they should be getting or not taking. Use it as a guide, no more or less.   Terry 11:26-11:47 Dr. Mackey, maybe we could ask a very simple question that may have a really complex answer, And that is, how do we feel pain? How do the sensors in our skin or elsewhere in our bodies send signals to our brain that become our pain experience?   Dr. Sean Mackey 11:48-14:05 Yeah. And that’s such an important foundational question because you’ve got to start there before you can really understand the nature of pain. So pain all starts typically with something happening out in your periphery, your periphery meaning in your body, your fingers, your hands, your legs, your arms, your abdomen, what have you. And in that, we have these little tiny sensors called nociceptors, technical term, but they’re just simply acting like a transducer.   Now, a transducer is defined as something that converts one form of energy into another form of energy. It just, this microphone is a transducer. It converts sound energy into electrical energy. Those nociceptors are converting pressure, temperature in the form of heat or cold into a little electrical signal that transmits up nerves. And we have special nerve fibers that transmit what will be the perception of pain. But it’s not pain yet, still in the body. It’s what we refer to as nociception.   Those signals go to our spinal cord. Back here, this long set of nerve fibers and nerve cells that are in our spine. And there’s some processing. There’s some little computers back there that are processing the signals, altering them, changing them, and then they’re sent up to the brain. And this is the key point. Until it hits your brain and it becomes the perception of pain, before then it’s all still nociception. But once it hits the brain, that’s where this experience, this wonderful and terrible experience of pain occurs. Wonderful. Because this experience of pain keeps us out of danger. We only had to touch a hot stove once to learn not to do it again. It keeps us away from injury, from harm. And back in the cave people days, it kept us away from being eaten and being prey.   Joe 14:06-14:21 Well, you know, Dr. Mackey, there are people who don’t have pain. And they are in terrible trouble because they do burn their fingers and hurt themselves because they don’t know how to avoid that hot stove.   Dr. Sean Mackey 14:22-15:25 You’re right. The problem that we’ve had is that those people are typically the protagonists in a TV show or a movie. And they’re made to look like supermen or women, where they can jump off buildings and land without getting hurt. Well, they don’t feel pain when they jump off the building or when they get stabbed, but they are getting injured. They leave that part out of the movie or the TV show.   It is a tragic, tragic situation to be born with this thing called congenital insensitivity to pain. These unfortunate children have to be continually protected from themselves because they can’t tell when they’re injured. And they typically die at an early age unless the parents go to extreme efforts to keep them safe. So you don’t under any circumstances, despite the movies and the TV shows, ever want to have that condition.   Terry 15:26-15:27 I’m assuming it’s very rare.   Dr. Sean Mackey 15:28-15:35 Very, very rare. I can’t even quote you how many zeros are before the final digit and the percentile. Very rare.   Joe 15:37-16:09 So pain is protective, but it also causes incredible agony and affects tens of millions of people. What worries me is that there are people who believe that suffering is good for the soul. If it didn’t kill me, it’ll make me stronger. And for those people, I think that is a real misnomer. It’s like, oh, no, pain is not good for the soul. Yeah, I’ve heard that one.   Dr. Sean Mackey 16:10-17:32 First of all, if you’ll allow me to gently add a zero to your numbers, it actually affects probably hundreds of millions. And I’ll even take it bigger if you want to go global and say billions. You know, you’re probably looking at a prevalence rate of around 30% or so. So, you know, close to one in three people on this planet probably have some level of chronic pain.   Now, people will listen to that and some will be skeptical and they’ll say one in three. I don’t see one in three suffering from chronic pain. And what you have to do is add some context to that. Meaning you have people with chronic pain that are self-managing at home. These are people like my father who, you know, had from all the sports injuries and everything else, a lot of back pain, a lot of arthritis, and wouldn’t see a doctor about it, wouldn’t even listen to me. And he just kind of sucked it up and dealt with it until it got too much.   And then you have people that end up in our clinic at Stanford, a tertiary referral center who have terrible high-impact chronic pain, who are seeking medical care, and everybody in between.   But pain is with us in society. It takes a terrible toll. In the United States alone, over half a trillion dollars we spend in chronic pain.   Joe 17:33-17:47 Dr. Mackey, we’re going to take a short break, but when we come back, we need to talk about what people can do for that chronic pain. One in three, that’s an astronomical number.   Terry 17:47-18:13 You’re listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey is a past president of the American Academy of Pain Medicine.   After the break, we’ll reconsider the idea that suffering is good for you. The FDA is changing its recommendations on opioids again.   Joe 18:13-18:25 Should patients avoid opioids? How have the new guidelines affected doctors and patients? You’ll hear about alternatives to opioids. When are non-drug approaches to chronic pain most appropriate?   Terry 18:39-18:42 You’re listening to the People’s Pharmacy with Joe and Terry Graedon   Terry 20:42-20:35 Welcome back to The People’s Pharmacy. I’m Terry Graedon.   Joe 20:45-21:08 And I’m Joe Graedon. Chronic pain, it’s debilitating. It can take over your life and make it hard to focus on anything else. There was a time when opioids were among the most prescribed drugs in the country. But now, most health care professionals are very cautious about prescribing medications such as hydrocodone, oxycodone, or fentanyl.   Terry 21:09-21:22 What other options are there for people in pain? Are there non-drug approaches that can be helpful in alleviating pain? Our guest today has a six-point strategy for pain relief that involves a number of different disciplines.   Joe 21:23-21:53 We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s chief of Stanford’s Division of Pain Medicine. His research aims to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.   Terry 21:55-22:17 Dr. Mackey, we have just floated the idea that seems to be popular in some quarters, probably not among the one in three people who are suffering chronic pain, that suffering itself is good for the soul in some way. Why is that such a questionable premise?   Dr. Sean Mackey 22:20-23:48 You know, I think where it’s come from, or at least the camps that I’ve seen it from in particular, are those who want to deny or restrict certain treatments from patients. And the problem is that once you cut those off, those people aren’t left with anything, anything else.   And so then the narrative turns to, well, it’s good for the soul. Back in the day when things were better, people would just suffer and it made them stronger. Well, it makes for a nice story, but the reality is it’s far from true. What you end up with is just increases in disability, further drags on the individual, society as a whole. There is zero evidence that suffering is good for the soul.   Now, is it true that some level of stress can help make people stronger? Yeah, but the data on stress is rather clear. You know, it’s when stress is controllable. It’s when it’s time limited. When you’re talking about chronic pain, this persistent type of stress, every study to date has shown that it is bad for the individual, bad for their family, and bad for our society.   So this is one of those comments, those premises that I think is rather easy to dismiss.   Joe 23:50-25:19 Dr. Mackey, the Food and Drug Administration has just recently changed its opioid regulations again, and it’s going to be making it harder for people to get opioid pain medicine. And I think a lot of Americans think, oh, that’s a good idea. We have problems with addiction in this country.   We went back and we looked at 2010, and the number one most prescribed drug in 2010 in the United States was hydrocodone with acetaminophen. 122 million prescriptions were dispensed that year, and oxycodone was another 29 million. By the year 2017, it was down to $40 million for hydrocodone.   And in 2022, it was half that, roughly $23 million. So from 122 million prescriptions dispensed down to $23 million because I think people are so afraid of opioids. Even people who go in for surgery, you know, like knee replacement surgery, they come back and they say, well, I didn’t take any opioids. I was tough. It hurt, but I was tough. I managed to survive without opioids.   Is that a good idea? And has this whole FDA and CDC initiative to dramatically cut back on opioids affected both physicians and patients?   Dr. Sean Mackey 25:21-31:20 Wow, there’s a lot to unpack there. These are great questions. So let’s try and take on a few of these. In answering this question, for people who don’t know me, it’s helpful for me to put my position forward. My usual mantra is that I’m not pro-opioid. I’m not anti-opioid. I’m pro-patient.   I come from personal experiences with a family history deep in addiction. I’ve lost close family members to opioid overdose, to alcoholism, and to other substances. And at the same time, I prescribe opioids for people with chronic pain, cancer pain, and acute pain. And I’ve helped people come down on those agents voluntarily.   So you can hold these concepts both in your head, and both can be true. They can be terribly damaging, and they can be incredibly helpful for patients. And that’s why I said, I’m not pro, I’m not anti, I’m pro-patient. They’re a tool. They’re a tool that physicians, clinicians need to learn how to use responsibly.   We were prescribing far too many opioids in the years that you mentioned. There’s no question about it. I think the data is rather clear there was too much being prescribed. And there were a lot of people that were getting prescription opioid addiction and opioid use disorder back then. Most of that wave, a large part, not entirely, a large part of that wave has moved into illicit opioids now, as I know you’re well aware. the question i think for all of us is has the pendulum swung too far from this very permissive state which was going on back in the late 90s the 2000s into this rather extreme now anti-opioid state that in in many cases exists now personally I think it has and I think we need to come back to the center.   This occurred in the state of California. I was a senior editor for the California Medical Guide for prescribing controlled substances that we just released this last year. And in that, we recognized that things had moved too far into the other extreme and that we needed to put forward guidance on how to use opioids as an effective tool for the right patient in the right context.   Opioids should never be a first-line drug for chronic non-cancer pain. I think everybody would generally agree with that, and it’s probably not a second line. It’s probably not a third line. It is to be used when there has been failure to all of the more conservative therapies that are available to that patient. And what I mean by available to that patient is the narrative sometimes from groups that want to severely restrict all opioids is, well, you know, they can go get cognitive behavioral therapy or they can go get acupuncture or they can go get this.   And the problem is people have to realize that a lot of those resources aren’t available to people with chronic pain. Most of the multidisciplinary, interdisciplinary, comprehensive resources are all consolidated in large centers in the big cities, but we have huge swaths of America that are rural, where people have very little access to healthcare. And we have to recognize those people and what they have available. And in some circumstances, opioids are indicated.   Now, getting to your point, I saw the FDA, you know, new guidance. Candidly, I didn’t see anything in there that caused me real concern. I thought what they did was they’ve updated the language and they’ve included in some contemporary data that has come about from two post-marketing studies where they followed people over time who were taking opioids. One in which they followed prospectively, that means forward in time, and one in which they looked retrospectively back in time. And they were able to put real numbers to the incidence of people misusing or abusing opioids over time and people having an overdose risk. In the past, they gave warnings that there are risks of misuse and abuse and overdose, but they didn’t have real hard numbers, and now they’re able to put those forward.   We’ve also been able to see language where they’re recognizing more and more that there is a dose-related increase in adverse events. Well, that’s kind of common sense. The higher the dose, the higher the risk you are. I don’t think many people would disagree with that notion either. So there are some languaging changes. I haven’t seen anything, and I’d love to hear your perspectives, by the way, if you think otherwise. But most of this is to clarify what we’ve already known and add in that additional language. What are your thoughts about it? You mentioned that it’s going to be more restrictive.   Joe 31:21-32:30 Yeah. Just briefly, Dr. Mackey, and then Terry has a question about other alternatives. But what worries me is that they have really come down hard against long-acting opioids. And for people who are in excruciating pain, who cannot function, who otherwise are bed-bound and unable to work, taking away or making it restrictive for people to have access to the longer-acting opioids that would otherwise allow them to work, allow them to engage in activities that allow them to, you know, be, you know, I won’t say normal, but allow them to function in society.   That’s what I think concerns me because we’ve heard from so many people who have been able to take longer acting opioids and just function pretty, pretty well in society. Your thoughts? Well, you’re right. So I get your concerns and they’re real.   Dr. Sean Mackey 32:33-33:33 Here’s the thing to be clear. The FDA guidance simply says that you should start and focus on intermediate, excuse me, immediate release opioids first. And they make a clarification that you shouldn’t be jumping right to extended release opioids and that start with the short acting and then if needed, move into the extended release.   Now there’s all this language. I read that language, I’m not that concerned about it. However, the problem is how that language is spun and how it’s interpreted by others. And we saw that with the original CDC guidelines on opioids in 2016. Because it’s really easy to take that language and weaponize it or misinterpret it and come out with the messages that you just suggested, which is to restrict, restrict,   Joe 33:33-33:45 restrict. That would be sad. Well, it’s time now to, Dr. Mackey, it’s time now to, I think, shift over to alternatives, because as important as opioids are for some people, many people, in fact, Terry, there are alternatives.   Terry 33:46-34:08 There are, but one thing we haven’t yet clarified is how do people end up in chronic pain? I’m assuming that most chronic pain starts as acute pain. What’s the transformation process like?   Dr. Sean Mackey 34:09-34:58 Yeah, we’re still trying to figure that out. We know that, as you said, most chronic pain almost all starts with an acute pain episode, an injury, an infection, some episode that the normal healing processes may have healed up the tissues, but the abnormal signaling that is related to pain still persists. And over time, that persistence transforms what was a symptom of an acute situation into a disease in and of its own right, much like diabetes, which initially starts as impaired glucose tolerance to eating a donut, becomes pre-diabetes and then moves into the frank disease of diabetes. We’re still trying to identify the vulnerabilities and the mechanisms of that so that we can have treatments that will prevent it.   Terry 35:01-35:15 Well, let me follow up then with this question of treatment. Especially non-pharmacologic approaches to pain relief, can you tell us what some of them are and when they might be appropriate?   Dr. Sean Mackey 35:17-36:32 Sure. I would suggest that non-pharmacologic approaches are always appropriate. That doesn’t mean that people should be excluded from pharmacologic approaches. It means that the best way to treat chronic pain is when you approach it from, we call it a multimodal standpoint. It simply means use all the tools at your disposal.   And we have at least six categories of tools for pain. Only one of categories are medications, interventional procedures. These are typically your nerve blocks to minimally invasive surgeries. Mind-body therapies are behavioral interventions. options, physical and rehabilitative options. We have complementary alternative medicine options, which is a little bit of a dated term, but we’ll probably get to it. And then the last one, the sixth one is self-empowerment, which is broad strokes. It’s getting educated and empowering yourself with that education.   Hopefully the people that are listening to your show being an example in that sixth category. So of those six categories, we recommend dipping into all six of them and not relying on just one.   Terry 36:33-36:56 Give us an example, if you would, please, of how somebody who has consulted you for a chronic pain problem, tell us a little bit about their situation and how each of these categories might contribute to them being able to cope with their chronic pain.   Joe 36:56-37:06 And we just have about a minute before the break. So when we come back, we’ll ask you to kind of extend that six categories in a little more detail.   Dr. Sean Mackey 37:07-37:54 Yeah. First, it all starts with an assessment. So it has to be individualized. This gets back to the earlier part of pain being an individual experience. And so, you know, you’ve got to take the person for whom they are and what they bring into it. Some people may benefit from more of a rehabilitative approach as a frontline.   Some may be from a more pain psychology behavioral approach. Some, there may be some simple interventional procedures to knock out that nociception, those electrical signals. And that may be an appropriate approach. It’s all about the initial comprehensive assessment of that person and putting together a tailored treatment plan for them. And I think that’s where things start.   Joe 37:55-38:07 When we come back from this break, we’re going to ask you to give us maybe a story, an example, so that people can understand how you come up with that tailored treatment approach.   Terry 38:08-38:42 You’re listening to Dr. Sean Mackey. He is Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. Dr. Mackey’s research strives to translate scientific discoveries into real-world pain relief. He is a past president of the American Academy of Pain Medicine.   Joe 38:43-38:50 And Terry, you know, this idea of cookie-cutter medicine just doesn’t work when it comes to pain. It has to be tailored or personalized.   Terry 38:50-38:51 Exactly right.   Joe 38:51-38:55 After the break, we’ll hear what can be done for lower back pain.   Terry 38:56-39:01 Dr. Mackey describes how a patient used a multimodal approach and how that worked.   Joe 39:02-39:09 What are the top five medications for chronic pain, not counting non-steroidal anti-inflammatory drugs or opioids?   Terry 39:10-39:15 You may have heard of low-dose naltrexone. Dr. Mackey shares his experience.   Joe 39:15-39:18 Which alternative therapies might be helpful?   Terry 39:30-39:33 You’re listening to The People’s Pharmacy. with Joe and Terry Graedon.   Joe 39:42-39:45 Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 39:45-40:03 And I’m Terry Graedon.   Joe 40:03-40:22 Have you ever experienced back pain? If not, you’re a rarity. It’s estimated that 80% of Americans will experience low back pain at some point in their lives. As we speak, about one-fourth of the population may be experiencing some discomfort in their lower back.   Terry 40:22-40:36 Coming up, we’ll learn what people do for back pain and other chronic pain problems. Our guest will discuss low-dose naltrexone, acupuncture, alpha-lipoic acid, cannabidiol, and self-hypnosis, among other things.   Joe 40:36-41:00 We’re talking with Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. His goal is to develop precision pain care. Dr. Mackey is past president of the American Academy of Pain Medicine.   Terry 41:01-41:38 Dr. Mackey, I know that in your clinic you see people with chronic lower back pain. They’ve probably, if they’re in your clinic, they’ve probably seen a lot of other doctors and maybe some other types of practitioners. Can you tell us about an individual who came to you, used some of these multimodal options that we’ve just been discussing, and what options did they use, and what was the outcome?   Dr. Sean Mackey 41:39-44:34 Delighted. So why don’t we take Bob as a patient? Bob’s a guy in his 40s. He’s working hard. He’s got a couple young kids. and Bob has chronic low back pain. And so Bob comes into the clinic and he, Bob represents America. Like Bob represents, he’s everybody’s person with low back pain.   Everybody’s situation is going to be a little bit different, but you’ll get the, you get the point. Bob injured his back. It kind of laid him up for a while, but the pain persisted and he comes in to see. And part of Bob’s problem is that nobody believes he’s got back pain. So one of the first things that we do is we make sure that we believe that Bob has real pain because Bob’s been typically invalidated everywhere he’s gone. So first rules are to assess Bob for any, what we refer to as red flags. And these are causes of his pain that represent a potentially severe issue, infection, tumor, nerve impingement, things that need an immediate medical response.   But let’s assume that we eliminate all those. And by the way, those only represent a small percentage of people with back pain, but you got to do the first principles. So what you’re left with is Bob has his chronic mechanical low back pain, and we’re not going to break it down into the different components that could be contributing to that because we don’t have the time for this show.   But let’s just say that Bob is also expressing a lot of fear of movement because every time he moves, he gets increases in pain. And the problem is that that develops into this fear avoidance approach where over a period of time, Bob doesn’t want to move around. So he walks around like he’s got a stick up his butt. He’s real rigid because he’s heard that his discs are exuding these chemicals that are causing irritation on his nerves.   So we want to look at Bob from a holistic standpoint. And typically that involved having to see a pain physician, a physical therapist that specialized in taking care of people with pain, and a pain psychologist. And then we typically would all come together for a team conference. Let’s assume we’ve done all that. And what we’re doing is an interdisciplinary type of treatment plan for Bob that would include maybe some options around medications. And we have over 200 medications that have shown analgesic benefit now for pain, only 20 or so of which are opioids.   Joe 44:35-44:59 And could you give me your top five, if we were to look at your prescription pad for someone like Bob, what would be your top five non-opioid pain relievers? and let’s get rid of the NSAIDs if you don’t mind because of the stomach damage and some of the other problems that go with NSAIDs. But they might be on that list, Joe. They might be on your list, but give us your top five.   Dr. Sean Mackey 45:00-45:46 Yeah, NSAIDs wouldn’t be on my list, but there’s a selection bias because by the time people have come to see me, everybody’s already tried NSAIDs, right? Of course. Yeah, that’s the easy stuff. So you wouldn’t see NSAIDs high on my list because everybody’s gone through them with some exceptions. You’d probably see duloxetine high on that list just because it’s an FDA-approved medication for musculoskeletal pain. You’d probably see a desipramine on that list, which is a tricyclic antidepressant but effective for pain. You’d probably see one of the gabapentinoids on the list. Gabapentin or pregabalin is on the list. In my hands, You frequently would see me prescribing low-dose naltrexone that maybe we’ll get to.   Joe 45:47-46:05 Whoa, whoa, whoa. You stop right there. Low-dose naltrexone is one of the more controversial treatments. Please, as quickly as you can, explain why it’s such an interesting drug and how some people are benefiting from this amazingly small dose.   Dr. Sean Mackey 46:06-47:27 Yeah, yeah. Naltrexone’s got its perhaps controversy because at the regular dose, it’s used to treat addiction. opioid and alcohol addiction. At lower doses, it works in a completely different mechanism. It blocks some of the neuroimmune systems that are playing a role in pain.   And so it doses like four and a half milligrams or so. We’ve seen in some people rather miraculous benefits for their pain, particularly in conditions like fibromyalgia, complex regional pain syndrome, and some other pain conditions. Why I prescribe it so much is because it is probably the safest medication that I can prescribe. There’s almost no side effects to it. It’s also dirt cheap. It’s been generic for decades. Insurance typically doesn’t cover it, but its cost from a pharmacy is usually very reasonable.   I have no financial relationship with any medication or devices, by the way. But I love its safety profile, and I love the wins in patients when they get them. And not only do they win on pain, but it frequently will improve their sleep, their fatigue, and their mood. So you get this triple or quadruple whammy. What are your thoughts about it? What are you hearing? You said controversial.   Terry 47:27-47:40 Well, I’m assuming that if you are able to improve patients’ sleep and their mood, that also all by itself would improve their pain, wouldn’t it?   Dr. Sean Mackey 47:40-48:29 It does. But, you know, we did some of the initial studies on this. I have to credit Jared Younger, who was with our group at the time with, you know, the initial studies. And we looked at daily assessments of people over time taking this medication. And what we found is the first thing that was improving was typically people’s sleep, followed by their mood, then followed by their pain.   Now, we didn’t publish that data, and it needs to be replicated. And we also know there’s this bidirectional relationship between sleep and pain. Bad sleep worsens next day pain. Increased pain worsens next day sleep. So we have to disentangle all of that. But what I can tell you is all of these seem to get better in some people.   Joe 48:29-48:36 So the controversy, Dr. Mackey, is that we hear from some people who describe what you’re talking about.   Dr. Sean Mackey 48:36-48:36 Yeah.   Joe 48:36-49:02 Wow. Tiny dose, great relief. And other people say, eh, didn’t do much, didn’t do anything, big waste of time. Yeah. And I think what it reminds me is that what for one person is excruciating pain, for another maybe, you know, no big deal. And so we’re all different. I guess that’s the take-home message.   Dr. Sean Mackey 49:02-50:16 Isn’t that wonderful? Yeah. We have to embrace that differences and stop thinking that we’re all, you know, wired the same way. This differences is what leads to the biggest challenge that we have in pain medicine and medicine writ large, and that is on average, the effect sizes, the impact of any treatment we have on pain is rather small. It’s typically on the range on average of about one point out of 10 on a 10 point scale. That’s pretty poor. But within that average, you typically have people that got hit the ball out of the park, amazing wins. And you probably also have people that got worse on that medication.   So this is where in our world, this is what my research is all about. And others is working to develop this field of precision pain medicine, which is to understand those individual differences, take the information and then tailor treatments so that we can be better at choosing the right treatment for the right person in the right context.   Joe 50:16-50:29 Now, you were about, I’d say, three to four medications into your top five or six. What else do you prescribe besides the low-dose naltrexone that for some might be a home run and for others might be barely a bunt?   Dr. Sean Mackey 50:29-51:00 Yeah. So, you know, I will sometimes reach into the sodium channel blocking medications, sometimes like the topiramate. to the, sometimes mexiletine. It depends on the clinical condition that I’m treating, but we try to use medications from different categories that impact pain processing pathways.   Joe 51:01-51:02 You haven’t mentioned ketamine.   Dr. Sean Mackey 51:03-51:19 I occasionally send people over for a ketamine infusion that we do. These days, we do those in a hospital environment. We’re doing those in the clinic. But ketamine can be effective for some people.   Joe 51:20-51:27 And it’s now being tested orally. Terry, you wanted to talk about some of the other non-pharmacological approaches.   Terry 51:28-51:58 Dr. Mackey, you mentioned complementary and alternative therapies. And I did want to ask about acupuncture or cognitive behavioral therapy. Are there any complementary and alternative? As you say, it’s a slightly dated or maybe a really dated term. But we have a general idea what we’re talking about. Are there any of those therapies that are right at the top of your list?   Dr. Sean Mackey 52:00-52:50 Yeah. And candidly, I frequently don’t even think in terms of complementary alternative medicine, but I need a category there that fits outside of the, I don’t want to say the mainstream allopathic or otherwise medical area. And cognitive behavioral therapy would tend to fit more in pain psychology. Acupuncture is more in that CAM focus. I use a lot of acupuncture, and we do acupuncture in our clinic. Mindfulness-based stress reduction, MBSR, has historically been in that camp, although it’s now so mainstream that I’m not even sure it belongs there.   And some have used more of the term integrative medicine as a way to characterize these. But then one other big category that maybe what you’re getting at is nutraceuticals or over-the-counter agents.   Terry 52:50-52:50 Yes.   Dr. Sean Mackey 52:51-53:20 And these are agents that are not part of the FDA regulatory pathway, as you well know. some of these agents have shown in randomized controlled trials to have nice impacts on pain. Such as? Such as acetyl-L-carnitine, alpha-lipoic acid. And some of these agents are actually prescribed medications in Europe. But here- What about CBD?   Joe 53:20-53:29 What about this controversial non, shall we say, psychoactive part of marijuana?   Dr. Sean Mackey 53:30-54:08 Yeah, I think the verdict is still out on that. We need, we’re right at the still early stages of clinical trials in that. These days, they’re still on the small scale. We’re still trying to figure out dosing, delivery, frequency. There are some mechanistic reasons why there may be some value to CBD. I think the story remains to be written on it. Now, with that said, you’re going to find people in the audience that will swear by it. And similarly, there’ll be people in the audience who’ll say, no, tried it. It doesn’t work for me. It’s just like everything.   Joe 54:09-54:35 Right back to the low dose naltrexone. We are almost out of time, Dr. Mackey. And I would like to ask you two quick questions, one about auto hypnosis and how that can be beneficial for some. And then I’d like to get your perspective on how people can find a pain management specialist or program in the two minutes we have left.   Dr. Sean Mackey 54:35-56:03 Yeah. Yeah. Auto hypnosis can be effective in the moment for helping you with pain. I, I love going to treatments that don’t have any significant side effects, first of all, and that fits into one of those categories. And there are a number of these, whether it be auto hypnosis or binaural audio in some people that can be very effective. So give it a try.   It’s going to be like everything else. For some people, it’s going to work great and others, it’s not going to work at all. The last question is one of the challenging ones is how to find somebody. And, you know, ask your friends, you ask your family doc, and otherwise you can get a list of names through the American Academy of Pain Medicine has a website with a list of docs. I think Doximity these days is listing pain docs.   It’s actually a real challenge that we have is how to find high quality pain physicians who can help with your problem. Clearly a nut to be cracked. I think the key message is don’t suffer in silence. Seek out and get good quality help. And if you’re not getting it where you’re being treated, then look elsewhere because there is help that’s out there. And it is an exciting time in this field. We’re seeing more and more treatments and better and better approaches applied to chronic pain.   Terry 56:04-56:21 Dr. Mackey, you’ve laid out for us very clearly that pain isn’t actually pain until the brain processes it and says, ah, you’re in pain. So what is happening exactly in the brain when pain gets bad?   Dr. Sean Mackey 56:22-58:01 Yeah. What we find when there’s this persistent, continuous experience of pain, that circuits in the brain that are there to be released during stress, for instance, or during fear of pain become solidified.   They can become “sticky” and you can get into this “sticky” brain state. And we know that there are specific circuits involved from amygdala to the prefrontal cortex, from areas like the nucleus accumbens, which is involved with reward circuitries and mesolimbic areas into some of these frontal or thought-related processing circuits in the front of the brain, that they can also become solidified. And with these circuit stickiness, if you will, you get a perpetual state of pain. And a large part of what we’re trying to do is break up or reverse these sticky brain states and help return them to a sense of normalcy.   Most of our medications actually work on these brain circuits. All of the mind-body therapies that we have work on these brain circuits. And the beauty of working on these brain circuits is that you also can learn how to take some control of this and help reverse some of those states as well. That doesn’t remove the notion of going out and doing something out in the periphery or in your body. But if you’re going to treat pain, the key is to treat the whole person and not just a particular part.   Terry 58:01-58:02 Thank you.   Joe 58:02-58:57 Dr. Mackey, when people are in pain for a long time, what we call chronic pain, not just for a few weeks or a few months, but oftentimes for years, it can make them angry. I mean, really angry. And it can also lead to depression. And I cannot tell you how many messages we have received from readers of our newspaper column and visitors to our website who say, you know, if they take away my opioid medicine that I have been using absolutely according to the doctor’s instructions for 15 years. I’ve never increased the dose. I’ve never abused it. But if they take that away from me, I will have to contemplate suicide. I’ll be so depressed.   So help us understand the anger and the depression that goes with chronic pain.   Dr. Sean Mackey 58:58-01:01:33 Yeah. So we know that both of those, anger, depression, and if I may, there’s another one that is becoming increasingly recognized, which is social isolation. And indeed, social isolation, we find, is one of the biggest factors contributing to chronic pain.   All of those can be a consequence of that pain. And it takes a terrible toll on the individual. It just sucks their soul dry. And those are all associated with those circuits in the brain that I mentioned before, that can get really out of whack. Now, the second part of what you’re describing is related to the use of opioids.   In my practice, in my opinion, if somebody has been responsibly using opioids for a long period of time, they have tried all the other approaches and those approaches have failed. And the opioids are providing them with increased function and quality of life, my approach is typically to leave them alone and just support that. And I appreciate how they’re feeling because there’s a lot of fear out there around what we refer to as these legacy patients who have been using these medications appropriately. And I think we as a society and as a healthcare profession have to come to grips with this and figure out how to help these people.   Because the message is not simply take them away and don’t give something else back that’s going to help them. What we have found by running that experiment is tragic consequences. People commit suicide, They decompensate, they get worse, or they turn to illicit opioids. And I have seen that over and over again from stories and docs in the community that think they’re doing well by taking people off these long-acting opioids and those people turn to illicit substances.   So it’s a complex problem. It’s going to need a complex set of solutions, but let’s not lose sight of the fact that these are people’s lives. And as healthcare professionals, We’re here to help them. And yes, to do it in a responsible manner, but working in a clinician-patient partnership.   Joe 01:01:35-01:02:15 Dr. Mackey, there is a category of medications. They’re called gabapentinoids. It includes gabapentin and something called pregabalin. And they have never been approved by the FDA for general pain. They’ve been prescribed for nerve pain, for example, after a shingles attack. But as far as treating a variety of pain problems, they’ve never gotten the green light from the Food and Drug Administration. And yet the number one most prescribed pain medicine in America is gabapentin.   Terry 01:02:16-01:02:21 But pregabalin has been approved for treating fibromyalgia. Fibromyalgia, right.   Joe 01:02:22-01:02:57 And so I guess what we have heard is some people love gabapentin. Some people hate gabapentin. They say it makes me spacey. It makes me unsteady. There are a lot of side effects associated with it. And there are other people who say, don’t cut back on gabapentin. It’s the only thing that allows me to function. So sort of back to the low-dose naltrexone story, and that is some people benefit. Some people get no real relief, and some people feel horrible on this drug. Help us understand gabapentin better.   Dr. Sean Mackey 01:02:58-01:06:45 Yeah. You know, gabapentin is in this class of anti-epileptics or anti-seizure medications. It was originally, it has been used by the neurologist, as I mentioned, for seizure. And it was found to have some pain-relieving properties over 25 or more years ago.   It did get FDA approval for postherpetic neuralgia, as you mentioned, which is a terrible nerve-like pain condition after shingles. But we all started prescribing it off-label, and we found that it was having benefit for a variety of different pain conditions. And most importantly, it had a relatively low side effect profile.   Rule number one in being a physician is do no harm. We tend to be conservative. We don’t want patients to get harmed. So this was an easy drug to prescribe, and we still prescribe it all the time. Now, its use is broadened out well beyond the FDA guidance, and that’s pretty typical of medications.   Low-dose naltrexone does not have FDA approval for anything, but we prescribe it off-label. And as you alluded to, individual variability in it. For some people, again, it’s a major win. For others, they can’t tolerate some of the side effects.   I’m very careful about prescribing it to what I refer to as knowledge workers. These are people that are using their brain for a living. I live in Silicon Valley, so a lot of the people I care for, they may be software programmers or engineers. And at the higher doses, gabapentin can lead to word finding problems and some cognitive slowing. It reverses if you reduce the dose or come off it. But for those people, they can’t afford to have their work impacted.   So it’s a medication worth trying, starting low, going slow, and seeing if people get benefit. If they do, great. If they don’t, just come off it. When you come off it, and this is on the new labeling that’s out there, come down slowly. You don’t want to just abruptly stop this medication because it can be associated abruptly stopping with seizures and agitation and increased excitability. And you don’t want any of that. So one of the common medications we use, you’re seeing more and more media out there that are playing up the potential adverse effects related to this medication. And this is now because it has gotten out in so many millions of people that researchers like me can go into administrative databases now and we can study millions of people.   And from that, we can pull out tiny little signals that show increased incidences of bad things with this particular drug. And that’s useful because that gives us a signal that we should look for in better controlled studies. So there are recent studies that show potentially an increased incidence of dementia on gabapentin or an increased incidence of fractures on gabapentin. Well, these are what we refer to as observational studies. They should be treated as hypothesis generating, simply meaning there’s something interesting there and maybe we should look further into it. but by no means should we use this new information to set policies. So, I don’t know, did I get at your question?   Joe 01:06:46-01:07:28 You did. I think we’re back to the individual variability situation. Some people get great benefit, some people not so much, and other people have too many adverse reactions to be able to tolerate it. And so we’re basically recognizing that everybody’s different and everybody responds to some medications in a positive way and others in a negative way and many people in the middle. And that’s why it’s, I think, critical for people to have personalized medicine with a physician who is really knowledgeable about how to treat chronic pain.   Terry 01:07:29-01:07:34 Dr. Sean Mackey, thank you very much for talking with us on The People’s Pharmacy today.   Dr. Sean Mackey 01:07:34-01:07:35 Thank you for having me.   Terry 01:07:37-01:08:08 You’ve been listening to Dr. Sean Mackey, Redlich Professor and Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine. Dr. Mackey specializes in treating people with chronic pain. He’s Chief of Stanford’s Division of Pain Medicine. His research strives to translate scientific discoveries into real-world pain relief. Dr. Mackey is a past president of the American Academy of Pain Medicine.   Joe 01:08:09-01:08:17 Lynn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Liederman composed our theme music.   Joe 01:08:36-01:08:43 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy.   Terry 01:08:43-01:09:12 Today’s show is number 1,445. You can find it online at peoplespharmacy.com. The show notes now include a written transcript of this conversation. At peoplespharmacy.com, you can also share your comments about today’s interview. Let us know about your experience with pain and its treatment. You can also reach us through email, radio at peoplespharmacy.com.   Joe 01:09:13-01:09:46 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this podcast, learn what’s happening in the brain when we feel pain. We’ll also look at the anger and depression that can accompany chronic pain and talk about the pros and cons of gabapentinoids. That’s gabapentin and pregabalin to help people feel more comfortable. Look for video with Dr. Mackey on the People’s Pharmacy YouTube channel.   Terry 01:09:46-01:10:07 At peoplespharmacy.com, you could sign up for our free online newsletter and get the latest news about important health stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer.   Joe 01:10:08-01:10:10 In Durham, North Carolina, I’m Joe Graedon.   Terry 01:10:10-01:10:42 And I’m Terry Graedon. Thanks for listening. Please join us next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money.   Joe 01:10:43-01:10:52 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism, please consider chipping in.   Terry 01:10:53-01:10:57 All you have to do is go to peoplespharmacy.com/donate.   Joe 01:10:58-01:11:11 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

For the last several decades, nutrition scientists have been debating the pros and cons of various dietary approaches. The Mediterranean diet has a lot of proponents, and we have interviewed some of them on The People’s Pharmacy. Dr. Barry Popkin and Dr. Walter Willett endorse olive oil, whole grains, fruits and vegetables with only small amounts of animal-sourced food. Listen to Show 1359: Is the Food on Your Plate Real or Fake? for more information. Dr. Will Bulsiewicz is a fiber evangelist. You can hear him on Show 1312: fiber, Phytonutrients and Healthy Soil. Plant-based diets can fall along a spectrum from mostly plants with some meat, fish and eggs to completely vegan. In contrast, there are experts who recommend a low-carb, high-fat ketogenic diet. Carnivore diets consisting of only animal products (meat, poultry, fish) are a subcategory of keto diets. That is the focus of this episode. Carnivore Controversy: We know that people have strong feelings about food. The DIETFITS study, one of the best randomized controlled trials comparing healthy low-carb to healthy low-fat diets found that both led to weight loss. Learn more by listening to our interview with lead investigator Dr. Christopher Gardner on Show 1126: Can You Find Your Best Diet? We have heard from fans of ultra-low-fat diets like those promoted by Pritikin or Dean Ornish, MD. We acknowledge that hearing about a carnivore diet may put their teeth on edge, at the very least. But information from knowledgeable sources about controversial topics is what we aim for, and this is indisputably controversial. At The People’s Pharmacy, we strive to bring you up to date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care, treatment, or diet. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Sept. 13, 2025, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Sept. 15, 2025. Ketogenic and Carnivore Diets: Doctors have long prescribed ketogenic diets to treat children with hard-to-treat epilepsy (Epilepsy & Behavior, Sep. 8, 2025).  Studies suggest that people with migraines or depression might benefit from a ketogenic diet (Brain and Behavior, Sep. 2025; Translational Psychiatry, Sep. 10, 2025). Most people now following carnivore diets, which are more extreme than ketogenic diets, began following this eating plan to lose weight and have more energy. Our co-host for this show, AAAS Mass Media Fellow Bianca Garcia, has done some investigation of this approach to nutrition, including a personal trial. She joined us in interviewing Dr. Eric Westman, an advocate for ketogenic and carnivore diets to help people with obesity and diabetes. What is a ketogenic diet? It minimizes the carbohydrate available as fuel by including only low-starch vegetables such as greens. High-fat food sources make up the bulk of the energy in the diet. This forces the body to burn ketones derived from body fat instead of glucose derived from sugar or starch. In a carnivore diet, the vegetables disappear completely and the high-fat food sources are all derived from animals. How Do Dietary Guidelines Mesh with Carnivore Diets? We asked Dr. Westman about changing dietary guidelines, and he pointed out that most of the national dietary guidelines have limited scientific support. Of course, randomized controlled trials of people following carnivore diets are also few and far between. A survey of more than 2,000 self-selected volunteers following the diet was published in 2021 (Current Developments in Nutrition, Nov. 2, 2021). The DIETFITS trial, which compared a healthy low-fat, high-carb regimen to one high in fat and low in carbs found no significant difference in weight loss over the course of a year (JAMA, Feb. 20, 2018). What Are the Effects of a High-Fat Diet? In the clinical trials he conducted, Dr. Westman found that blood insulin levels were lower as people followed a ketogenic diet (Expert Review of Endocrinology & Metabolism, Sep. 2018). The body does not require insulin to utilize ketones for fuel. As a result, people with type 2 diabetes have better control of their blood glucose when following a low-carbohydrate ketogenic diet (Nutrition & Metabolism, Dec. 19, 2008). He and his colleagues have published a case series suggesting that a ketogenic diet could help people with food addiction (Journal of Eating Disorders, Jan. 29, 2020). There are also hints that people with other psychiatric conditions might benefit from a ketogenic diet as well (Psychiatry Research, May 2024). What Is Driving the Interest in Carnivore Diets? Bianca Garcia and Dr. Eric Westman agree that the internet has a huge influence on people’s interest in carnivore diets. Podcasters like Joe Rogan and multiple influencers have promoted this approach, especially to younger people. This can contribute to social pressure to try it. Dr. Westman warns listeners that adopting a ketogenic or carnivore diet should be undertaken under knowledgeable guidance. A drastic dietary change can alter how medications work, so people with chronic illness really need to work closely with health care professionals. That may require searching for someone who is open to this approach with the expertise to recommend when supplements or salt might be needed and provide information on doses. This Week’s Guest: Eric Westman MD, MHS, is an Associate Professor of Medicine at Duke University. He is Board Certified in Obesity Medicine and Internal Medicine and founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low-carbohydrate ketogenic diets. Dr. Westman is a past President and Master Fellow of the Obesity Medicine Association and Fellow of the Obesity Society. He is a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society. In addition, he has written and edited numerous bestselling books and is a co-founder of Adapt Your Life Academy (www.adaptyourlifeacademy.com), which provides science-backed education on a range of subjects rooted in the therapeutic effects of dietary carbohydrate restriction… including his newest course, Carnivore Made Simple, which is open now for enrollment for a limited time. Eric Westman, MD, Duke University Our Co-Host: Bianca Garcia is a Filipina-American anthropologist, foodie, and radio person. She holds a master’s degree in Media, Medicine, and Health from Harvard Medical School, where she created an audio documentary on the carnivore diet. She was a AAAS Mass Media Fellow covering health and science at WUNC, North Carolina Public Radio when we conducted the interview; her favorite stories to cover always involve what people eat, and why. Bianca Garcia, photo copyright Christina Thompson Lively Listen to the Podcast: The podcast of this program will be available Monday, Sept. 15, 2025, after broadcast on Sept. 13. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll hear the real patient story of a doctor who weighed 350 pounds and suffered from POTS (postural orthostatic tachycardia syndrome). Do we have any idea of how a carnivore diet affects the gut microbiome? Dr. Westman describes his study on how a low-carb diet helps GERD (gastroesophageal reflux disease). Years ago, Joe looked for evidence on the traditional heartburn diet limiting fat, alcohol, coffee and tomatoes and couldn’t find any. What we have found is that science changes as researchers pursue further studies and that is not a reason to mistrust science even though the changing recommendations may be frustrating. Dr. Westman offers a message to everyone trying to make the right dietary choices but feeling overwhelmed by many different messages about food. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript for Show 1444: A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon.   Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of The People’s Pharmacy.   Joe 00:06-00:26 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Americans have been fighting about food for decades. What’s healthier: low‑fat or low‑carb eating patterns? This is The People’s Pharmacy with Terry and Joe Graedon.   Terry 00:33-00:44 We’ve talked with many experts about the value of a Mediterranean diet, rich in produce and low in red meat. Today we’re going to find out about the carnivore diet.   Joe 00:44-00:49 What’s the difference between a carnivore diet and a ketogenic diet?   Terry 00:49-00:59 Our guest is Dr. Eric Westman of Duke University. He started as a skeptic of the Atkins diet. Then he conducted research that turned him into an advocate.   Joe 00:59-01:15 Coming up on The People’s Pharmacy, the food fight over fat. Learning about keto and carnivore diets.   Terry 01:13-01:56 In The People’s Pharmacy Health headlines, COVID cases are increasing, especially on the West Coast. Oregon has seen a late summer surge in cases. California has also seen an alarming increase. Hospitalizations for COVID patients have almost doubled in recent weeks. An objective measure of viral spread comes from wastewater samples. The CDC’s wastewater surveillance system reports very high genomic sequencing levels for the SARS-CoV-2 virus. There is hope, however, that the summer surge will ease soon, though public health officials worry another COVID wave could start as early as November, just in time for holiday travel.   Joe 01:56-03:07 People who are trying to avoid COVID-19 might want to consider an inexpensive, low-risk strategy to stay safer. A study published last week in JAMA Internal Medicine tested the nasal spray Azelastine for prevention of SARS-CoV-2 infections. This over-the-counter antihistamine is sold under the brand names Astelin and Astepro. Beyond its anti-allergenic and anti-inflammatory properties, this medication has antiviral activity against several respiratory viruses from SARS-CoV-2 to RSV and flu. A double‑blind, placebo‑controlled trial in Germany included 450 patients who spritzed either azelastine or placebo into their noses three times daily for roughly two months. During that time, five people spritzing the antihistamine came down with COVID. In the group using the placebo spray, there were 15 positive cases. The authors concluded that their results support the potential of azelostine as a safe prophylactic approach, warranting confirmation in larger multicenter trials.   Terry 03:07-03:57 A different study tested the effects of inhaled nitric oxide against COVID-19. The investigators note that this gas is produced naturally in the body and is well known as a vasodilator. It also has antiviral and anti inflammatory properties. In a recent study, fifty-five patients hospitalized with COVID associated pneumonia got inhaled nitric oxide or usual care. Those who had up to six hours exposure to high dose nitric oxide were released from the hospital more quickly and needed less supplemental oxygen. According to the investigators, the inhaled nitric oxide treatment was safe and well‑tolerated. They suggest this approach might be helpful against other pulmonary infections.   Joe 03:58-05:11 Generalized anxiety disorder, GAD, is one of the most common psychiatric conditions in the U. S. Doctors may prescribe anti-anxiety drugs such as alprazolam or diazepam. But these benzodiazepines may not be suitable for long-term use. SSRI antidepressants are also prescribed, but they too don’t work for everyone with anxiety problems. Now, scientists report a single dose of the hallucinogen LSD can have lasting effects. Nearly 200 patients were recruited for the study. The researchers randomly assigned them to take placebo or one of four different doses of the active compound. The two lowest doses of LSD did not have an effect that was significantly greater than placebo. People receiving the two highest doses—100 or 200 micrograms—were significantly less anxious one month later. Adverse effects included hallucinations, nausea, and headache during the treatment. This helps establish the groundwork for further research on the potential benefits of one dose of LSD to treat disabling anxiety under careful medical supervision.   Terry 05:11-06:17 Are you a coffee lover? How do you drink your brew? Previous studies have shown that regular coffee drinkers get substantial health benefits. They tend to have a lower risk of liver cancer, diabetes, dementia, and cardiovascular disease. Few studies get into the details of coffee consumption, though. Now a cohort study of more than 42,000 American adults participating in the National Health and Nutrition Examination Survey. demonstrated that higher coffee consumption was associated with a lower likelihood of dying between 1999 and 2018. People drinking one to three cups daily got the most benefit, but they needed to drink their coffee black. Adding sugar or cream or non-dairy creamer blunted the effects. And that’s the health news from The People’s Pharmacy this week. Welcome to The People’s Pharmacy. I’m Terry Graedon.   Joe 06:17-06:30 And I’m Joe Graedon. You’ve heard a lot about the health benefits of the Mediterranean diet here on The People’s Pharmacy. We’ve also talked to guests like Dr. Will Bulsiewicz about the value of fiber in our diet.   Terry 06:30-07:02 Today we’ll be considering a different dietary approach. Is there any science to support the keto or carnivore diet? Joining us for this interview is Bianca Garcia. She holds a master’s degree in Media, Medicine, and Health from Harvard Medical School, where she created an audio documentary on the carnivore diet. She served as the AAAS Mass Media Fellow at WUNC. We invited Bianca to co-host this interview.   Joe 07:00-07:30 To help us better understand the carnivore diet, we turn to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low-carbohydrate ketogenic diets. He’s written a number of popular books, such as End Your Carb Confusion and Keto Clarity, his newest course, Carnivore Made Simple, is open for enrollment.   Terry 07:31-07:35 Welcome to The People’s Pharmacy, Dr. Eric Westman.   Dr. Eric Westman 07:35-07:36 Thank you. It’s great to be here.   Terry 07:37-07:42 And we are… (DR. WESTMAN 07:38-07:38) Again. Yes, again for the I don’t know how many-eth time.   Dr. Eric Westman 07:42-07:43 I lost count.   Terry 07:43-08:00 Okay, me too. And we are really pleased to have with us in the studio helping us with the interview. Bianca Garcia, who is a journalist and I might say a medical anthropologist. We’re glad to have you here, Bianca.   Bianca Garcia 08:01-08:02 It’s my pleasure.   Joe 08:03-08:27 Dr. Westman, I have to tell you, when it comes to food, I get so confused It seems like the dietary guidelines have changed so much in my lifetime. How do you keep up and tell us what you think about this whole process? Because you’ve been studying food for decades.   Dr. Eric Westman 08:27-08:51 Well, so you have to think about uh the human body first. not the well this is my perspective. I’m an internal medicine specialist. So I got trained in an era where we were dealing with Oh, diabetes a little bit, high blood pressure a little bit. No obesity. I mean in the 80s in training, there’s really nothing there.   Terry 08:51-08:52 Obesity existed.   Dr. Eric Westman 08:53-13:16 Yeah, but not like today, right? So uh you know, my colleagues started giving pills and shots for everything. And I started to work here in Durham at the Durham Veterans Affairs Hospital. and started to learn about research and worked with the inventor of the nicotine patch for ten years, Jed Rose in Durham. So I got to learn about science and how to apply the scientific method to humans, I mean to clinical research. And so randomized trials were paramount. And really you might even say ignore everything until there’s a randomized trial. Well, that worked for a while. I after ten years I realized I was not fixing anything. I mean and after ten years of my patients at the VA I l I loved them dearly, and they were all kind of getting worse. So two patients show up in my office right about the same time having fixed their diabetes and obesity and I asked them what they did. They said, all I did is eat steak and eggs. I’m like, what the heck? This is nineteen ninety-eight, okay? And so I’m thinking to myself, uh, well, lightning strikes And yet then another patient comes in. All I did is do the Atkins diet. I said, What’s that? And he said, Well, you know This book, it probably came out before you were born. And that wait wait a minute. Now you’re getting personal. So I I go to the bookstore and sure, there’s the Atkins diet, there’s the Ornish diet. There back then there was the Uh even “The Zone” hadn’t come out yet. So there weren’t a whole lot of books on the shelf. But there was a doctor who had a clinic that you could visit, and that was Dr. Atkins. So I wrote him a letter, he calls back and invites me to his office with a couple of young researchers who were doing a different job at the time. And so I saw a clinic in action and after he seeing two people do the total opposite of everything that I was taught. And even then one of the patients who I was treating at the VA said, What are you worried about? And I said, Well your cholesterol. Your cholesterol will go up. Remember this is 1998 for me. And he looked at me and said, Well, why don’t you check it? And he the lab was down the hall at the VA and didn’t cost anything for me or him to do it. So in two cases, people lost weight. These were men- lost over fifty pounds and their cholesterol levels got better regardless of how you look at it total in LDL triglyceride and HDL Like, what the heck’s going on? So I had to learn basically for myself as an internist, as a clinical researcher, about nutrition. And when I went to the diet dietary meetings, the nutrition meeting, there was like, everything’s low fat, everything’s now plant-based. And I’m like, well, but but what about the patient sitting in front of me who’s fixed conditions that doctors can’t fix by doing the exact opposite of what they were taught. And I met uh Michelle Hurn who wrote the book, “The Dietitian’s Dilemma.” What if you have to do the exact opposite of what you were taught to fix yourself? And that’s Michelle, she is a dietitian and you know I’m on a board of a new society with her, so I’ve got to know her, uh gotten to know her pretty well. So I guess, you know, looking back, What do you eat matters? You know, if if I could be dean of the all the schools of medicine and even DO schools, I’d say, you know: nutrition should be key to your education of what a human body needs attention to And in my last 25 years, we’ve documented over and over again, and other people have documented, there’s no nutrition training for doctors. They’re or they get taught the wrong thing. So so here I am today asked to talk about low carb and keto and LCHF and, and I gave a talk in London recently, and it was The Fad That Never Fades. The Fad That Never Fades was the title of my talk. And so the concepts of what we’re talking about has been here you know, for hundreds of thousands of years, the name has changed.   Terry 13:16-13:25 Okay. Bianca, how did you get interested in the carnivore diet? Because you’ve been following up on this for at least a year now.   Bianca Garcia 13:25-14:39 That’s right. I was pursuing my master’s of science and I was thinking about media and health together. And I was as a social media user starting to see a lot of social media content on the carnivore diet. Someone who’s looked at nutrition, who’s been interested in nutrition, I thought it was really, really strange that people were eating, as Dr. Westman said, just steak and eggs. So I wanted to look into kind of the anthropology of this. What is, what is making people eat the way that they are eating? And how do we think about this personal sort of decision as it weighs up against the weight of the medical institution, and that kind of knowledge. And so I have a yet unpublished audio documentary on the carnivore diet called Against the Grain. And in doing that research, I’ve seen Dr. Westman’s content. I’ve seen the content of many other creators. I’ve spoken to carnivores and learned about their personal experiences, and I’ve spoken to doctors who are also equally skeptical of the diet. So there is a wide range of opinions out there that I have been interested in following up on as a journalist.   Terry 14:40-14:52 Dr. Westman, I can imagine that you get some reactions, probably not so much from your patients, because your patients are coming to you saying, This is what I want to do, right?   Dr. Eric Westman 14:53-15:34 Well, not necessarily. Although although that that’s uh a good expectation that no uh, I’ve in fact this week, that’s why I’m in clinic at Duke four days a week in a private practice insurance pay system. Um no, actually some people have no idea who I am. I and there was just recently someone who uh goes to the Lincoln Community Health Center was referred to me and I had to kind of figure out how do I help this uh person from Mexico navigate the foods and when I say you can have all the chicharron you want, the eyes light up. You can have all the pork rinds you want. That’s also a telltale sign for uh someone from North Carolina typically. Uh but uh so   Terry 15:34-15:38 But thank you for translating Chicharron.   Dr. Eric Westman 15:38-15:51 Chicharron is or uh I’ve had the best chicharron, in uh in Colombia. The kind it was really pork belly. But anyway, it has no carbs and it’s kind of a secret trick if you’re trying to (TERRY) it’s very high fat. It’s very high fat.   Terry 15:51-15:54 Which is great on a carnivore or keto diet.   Dr. Eric Westman 15:54-16:37 It it may not be great on a low fat diet. I, I understand. And I think there are a lot of ways to be healthy, just to kind of declare I’m not just a carnivore keto proponent. I in fact it was recently when Lucia Aronica at Stanford asked Christopher Gardner to do a sub study of his paper. It’s called the DIETFITS study. The substudy was let’s look at people who did ultra low fat and let’s look at people who do did ultra low carb. And and so it selected out people who were actually following those, and looked at health parameters and actually the ultra-low carb diet looked very similar to the ultra-low fat diet.   Terry 16:37-16:38 In terms of outcomes?   Dr. Eric Westman 16:38-16:41 In terms of improving insulin resistance.   Terry 16:41-16:41 Uh-huh.   Dr. Eric Westman 16:41-16:45 Improving what we understand now is probably the root cause.   Joe 16:47-17:04 Well we just have a minute before the break, but I would love to have you explain insulin resistance because we are hearing about it so frequently now and it’s so critical. But I fear that a lot of people don’t yet understand it. So you have one minute to give us the insulin resistance overview.   Dr. Eric Westman 17:04-17:52 Yeah, so insulin resistance uh actually is a term, I don’t like it. It, you really should say high insulin levels. Because insulin resistance gives the connotation that there’s something wrong in the person, something wrong in the cell, and you just need a drug. But what insulin resistance functionally is, is that insulin is not working to lower the blood glucose like it used to. So what you see is an elevated blood glucose compared to before or A1C, the hemoglobin A1C, the three month average of the glucose. And but you see the insulin resistance also means your insulin level is high. So I would rather have you talk about high insulin levels and how to get those down than insulin resistance, which is this, you know, term out there you need a drug for.   Terry 17:52-18:08 You’re listening to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society Dr. Westman is a specialist in internal and obesity medicine.   Joe 18:09-18:13 After the break, we’ll consider why dietary guidelines haven’t made a difference.   Terry 18:13-18:19 There’s not impeccable evidence to support the current guidelines, but that’s also true for the carnivore diet.   Joe 18:19-18:21 What does science tell us about how it works?   Terry 18:21-18:25 How do carnivore and keto diets differ?   Joe 18:24-18:29 What are the pros and cons for patients following a carnivore diet?   Terry 18:39-18:48 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. This podcast is brought to you in part by Sonu.   Joe 18:48-19:12 Ready to breathe like never before? Meet Sonu, S O N U, the world’s first FDA‑approved wearable headband that gives you drug-free relief from nasal congestion in minutes. It’s safe for adults and kids 12 and up, making it perfect for families dealing with allergies, sinus issues, or chronic stuffiness.   Terry 19:12-19:31 Sonu uses personalized sound-based therapy to naturally open nasal passages. No meds, no steroids, no sprays. Even better, up to four users can share one account so the whole household can benefit. It’s compatible with both Apple and Android smartphones.   Joe 19:32-19:52 Learn more at getsonu.com and sonu.com. Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 19:52-20:15 And I’m Terry Graedon. On The People’s Pharmacy, you hear a lot about the value of vegetables. We’ve interviewed nutrition experts like Dr. Walter Willett and Dr. Christopher Gardner who are enthusiastic about a plant-based dietary pattern. Today we’re considering a different approach to eating. What are the benefits of a carnivore diet?   Joe 20:15-20:24 What’s the difference between a ketogenic diet and a carnivore diet? What are the benefits and risks of such eating patterns?   Terry 20:24-20:52 Our guest is Dr. Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in 2006 after conducting clinical research regarding low carbohydrate ketogenic diets. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society. His areas of expertise include obesity and metabolic disorders.   Joe 20:52-21:12 We’re also joined by Bianca Garcia. We invited her to co-host this interview while she served as WUNC’s AAAS Mass Media Fellow. She holds a master’s degree in media medicine and health from Harvard Medical School where she created an audio documentary on the carnivore diet.   Terry 21:12-21:28 Dr. Westman, we’ve uh kind of reviewed the, a little bit of history of dietary guidelines and advice. Do we have any idea why so many of these dietary guidelines don’t seem to have done the job?   Dr. Eric Westman 21:29-22:07 Well, you know, uh the way I look at it is the there was never any science behind these dietary guidelines. That’s pretty clear. And people have written papers on uh there have been a paper uh was a thought piece of was there any evidence when the dietary guidelines were made that that there were we should have those guidelines and basically know there wasn’t any evidence. So I think it was the government being lobbied to make the foods America makes be consumed more by Americans. Thus we don’t have coconut oil in the guideline because we really are not big producers of coconut oil.   Joe 22:08-22:15 True enough. But before we go any further, when we say the guidelines, uh what are we even talking about?   Dr. Eric Westman 22:15-23:25 Well I know and you know I, fortunately, the guidelines are pretty much uninterpretable right now to the average consumer, except institutions are still somewhat beholden to them. I was just on a panel recently at a meeting where we all kind of agreed no guideline is better than a bad guideline. And I was past president I am past president of the Obesity Medicine Association. We lobbied the government at the time and I sat in the office of the woman who created the food pyramid, Susan Susan Davis. And we said, you know, people aren’t healthy. She said, well this is a guideline for healthy Americans. And we said, no, people aren’t healthy. I’m, you know, advocating for obesity treatment. So I think the first uh question is, are we giving guidelines to healthy people? Or like the studies say and you just look around at the mall, are should we give guidelines and guidance to people who need a corrective therapeutic diet generally. So I’m not a big guideline guy and and uh I work with the patient in front of me and get results. And I yeah I think the guidelines have been a bad idea. Even even the latest ones.   Bianca Garcia 23:26-23:49 And Dr. Westman, as you’re pointing out, there’s not a lot of evidence for the current guidelines, but from what I’ve seen, there is not a lot of published evidence about the carnivore diet either. But we can intuit from the keto diet and other similar low carbohydrate diets why it might work. So can you walk us through a little bit about the science of why the carnivore diet works?   Dr. Eric Westman 23:49-24:58 Absolutely. And I, I share your kind of assessment that there’s not a whole lot of published literature. If you search carnivore, you know, you’ll get a survey. There was a survey from the Harvard group, Belinda Lennerz and David Ludwig, where they surveyed self-described carnivores and what happened to their health and all that. We actually surveyed a a group who was of type one diabetics, as people affected by type one diabetes as well. It was a Facebook survey and it was the most cited publication in the journal Pediatrics at the time. So I, I don’t discount this information, but you have to keep it in, you know, it’s preliminary um information. The the grassroots change that we’ve seen over the last ten to fifteen years is that people are changing their own diet with influencers or or just word of mouth. And getting amazing changes, including keto, including carnivore, and I think the mechanism is that they both really fix insulin resistance, meaning they lower the insulin levels. And really any effective diet can do that.   Terry 24:58-25:10 Dr. Westman, we’ve been talking about the carnivore diet as if we all know what it is, but I don’t. So maybe you can tell us what are people eating? What is the carnivore diet?   Joe 25:10-25:15 And before that even, what is the keto diet? So how do they differ and what are they?   Dr. Eric Westman 25:16-25:30 Yeah, so uh I think there are many different versions of these things. Carnivore, I think, can be best described as just animal-based foods. So kinda like you’re used to saying plant-based, plant-based, plant-based, plant, uh oh. That’s kind of…   Terry 25:30-25:31 Or plant forward.   Dr. Eric Westman 25:33-26:09 Oh, it changed. Oh that’s one way to do things, but you know, uh people who come to me, yes, some do self-select, they want to follow what I, not everyone comes not knowing what I do. A lot of I would say two-thirds of the people come seek me out because of the teaching that I give. I I have to admit that. But so two years ago there was a textbook called “Ketogenic: The Science of Therapeutic Carbohydrate Restriction” and I use this as show and tell to people from a first visit to my office to just show that there is a body of knowledge now out there on the keto diet.   Joe 26:09-26:23 And keto really makes it Let me read the the subtitle of the book you’re holding up. It’s “ketogenic, the science of therapeutic carbohydrate restriction in human health.” That’s it. Tell us about it.   Dr. Eric Westman 26:23-29:28 Well, Dr. Will Yancey and I at Duke have been doing research since 2002 and we contributed chapters on obesity and type 2 diabetes reversal in this textbook. But it’s much more detailed. In fact, I I haven’t read every word in it yet because, you know, uh there’s a lot of information on the keto diet. Well, keto really means that you’re using ketones in your body to an extent that you didn’t before. Is there a certain level? No, no, not really. And i is there a maximal or greatest greater keto diet? I, I don’t think we know that yet. So to me, a keto diet is a very low carbohydrate diet that allows your body to access the fat stores in a flexible manner, so that you can be burning your body fat and and as a result your ketone level goes up compared to those who eat carbs. Uh and uh the idea of fat loss, weight loss has been implanted, and that’s how I learned it. The keto diet was a weight loss diet. But it does much more than that. And now I have people coming to me whom I’ve taught a keto diet for years and and there’s a few conditions that still remain I haven’t been able to fix; I can fix almost every internal medicine problem that my colleagues use drugs for. I can fix,  uh reverse type 2 diabetes, obesity, PCOS, heartburn, migraines, all these things. But there’s a a nagging uh uh uh uh component of problems that have to do with inflammation and autoimmunity that keto doesn’t quite fix. And and I have to say that the keto, the way I teach it, it’s unlimited meat, poultry, fish, and shellfish and eggs, till you’re comfortably full. And one cup of non-starchy vegetables, and two cups of leafy greens. Now I don’t enforce those vegetables and and so what I teach is not strictly a carnivore diet. It allows for these vegetables and leafy greens. But people are coming to me now over the last few years fixing these autoimmunity conditions by dropping those vegetables. And so I’m I’m just wondering it, you know, so what I teach is carnivore-ish. And I passively allow people eat a carnivore diet under my care. You know, I, I monitor things. And it the science I want to go in the direction They’re case series, case studies of people who fix their inflammatory bowel disease, ulcerative colitis, the rheumatoid arthritis, and and we have a case study brewing trying to get it published of of palindromic arthritis that was basically fixed by just changing the food. So, so keto means ketosis, keto means fat metabolism. Carnivore to me is a subset of a low carb keto diet so that it doesn’t seem as far afield to me as it might to someone else.   Bianca Garcia 29:29-29:50 Still, this is a pretty socially and scientifically divisive idea. So I wonder how your peers and your colleagues look at um this kind of keto carnivore-ish diet, especially without uh the immense evidence base that like a plant forward diet might have. Well what kinds of reactions do you get from your colleagues?   Dr. Eric Westman 29:51-32:32 So actually there will never be uh uh unanimity in diet. Let that be just my first statement. There were and and that’s one reason why I’ve kept keto out of the press. In fact, whenever I’d get onto the the press or something, they would try to find someone against it. Well you can always find someone against it. You can always find a plant-based is best. No, there’s no evidence that a plant-based diet is better than a carnivore, animal‑based diet. It’s all implanted in people’s minds. So, no, because that Stanford study where they finally looked at insulin resistance between these two different very extreme diets, they both worked. And you know, I remember, gosh, how long has it been, Joe and Terry? We were talking the Duke Rice diet started all this at the Duke campus in the nineteen thirties or you know the history of (TERRY) Yeah, before our time even. Yeah, well And then, you know, the rice diet no longer exists, although there’s still people who remember that. That was would be like an Ornish/Pritikin ultra‑low‑fat kind of diet. And and I I think it works, you know, but it doesn’t mean there’s no other way to do it. So I guess um coming around, uh Bianca, that there never will be agreement among the the experts. And so what I’ve learned is I, I, I put my head down, created a clinic. And over the last 15 years, I learned as much as I could about using a keto and carnivore diet in a clinical setting. And if other people say, well, it doesn’t work, that’s not true. The long-term effects remain unknown, but that’s true, true for any diet. So that, you know, w we get into this, you know, oh there’s no evidence. Well, there’s really precious little evidence even for the Mediterranean diet, which everyone believes is the best. So in evidence meaning randomized trials long‑term. So we’re we’re left with what is biologically sensible and and also therapeutic. I just want to loop back to this textbook. I think there’s general consensus that a keto diet can be a therapeutic tool. I mean, so even my naysaying colleagues who don’t like the idea of carnivore and keto will say, okay, well, you can reverse things and fix things, but then what? You know, you gotta get off that eventually. And I’m like, well, but if it reversed all their problems, why would you want that get them off it? You know? And because they just know that it’s bad. I mean, if it if it’s not known, it must be bad, which I learned, you know, you and I sat in a room like this. when that first Atkins paper came out and oh the controversy and now nobody really knows that name other than the the food on the shelf.   Terry 32:33-32:54 So, Dr. Westman, would you please tell us briefly what you have seen as the clinical benefits for people who are following this carnivore or even carnivore-ish diet? And then we’d also like to talk about some potential downsides.   Dr. Eric Westman 32:54-34:52 Absolutely. So from my bench or or clinic, um what I see for those who follow uh carnivore or keto kind of diet with instruction from someone who knows what they’re doing. Now you know, internet and carnivore internet and keto internet there are so many different places to learn, it’s very confusing. But so you want to learn from someone who knows what they’re doing and if you’re on multiple medications, you wanna be sure to be working with someone who knows how to get you off those medicines safely. And so what I see is uh the average patient coming to me is 60, 65 years old on seven to ten medications. Medications for diabetes, high blood pressure, heartburn, arthritis. Many of these people have already had hip and joint replacements, and and now they’re have they have obesity too. And so I simply tell people that we store fat on our bodies for energy and we want to get access to that fat store. And I could use a keto, a low glycemic, a a carnivore type of diet based on this someone’s preference. And over time I can fix, reverse all of those medical conditions by changing the food. It’s so unbelievable you won’t believe me. So for the last 10 years I’ve at medical conferences I’ve said, come to my office. And partly I set up this clinic so that it could be a teaching clinic, not only for for the patients, but for doctors. So residents and students at Duke come through my office. Other doctors have come even from around the world to see it in action. And so basically it’s the all the internal just about all of the internal medicine problems that are treated with medications today can be reversed or greatly reversed just by changing the food.   Joe 34:53-35:43 I want to ask you a little bit about a couple of conditions that are widespread in our society, and we don’t have good treatments for. Inflammation, which I’d love to have you define what that means from a biological perspective, and also the impact on the brain, on mental clarity, because there are a lot of people in the age bracket that you’re talking about who are complaining about mental fogginess, in you know just functionality. I, I can’t remember those names anymore the way I used to. And they were also complaining about their knees and their elbows and their fingers. What impact does this approach have on those two areas?   Dr. Eric Westman 35:44-36:12 Yeah, so inflammation is basically your body’s ability to clot, to fight infection, to to function. And you need some inflammation. So you don’t someone came to a meeting, an expert, and said, Well I don’t eat that ’cause it causes inflammation. I don’t eat that ’cause it causes inflammation. The first question at the microphone was, Well, what do you eat? Basically you said, I fast because eating causes inflammation. And I mean that’s to the absurd degree.   Terry 36:14-36:15 Not a long‑term strategy.   Dr. Eric Westman 36:15-37:26 Yeah. So so you w n you want some inflammation, but you don’t want too much. I guess it’s like Goldilocks, you know. You want a little bit uh of inflammation but not too much. And I I think the the elephant in the room is that food causes inflammation. Of course, stress causes inflammation and and so food, the carbs are uh and refined sugar and flour are really kind of the the ones that are causing most of the inflammation today. Uh you know, the brain function is fascinating and I think the common consensus is that insulin resistance, oh, remember that term? High insulin levels. over a period of time actually cause Alzheimer’s. Just cause. But the problem is once you get a a memory issue from Alzheimer’s, it’s too late. So it’s like the you know, the plane’s going down. So everything I’ve learned about Alzheimer’s is that you want to take action now. Like if you have a family history of it, uh a loved one where you want to address that insulin resistance and there are numerous uh dietary ways to do that.   Terry 37:27-37:59 You’re listening to Doctor Eric Westman, Associate Professor of Medicine at Duke University. He founded the Duke Keto Medicine Clinic in two thousand six after conducting clinical research regarding low carbohydrate ketogenic diets. His newest course, Carnivore Made Simple, is open now for enrollment by People’s Pharmacy listeners for a limited time. Bianca Garcia, a AAAS Mass Media Fellow at WUNC, joined us in co-hosting this interview.   Joe 38:00-38:05 After the break, we’ll find out what people are saying on the internet about the carnivore diet.   Terry 38:04-38:08 How long does it take for people to see weight loss from a carnivore diet?   Joe 38:08-38:13 What downsides might we expect from such a diet or the keto diet?   Terry 38:13-38:18 Bianca will share her experience trying a carnivore diet. How did that go?   Joe 38:18-38:23 Should we change our thinking on nutritional science?   Terry 38:35-38:39 You’re listening to The People’s Pharmacy with Joe and Terry Graedon.   Joe 38:47-38:51 Welcome back to The People’s Pharmacy. I’m Joe Graedon.   Terry 38:51-38:52 And I’m Terry Graedon.   Joe 38:52-39:06 What’s a healthy way to eat? Humans around the world have come up with different answers to this question. Most nutrition scientists agree that the standard American diet falls far short.   Terry 39:06-39:38 Our guest today is Dr. Eric Westman. He is Associate Professor of Medicine at Duke University, where he founded the Duke Keto Medicine Clinic almost 20 years ago. Dr. Westman is a co-founder of Adapt Your Life Academy, where his newest course is Carnivore Made Simple. It’s open for enrollment by people’s pharmacy listeners for a short time. Bianca Garcia, a AAAS mass media fellow at WUNC, joined us in co-hosting this interview.   Bianca Garcia 39:40-40:12 Dr. Westman, you were talking about the internet culture of this diet. And you were saying how, you know, it’s important to get instruction from people who know what they’re doing and how to get you off your meds in order for you to, you know, safely carry out this diet. But I think I want to talk a little bit about the internet culture and you know, how this diet is spreading popularly. What are you seeing out there? What do we have to be aware of as people might be encountering this diet in the wild?   Dr. Eric Westman 40:13-42:05 Uh yeah, great and you know I’m uh just kind of in awe of the internet compared to twenty years ago. And it’s a wonderful thing and a terrible thing all at the same time. So the big line of, of demarcation should be if you see a doctor for a a problem that you’re taking a medicine for. Be sure to do this with a doctor who knows what they’re doing, because medicines can become too strong on the first day. I’ve had people have low blood sugars from insulin and other diabetes medicines on the first day. So if you’re consuming this information online and it’s to the general healthy person, I’m not so worried about it. But once you get into that clinical population, now, you know, I don’t know uh uh any of my patients who are on TikTok. So that that might all automatically select the ’cause the people who come to me are generally older. But that’s that’s not always the case. So I I’m getting patients who come to me because I kind of passively endorse a carnivore diet as a subset of a keto diet. That uh I think uh you want to do things um that um and not only feel feel right isn’t the right word. It’s the thing uh changes that make you feel good. I mean that that may correct a problem that you have. And if it even if it’s excessive hunger and all you can do is think about food. Then this is something the food is really the answer and and um I’m afraid doctors don’t have that information and you know it it really is hard to police this, isn’t it? But uh to me I I try to make sure that if you’re you know older, you’re on medicines, that you have someone who knows what they’re doing help you.   Bianca Garcia 42:06-42:50 I also want to add though from my field work and from the interviews that I do that young people are exploring this diet. I think there’s a lot to say about the simplicity of it. People are attracted to it because unlike the Mediterranean diet, which has like very strict um ideas of what you can and can’t eat. This is just like take out everything and stick with just meat. And that’s pretty intuitive and simple. But at the same time, that can have some, let’s say bodily impact. I tried the carnivore diet for a little bit. I couldn’t stick with it. So what can we expect about people who just get on the diet? And I guess the the essence of this question is like: how long does it take for this thing to work?   Dr. Eric Westman 42:51-43:07 Well, I um it depends what you’re doing it for. So uh y I I have no problem compared to all the other things you can do in terms of nutrition. I think can we agree that the standard American diet just isn’t highest on the list?   Terry 43:08-43:09 I think we can all agree with that.   Dr. Eric Westman 43:10-43:21 So what’s then next? Can everyone do a super strict eat local, go to the farmer’s market, um, never go to McDonald’s and all or Burger King or Wendy’s?   Terry 43:21-43:22 Not everyone.   Dr. Eric Westman 43:22-45:38 Not everyone. So we have to have some sort of compromise, I believe. And and that’s also my doctor perspective. I don’t just preach as an influencer, do this and you have to be perfect. There are those who do that. They preach that and and I see people coming in worried about the the carblets, the the little microcarbs and the maltodextrin in the cheese and the I mean, come on. That’s not metabolically substantially anything you should worry about. So how you get it taught matters a lot. And the carnivore diet as it’s taught today, just eat meat. Well, I think it’s relatively healthy and and you know, if there’s if I could go back, Joe and Terry, twenty-five years ago, I would have said, show me a study that Atkins diet is bad. There never was one. And it took me just two years ago in with Jeff Volick, a researcher who’s been with me in this space for twenty-five years. For him to be on a podium and say, you know, there’s never been a study that showed that nutritional ketosis, the Atkins diet induction even, which now, you know, is carnivore, there’s never been a study to show that it’s bad. When I thought about that and look back, we had the wrong emotional reactive position of we had to try to prove that it was good, when nobody had shown that it was bad. It was prejudging. And I have that same feeling here. Yes, it’s a feeling, and I want science. I want more science. That that’s what’s going on today. Hey, it’s just eating meat, which is a lot better than eating all that other garbage and and you know in a scientific venue, I I do say things like, you know, prove that a keto diet is bad, you know, using the method that I use. Because we don’t see that it’s bad and if you just say a keto-ish diet from nutritional epidemiology shows that it’s bad, that doesn’t count. But so anyway, I I’m I you know me, I I was taught to to protect my data, and and protect what I saw in front of me, but then I cheated. I went to doctor’s offices who they’d done it for thirty years before me.   Terry 45:39-46:01 Well, Doctor Westman, here at The People’s Pharmacy, we rarely hear about a medical intervention that is just all good and has no downside ever for anyone. So can you tell us about some downsides that people might want to be aware of that could happen while you’re following a carnivore diet?   Joe 46:01-46:22 Or a keto diet. Because what we have learned over the years. And it took us about 40 or 50 years to recognize that some people will say, oh, this drug is marvelous. I love gabapentin, It takes away my nerve pain. And other people say gabapentin ruined my life.   Terry 46:23-46:23 Made me crazy.   Joe 46:24-46:58 I had hallucinations, it was, my brain stopped working. So nothing is ever really black or white. And some people, I am sure, as we’ve interviewed in the past, I love fiber, fiber, fiber fuel diet. It’s the best diet. And then other people say, oh my gosh, I just had so much gas I couldn’t tolerate it. So give us the pros and the cons. You’ve already given mostly the pluses, but are there some people who have problems with a keto or carnivore-ish diet?   Dr. Eric Westman 46:58-49:20 Well, that’s a great point. And that raises the issue and and the reason why formal research is necessary. Is that I learned a long time ago that if someone is just selecting out to come see me that because they have good results. Then I have a selection bias, what happened to people who couldn’t follow it? What happened to someone who had a problem and they didn’t come? So it’s important to have a study not only to I don’t think we need studies to show efficacy. I mean, I I could show efficacy with fifty people compared to a standard American diet for diabetes. We, our study of low glycemic versus low carb diets published in 2008 only had 50 people in it. So we can show efficacy. And it’s the safety side that you need more people involved and, you know, you get a hundred people, you get thousands of people. Then well, with a drug, then you get millions of people, then you start to really get an idea of the side effects. But so I I think the um side effects that most people have with keto or carnivore are manageable. We teach how to have keto adaptation at first where you add salt back in if you don’t have a salt sensitive condition. If someone has headache or cravings that goes away typically in a few days or a week. There might be change in bowel function where you you treat that with a little magnesium early on or some other electrolyte supplement. What s being able to stay on the diet to me i is is not only the biologic change that occurs, it’s also how that person perceives other people think of them and if they don’t want to go to the store and just have meat in their grocery cart. I mean that that’s a different so metabolically I have yet to see someone who cannot do a keto or carnivore diet metabolically because all of those problems are kind of screened out in pediatrics. So if if you have a serious fatty acid disorder, you can’t burn fat, you don’t really get out of childhood. So as an internist, as an adult I’m comfortable having people do a keto or carnivore diet. And most of the side effects, if if this were a drug, we’d say, well, these are mild and manageable.   Bianca Garcia 49:21-51:07 I’ll tell you a little bit about my perspective because like I mentioned I tried and I failed the carnivore diet. And before, before I get into that experience, I think I’ll frame it by saying like I’m a generally pretty healthy person. I was trying this as like a social experiment. There was nothing really keeping me going when I hit these roadblocks. And so for a lot of people who approach the carnivore diet, they’re doing it because they need something out of their health experience that they’re looking for at in the carnivore diet. That wasn’t my that wasn’t my case. So when I got the keto flu, as it’s popularly known, I was nauseous. I had headaches. I couldn’t get up in the morning. I was like, oh my gosh, this isn’t for me. But also, I felt the immense social pressure of the diet. I couldn’t go out and eat with my friends the way the the way I wanted to. I am a foodie and I felt a little depressed about not getting to eat the colors on my plate. Uh and also meat is kind of expensive. So, you know, I was feeling that in my wallet. These are all social things about the carnivore diet that are pitfalls of it, and I think that we need to talk about these because nutrition is inherently social. So while there could be and while there is evidence for these like immense changes to embodied health, there’s also the social health that’s important to think about. But I do want to follow up with a question for Dr. Westman, uh, which is about the common skepticism for this diet, which is like, what do we do with this information that we’ve all heard that red meat is carcinogenic and that if we don’t eat vegetables, we’re gonna get like a vitamin C deficiency? How do I think about that?   Dr. Eric Westman 51:08-51:16 Well, that’s a lot to unpack. Thanks for sharing your story. I wonder if you added salt during the keto adaptation.   Bianca Garcia 51:16-51:26 I learned afterwards that I should have been doing that. And I was going off the internet, you know? I think that’s the other thing. Which is…   Dr. Eric Westman 51:26-53:09 Ignore every internet thing except mine. Isn’t that funny? So but uh the the social things are are are real and but you know I I think back in the nineteen seventies, people started jogging and it wasn’t socially acceptable. In fact, people started starting to get treadmills and jogging I mean I’ve traveled to Europe and I was jogging and the Europeans looked at me like I was a nutcase ’cause you just didn’t jog in Europe. I didn’t see a whole lot of Europeans jogging even today. But so social acceptance can change over time. And i if you’re I think that trade-off for you w r wasn’t right. You know, you weren’t getting some benefit that you were, you know, fixing your ins incessant hunger. Or or um so I’m watching some influencers and I do React videos. One of the things that’s really important to remember if you’re exercising a lot, And if that’s part of your life. You’re at the gym and all that. That’s not where the the clinical application of keto and carnivore came from. It started with people who were unable to exercise, fixing metabolic issues. And so th there that’s a different context that you need to learn from people who’ve figured that out online. There are I think there are some good influencers online who’ve helped a lot of people. But again the the selection bias is a problem. So that perhaps your story or your your result is some biologic factor, not just social, and and maybe that’s underrepresented in the internet, you know, the highlight reel of, oh look me, look at I all I did all this And those who are not getting results don’t say it publicly.   Terry 53:10-53:21 Dr. Westman, how does what we have learned now about the carnivore diet change how we think about nutritional science?   Dr. Eric Westman 53:21-54:24 Well, that’s a great question, and I’ve always been a critic of nutritional epidemiology. Where you ask people what they eat periodically, sometimes once a year, and then you follow their health outcomes without any sort of experimental manipulation. And so I’ve I’ve always been critical of that and I’m a clinical trialist and so I value the Stanford paper with a couple hundred people on the diet and they were they know they were following it and and I trust the prospective data more than the cohort studies. So that so my perspective is we have to get to biology. So I’ve started to teach, let’s look at what the body’s made of. Let’s understand that we’re mostly water, protein, and fat. In fact, there’s no carbs stored on our body. I go over this with the body composition personally with my patients now. And I explain that we store fat on our body, not carbs.   Joe 54:25-55:23 Dr. Westman, people learn best from stories. And I know it’s not science. But on the other hand, we we can begin to have some sense of your many decades of experience with um first the Atkins diet, then the keto diet, now the carnivore-ish diet, you’ve had, you know, probably hundreds of patients, perhaps now thousands of patients. Tell us about some that stand out in your mind where they they came in perhaps overweight, perhaps with a diabetes problem, perhaps taking, as you said many medications and not feeling well. Tell us about, without actually naming someone who could identify him or herself, how your approach has changed their lives.   Dr. Eric Westman 55:24-55:39 Well, that’s a great question. And I I don’t know where to begin. I mentioned the kind of garden variety reversal of diabetes, hypertension, obesity, PCOS, and GERD. And I would say those are uh papers that we have published.   Terry 55:40-55:51 Now, Dr. Westman, I’m gonna call you on the alphabets. You need to tell us what PCOS means. And a lot of people know what GERD means, but not everybody, so you’ll have to explain that one too, please.   Dr. Eric Westman 55:52-58:03 Sure. PCOS means polycystic ovarian syndrome. And then GERD is gastroesophageal reflux disorder or heartburn. Heartburn. So these are things that either my colleagues who are internists can’t fix or they give drugs for. So uh I I think the extreme cases that I’m seeing now that I’m really kind of proud of, ’cause I stick to my guns. I I don’t I I just I’m a I’m a source where people can come and say, Hey I relapsed to sugar. And there are several patients who just when they relapse to sugar, they can gain 20 pounds in two months. And they come back and they have the safe zone almost like um I I don’t know, like be getting in a church and having sanctuary, because we know now that sugar is as addictive as any other drug. It was regarded as a drug and then in Gary Taubes’s “the case against sugar,” book he gives the history of that. So I think this um uh woman who’s stressed just stressful life and and and the sugar is just uncontrollable for that person. Um and and that’s kind of the new frontier of understanding that sugar is an addiction, uh and it’s okay not to have it. Um but the other the medical side if I put on my internist hat, it’s the inflammatory bowel disease that goes away. It’s the again, uh my my colleagues have super strong anti-inflammatory drugs now. They can give shots that cut out any symptom from inflammatory bowel disease, Crohn’s, or ulcerative colitis. The problem is those shots are so good, you’re at risk for having cancer, because you need that anti-inflammatory response to fight cancers. And so these drugs are so strong they’re being used and then most people don’t think they need to change their diet. So I like people to understand that there’s just another way to go about things. It’s not wrong to take the drugs and eat carbs and and all, but their lifestyle is so important and so powerful when it’s done right.   Joe 58:04-58:24 So I’m gonna ask you in your mind to imagine John Doe or Jane Doe, a patient, a real patient, who came in struggling, came in frustrated. Their diets haven’t worked in the past, their medications are only working so well. And tell us their stories.   Dr. Eric Westman 58:24-58:53 Yeah, well, uh a doctor comes to mind. who uh who’s weighing three hundred and fifty pounds ish, so it doesn’t matter how tall you are, you’re gonna find you’re gonna hit the high BMI obesity category. But he he also had a really serious metabolic problem called POTS, postural orthostatic tachycardia syndrome. I’m seeing a lot more of that. And it actually he was so skeptical. I mean, come on.   Joe 58:53-58:55 And what’s it like to have POTS?   Dr. Eric Westman 58:55-59:09 Well POTS makes you uncomfortable when you stand. You might get tachycardia at a fast heartbeat, you get flushing, and then you can even pass out. So he was finding himself on the floor at home. His family would come find him.   Terry 59:10-59:13 And so he’s at three hundred and fifty pounds they couldn’t lift him up.   Dr. Eric Westman 59:13-01:00:30 Yeah. Well that that that all goes without saying. The the problems of the obesity too. I mean, so it’s like, the obesity’s kind of become, oh yeah, I can fix that, no problem. I just explain w we have fat on our body, we need your body to burn fat. It’s these other conditions. So that when he came back thinking uh or uh seeing the weight loss, that was one thing. But then when he starts saying, you know, I’m not having those spells anymore. You know, you are starting to understand the metabolic changes that are happening go beyond just the weight loss. And this could apply to any number of things. It’s common today for people to be very skeptical and then they come back sort of the tail between their legs, you know, I didn’t think this was gonna work. Uh one gentleman in his seventies, uh and he and his wife came back and and they were like, Wow, this really does work, down, you know, twenty pounds in the first visit dur uh duration since the first visit. And so uh that kind of change can happen fast, and the idea that you could change these medical issues just by changing the food, that’s just not common knowledge. It’s not commonly known. And food really is is king   Terry 01:00:28-01:00:35 Do we have any idea how a carnivore diet affects the gut microbiome?   Dr. Eric Westman 01:00:36-01:00:37 Oh, it changes it for sure.   Terry 01:00:37-01:00:44 I would imagine it would because uh what what you eat does change the microbes inside you. Well what’s the impact?   Dr. Eric Westman 01:00:45-01:02:03 I I wrote a book with uh super smart uh writer that’s my my method is I team up with other people for books and we would go, not the microbiome again, you know, it’s another study, another distraction. So of course the microbiome changes, and it changes in a favorable way. Best way I can it can can explain it is like a a scientist who showed me at a at a world class meeting. He showed, click, here’s a slide of this jungle, like the Amazon, and here’s your microbiome. It’s beautiful, it’s of colors, and I’m like, well, there are things that can kill you there. It’s uh, you know, it’s the Amazon, little frogs and th and then he goes, Click, and here’s the microbiome on a low carb diet and it was like a desert. And I’m thinking, man, Zen meditation and and uh resort area. This is really calm. That’s what happens. Your microbiome calms down when you do a current, of course it changes. And it’s fascinating today. Well we, we study carb eaters and look at their microbiome and say, well, if we can just have that bacteria and put that in another person who doesn’t eat carbs, we’re gonna get all no, no. So the best thing for your microbiome is to cut the carbs out.   Joe 01:02:03-01:03:02 I’ve got a question, Dr. Westman, about GERD. I remember a paper that you wrote that was I would say semi-heretical, because at that time uh the H2 antagonist drugs were in the ascendancy, and then along came the proton pump inhibitors, which were going to be even so much better. And no more heartburn, no more GERD, we’ve got drugs. And you did a study, not a huge one, but it said a low carb diet could change everything for people suffering from GERD, from bad heartburn, esophagitis. And then we started writing about it and people started reporting, hey, you know what? It works. Even though conventional west wisdom from the medicine community was, oh, just give them a PPI.   Terry 01:03:02-01:03:06 Oh, and you should not be eating fat, obviously, if you have GERD, right?   Joe 01:03:06-01:03:06 Exactly.   Dr. Eric Westman 01:03:07-01:03:08 Or caffeine or chocolate.   Joe 01:03:08-01:03:09 Or any of that stuff.   Dr. Eric Westman 01:03:09-01:04:59 So that’s all the old, old stuff that doesn’t really work. (JOE) So give us an update. Dr. Eric Westman Well uh looking back, the studies we did really are proof of concept studies, right? So they aren’t big randomized trials looking at different types of diets. So differ many different diets could work. But this was a interesting study by a GI fellow at UNC. So we actually had a Duke UNC collaboration at the time and he put a pH probe down the nose into the stomach of these people with refractory heartburn. and and looked just over a few days of changing the diet, the acidity changed. So you actually were changing the diet was like taking an antacid. So whoa, yeah, so that was after the clinical signal is so strong. If I put someone on twenty grams, total grams, not net of carbs a day. The heartburn goes away almost uniformly, a hundred percent. But now time passes, so so uh another study comes out where they gave a hundred grams of carbs, you know, the typical American may have two to three hundred grams. And they changed, cleaned up the food so it wasn’t junky. A hundred grams of carbs a day reduced the heartburn as well. So if we do a study that says 20 grams or less can fix, you know, 10 people, it doesn’t mean 50 grams can’t or a hundred grams can’t. And so there’s all this level of carbs that needs to be studied in my mind, or you just try it yourself, uh if you uh but the problem with that a hundred gram fixing or reversing heartburn is it didn’t work a hundred percent like the twenty gram one did. So uh yeah, that was uh a signal that, you know, I I cheated and I read that in Dr. Atkins book. Dr. Atkins health revolution, because he had seen this in his clinical practice. You know, you know.   Joe 01:05:00-01:05:22 You mentioned the science. Oh, we’re always looking for the science because we hear, oh Evidence-based medicine, randomized controlled trials. I searched high and low for data to support the traditional heartburn diet. Which as you say, it was uh no chocolate, no coffee, no fat.   Terry 01:05:23-01:05:23 No alcohol.   Joe 01:05:23-01:05:33 No alcohol. I mean, I I I looked for the data. Because this diet was given out by gastroenterologists all across the country for anybody who came in with heartburn. I couldn’t find it.   Dr. Eric Westman 01:05:34-01:06:04 Yeah, and I I think we can understand why. The mechanisms have been key for so long. So there’s the oh well caffeine loosens the lower esophageal sphincter. So it is c chocolate and and protein makes the glomerular filtration rate go up, therefore it must be bad. So if you only talk about mechanism, you can get into these strange rabbit holes. I really value whole human research where you’re not just focusing on those little things.   Bianca Garcia 01:06:04-01:06:52 Yeah, I think this is a really great transition into what I wanted to ask because science changes. And the carnivore diet kind of rose in popularity around COVID-19. And this was a time when scientific mistrust started to grow in the public. And we saw that as COVID guidelines changed, people were like, wait, why is science so flip-floppy? And there’s kind of a parallel here with the carnivore diet too. We’ve all been told plant-based, plant forward. Now it’s like, okay, meat forward. What do we do about this? And I think, you know, you’re you’re telling us a little bit about how science changes, but what would you say to somebody who was trying to make the right choice, but maybe feeling a little bit overwhelmed with the scientific method.   Dr. Eric Westman 01:06:53-01:09:27 Yeah, well, uh we do the best we can, and the basic biology to me rules. And nutrition epidemiology, even that’s the red meat causes cancer thing, it’s weak, observational, and to me that’s not something I use in my clinic. I don’t value that. That red meat does not cause cancer to the level of certainty that I need to say don’t eat red meat. And I I know I’ve been on panels with folks and there are international organizations that are based on plant-based anti-red meat principles. I understand that. But the group at McMaster, whom I visited in the late 1980s is evidence-based medicine for the world, basically. Uh and they call out that this evidence about red meat and cancer is weak. And it’s not clinically relevant. So so I don’t worry about that. But getting back to the basic principle, don’t eat a lot of junk food. Uh ultra-processed food today unfortunately suffers from this definitional thing. And, and processed food, people come to me saying, You mean I can’t have bologna and it can’t have that I said, No, you can have bologna, but that’s processed. No, that that’s minimally processed. There’s more nitrates in beets and and broccoli than in these other you know, so I, yeah, it gets confusing, doesn’t it? So you want to eat protein, we’re made of protein. It doesn’t matter to me if it comes from an animal or a plant. We’re made of protein. Water is a given. You’re gonna have thirst. Then you can run your body on carbs or fat. It’s your choice. You can, you know, to sustain whatever kind of activity you’re trying to do. So that opens the idea that you might do a keto or carnivore diet because you’re running on fat. And that’s why we see people having such success with it. The body works just fine. If you don’t like that way of eating and the social things today, I mean but let’s get real. Were we really designed to eat at a Thai food place and then a Mexican place and then a and then a uh you know, all these great flavors, not you know, I don’t think that’s particularly a good thing, healthy thing to do. Uh it’s very new and and uh you want to be um honest about your ability to control things. If you’re out of control with sugar, you avoid sugar. If you’re out of control with bread, you avoid bread. You know, if you’re uh so I think protein comes first. Instead of plant forward, I wish we would say protein forward.   Joe 01:09:28-01:09:37 Final words? (Dr. ERIC WESTMAN) To summarize about a carnivore diet?   Dr. Eric Westman 01:09:35-01:10:14 I think it’s a reasonable tool, and it may even be a healthy way to eat in the long run. There’s a study that just came out, meaning in the last few years. where they looked at women who had been keto‑adapted for an average of three years and all of the biochemical parameters they were able to check looked great. They fed them a UK based diet with carbs and everything went to hell in a handbasket, I know, a great scientific term. And then they went back on a keto diet, and everything looked great. The average age was 32 years old. So what’s unknown is is this a long-term thing, but it might be.   Terry 01:10:15-01:10:21 Dr. Eric Westman, thank you so much for talking with us in The People’s Pharmacy today.   Dr. Eric Westman 01:10:21-01:10:22 My pleasure.   Terry 01:10:23-01:10:26 And thanks to you, Bianca Garcia, for helping us with the interview.   Bianca Garcia 01:10:27-01:10:28 Thank you.   Terry 01:10:28-01:10:43 You’ve been listening to Dr. Eric Westman, Associate Professor of Medicine at Duke University. He’s a board member of the Society of Metabolic Health Practitioners and the American Diabetes Society.   Joe 01:10:43-01:11:00 We had help today from Bianca Garcia, a medical anthropologist, foodie, and radio person. She served as a AAAS mass media fellow covering health and science at WUNC North Carolina Public Radio.   Terry 01:11:01-01:11:13 Lynn Siegel produced today’s show. Daenerys Thomas and Al Wodarski engineered. Dave Graedon edits our interviews. B. J. Leiderman composed our theme music.   Joe 01:11:13-01:11:21 This show is a co-production of North Carolina Public Radio WUNC with The People’s Pharmacy.   Terry 01:11:21-01:11:40 Today’s show is number 1444. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio@peoplespharmacy.com.   Joe 01:11:40-01:11:51 Our interviews are available through your favorite podcast provider. This week we’re celebrating 10 million downloads.   Terry 01:11:51-01:11:52 That’s cool.   Joe 01:11:52-01:12:18 Yes. You’ll find the podcast on our website on Monday morning.   Terry 01:12:18-01:12:42 At peoplespharmacy.com, you could sign up for our free online newsletter. That way you get the latest news about important tell stories. When you subscribe, you also get regular access to information about our weekly podcast. We’d be grateful if you’d consider writing a review of The People’s Pharmacy and posting it to the podcast platform you prefer.   Joe 01:12:42-01:12:45 In Durham, North Carolina, I’m Joe Graedon.   Terry 01:12:45-01:13:28 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to The People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money.   Joe 01:13:28-01:13:38 If you like what we do and you’d like to help us continue to produce high quality, independent healthcare journalism please consider chipping in.   Terry 01:13:38-01:13:43 All you have to do is go to peoplespharmacy.com slash donate.   Joe 01:13:43-01:13:59 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.  

Americans take a lot of medications. Luckily, the Food and Drug Administration only approves those that are safe and effective. However, the agency’s definition of “safe” includes medicines that can harm or kill some people, and the definition of “effective” covers some drugs that only work a little better than placebo. Has the FDA changed its standards? Maybe we should be rethinking medications. At The People’s Pharmacy, we strive to bring you up‑to‑date, rigorously researched insights and conversations about health, medicine, wellness and health policies and health systems. While these conversations intend to offer insight and perspective, the content is provided solely for informational and educational purposes. Please consult your healthcare provider before making any changes to your medical care or treatment. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Sept. 6, 2025, at 7 am EDT on your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Sept. 8, 2025. Rethinking Medications: If you watch television or streaming video, you probably see a lot of commercials for prescription pharmaceuticals. Decades ago, prescription drugs weren’t advertised on television, and the prices for prescriptions were much lower. How has the pharmaceutical industry changed? On this episode, we talk with an expert observer of the industry and its regulation. Dr. Jerry Avorn is one of the country’s most respected pharmacoepidemiologists. He describes how the business of making and selling medicines has evolved. What Is the Role of Orphan Drugs? The Orphan Drug Act was passed in 1983. Its goal was to offer incentives to drug companies to develop medicines for rare diseases.  The FDA encouraged Congress in this, viewing these as “significant drugs of limited commercial value.” The idea was to make sure that even though only a few hundred Americans might have leprosy, for example, that drugs would still be developed to treat their condition. Tax breaks, patent extensions and market exclusivity made the proposition more appealing. In fact, one of the reasons Americans spend twice as much on drugs per capita as citizens of Canada, Australia or other countries is the cost of orphan drugs. Although these compounds were seen as having “limited commercial value,” the industry has figured out how to charge exceedingly high prices for anything considered an orphan drug. How Effective Is Your Medicine? When it comes to evaluating effectiveness, pharmaceutical firms have a powerful tool. Dr. Avorn considers it one of the best inventions of all time, although it is a concept rather than a thing. RCT stands for Randomized Controlled Trial, which in turn is shorthand for randomized placebo-controlled double-blind (or in the UK, double-dummy) clinical study. The idea is to take a group of people who are alike in some important ways, so that they are equally likely to develop some type of health problem. Divide them up using a random number generator or some other similar impersonal technique. Those on one side of the divide get the medicine, while those on the other side get an indistinguishable placebo. Neither the participants nor the investigators know who is in which group. At some pre-specified time, the researchers will check to make sure there have not been too many adverse reactions. They may also check that the intervention appears to be doing something. When the trial is over, the methods and results should be described in a publication so that doctors will know if they should incorporate the treatment into their practice. We love RCTs when the outcome is avoiding some serious problem such as a stroke or a cancer diagnosis. For us, biomarkers are less compelling, even though they have become far more common. What is a biomarker? It is easy to measure, like blood sugar or blood pressure. The biomarker is a stand-in or surrogate for a condition like diabetes or heart disease because they are often correlated. It is important to remember, though, that the biomarker is not the disease. Comparing Absolute and Relative Risk While Rethinking Medications: Once the company has completed its RCT, more than likely it will want to publicize the results to promote the drug. How it describes effectiveness can change the way people think about the medicine. One of our favorite examples comes from a print advertisement for Lipitor. It boasted that Lipitor (atorvastatin) lowered the risk of a heart attack (myocardial infarction) by 36 percent. That sounds great, doesn’t it? There was an asterisk next to that number, and in small print lower on the page was an explanation. During a five-year trial, out of 100 people on Lipitor, two had heart attacks. Out of 100 people on placebo for that trial, three had heart attacks. So you can see the absolute difference between Lipitor and placebo was just one heart attack per hundred (the absolute risk reduction). That probably would not have sold many pills. But stated as a relative risk reduction of 1 fewer heart attack compared to the baseline of 3 (1/3), using larger numbers because there were thousands of people in the study, you get 36 percent. What Do We Know About Safety? When patients see multiple health care providers who don’t talk with each other often, it may be difficult to detect serious safety problems. That was the case with the anti-inflammatory drug Vioxx. Early warning signs of cardiovascular problems resulting from this pain-reliever were overlooked for years. Researchers detected trouble as early as 2001, but the drug company resisted removing the drug until 2004. As a result, millions of people were needlessly exposed to danger and too many died. The silver lining to this cloud is stepped-up surveillance for side effects. Rethinking Medications with Respect to Side Effects: Some years ago, Dr. Avorn and his colleagues conducted a brilliant study (Drug Safety, 2009). They compared the side effect profiles from RCTs of different antidepressants. Mind you, they were not looking at the side effects of the drugs. They examined the side effects of the placebos in studies of tricyclic antidepressants and compared them to side effects of placebos in studies of SSRI antidepressants. All the participants had depression, so there should have been no differences due to the underlying condition. Yet the placebos had vastly different side effect profiles, mirroring the divergent side effects of the active agents. This striking difference might be due to changes in the way researchers elicited symptoms. Or it might be due to the nocebo effect, in which a person who expects to feel nauseated becomes queasy. Nocebo is like an inverse of the placebo effect. Either way, it suggests that when side effects of the placebo are similar to those of the investigational drug, we shouldn’t assume that the drug has no side effects. How Can You Protect Yourself? In rethinking medications, it is important to make sure that you really need all the drugs you are taking. Dr. Avorn strongly recommends a brown bag review periodically, in which the patient brings in everything he or she is taking, including OTC meds and dietary supplements. The health care provider reviews them, looking for duplication or incompatibilities. If they find problems, it’s time for a conversation about alternatives or deprescribing. Some medicines cannot be stopped suddenly, so the prescriber should provide detailed instructions about tapering and should monitor progress as the patient reduces the dose. This Week’s Guest: Jerry Avorn, MD, is a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham health-care system. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies and developed the educational outreach approach known as “academic detailing,” providing evidence-based information about medications to prescribers. One of the nation’s most highly cited researchers, Dr. Avorn is the author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs, and he has written or cowritten over six hundred papers in the medical literature as well as opinion pieces in TheNew York Times, The Washington Post, JAMA, and The New England Journal of Medicine. Dr. Avorn’s new book is Rethinking Medications: Truth, Power, and the Drugs You Take. His website is www.RethinkMeds.info Jerry Avorn, MD, author of Rethinking Medications Listen to the Podcast: The podcast of this program will be available Monday, Sept. 8, 2025, after broadcast on Sept. 6. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, we discuss sourcing medications from abroad. How does that affect drug shortages? How will tariffs affect costs? In addition, you’ll get more details on a brown bag review. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1443: Rethinking Medications: Uncovering the Truth About Common Drugs A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. If you have any questions regarding the content of this show, we encourage you to review the original audio recording. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Americans spend more on drugs and have less to show for than people in other countries. Today, rethinking medications. This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:34-00:41 The FDA used to be the envy of the world. Has it been captured by the pharmaceutical industry it’s supposed to regulate? Joe 00:41-00:52 You’ve heard of Ozempic and Wegovy. They both contain semaglutide as the active ingredient. How could they have dramatically different rates of side effects? Terry 00:52-00:59 Are you fed up with all the prescription drug commercials on TV? What about the high price of many prescriptions? Joe 00:59-01:15 Coming up on the People’s Pharmacy, uncovering the truth about common drugs. Terry 01:14-02:31 In the People’s Pharmacy Health Headlines, lowering sodium intake is good for cardiovascular health, but increasing potassium intake may be just as important, if not more so. A Danish study of twelve hundred patients with implanted cardioverter defibrillators, or ICDs, compared usual care to a strategy designed to get potassium levels into the upper end of the normal range. All of these study participants were at high risk of atrial fibrillation and all started with potassium levels at the low end of the normal range. The outcomes of the study were ventricular tachycardia, which is a dangerous heart rhythm, or having the ICD kick in appropriately. In addition, the investigators looked at hospitalization for arrhythmias. The patients assigned to the high-potassium group were prescribed potassium-sparing blood pressure medicines, such as ACE inhibitors. They were encouraged to follow a diet rich in potassium, including foods such as cabbage, beets, white beans, bananas, spinach, nuts, and fish. If those steps were unsuccessful at nudging potassium into the high normal range, the researchers prescribed potassium supplements. Joe 02:29-03:12 In this vulnerable population, targeting high normal potassium was helpful. They had significantly fewer episodes of ventricular tachycardia or hospitalization for arrhythmia, and their ICDs activated less frequently. A hundred and thirty-six of them experienced such an event, a rate of 7.3 per 100 person-years. In the usual care group, 175 volunteers had one of these dangerous episodes, a rate of 9.6 per 100 person-years. The patients in the high normal potassium group were also less likely to die during the three years of the study. Terry 03:11-04:10 The VITAL trial is a randomized controlled study of vitamin D and omega-3 fatty acid supplementation. The initial findings were that neither supplement reduced heart attacks or cancer in otherwise healthy middle-aged people. After four years, however, people taking 2,000 international units daily of vitamin D3 had longer telomeres than those taking placebo. Telomere length is a powerful measurement of aging. Telomeres are located at the tips of chromosomes and appear to protect them. As a result, shorter telomeres are associated with chronic diseases such as cancer and cardiovascular disease. Longer telomeres are a biomarker for slower aging. The authors conclude that vitamin D3 supplementation reduced telomere attrition and preserved telomere length, supporting an anti-cellular aging effect of vitamin D. Joe 04:11-05:17 Scientists have known for years that people with high blood pressure can benefit from drinking beet juice. British scientists have now done a more thorough study of this effect. They compared the reaction of 39 people under 30 to that of 36 volunteers in their 60s or older. Each group took nitrate-rich beet juice every day for two weeks or a placebo juice that had the nitrate removed. After a two-week washout period, they took the other treatment for two weeks. During this time, the researchers monitored participants’ blood pressure and their oral microbiome. In older volunteers, both oral microbiome and blood pressure improved with beet juice. A healthier mix of microbes in the mouth helps metabolize the nitrates in beet juice into nitric oxide that relaxes blood vessels. The investigators point out that beet juice is not a substitute for prescription blood pressure medication, but it can help. People who don’t like beets might consider other nitrate-rich vegetables such as spinach, celery, and kale. Terry 05:17-06:16 For decades, cardiologists prescribed beta-blocker heart drugs to almost everyone who had a heart attack. A new study published in the New England Journal of Medicine calls that practice into question. The randomized controlled reboot trial assigned over 8,000 patients to receive either a placebo or the beta-blocker bisoprolol. After nearly four years of follow-up, there was no difference in outcomes. The new consensus is that many heart attack patients with good heart function don’t need beta blockers. Those with poor ejection fractions may still benefit. And that’s the health news from the People’s Pharmacy this week. Welcome to the People’s Pharmacy. I’m Terry Graedon. Joe 06:17-06:29 And I’m Joe Graedon. Americans love pills. We take more medicines, spend far more on them, and see way more prescription drug ads than anyone else in the world. Terry 06:29-06:43 The Food and Drug Administration was once regarded as the best regulatory agency. Over the past decade, though, standards for drug approval have changed. Are Americans more vulnerable now than they were before? Joe 06:43-07:19 To help us tackle questions about drug safety and effectiveness, we turn to Dr. Jerry Avorn. He is a professor of medicine at Harvard Medical School and a senior internist in Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of “Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs.” His new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.” Terry 07:19-07:23 Welcome back to the People’s Pharmacy, Dr. Jerry Avorn. Dr. Jerry Avorn 07:24-07:25 It’s good to be back. Joe 07:26-08:00 Dr. Avorn, during your really long and illustrious career at Harvard Medical School, you have focused so much of your research on the benefits and risks of pharmaceuticals. I would have to say you are probably the country’s most respected pharmacoepidemiologist, and we have been tracking your work for decades. We’re honored, honored to have you as a guest today on the People’s Pharmacy. So thank you so much for writing Rethinking Medications and joining us today. It’s a pleasure to be with you. Terry 08:01-08:11 Dr. Avorn, I’m wondering, how has the pharmaceutical industry changed since you started studying medications that Americans are taking? Dr. Jerry Avorn 08:11-08:35 Well, it has become even bigger business than it was, which is something we need to all be kind of cognizant of. But also the science has gotten more and more impressive, both within the industry and also within medical schools and academic medical centers where we’re just really discovering things and putting them into practice in ways that would have been unthinkable even 30 years ago. Joe 08:36-08:46 What about the FDA, Dr. Avorn? I mean, it seems as if the FDA has also changed over the last couple of decades. Dr. Jerry Avorn 08:46-10:10 Yeah, and that’s I think a less happy story, in the sense that uh a lot of the mischief began with the best of intentions back in the nineties at the height of the AIDS epidemic and there was concern that FDA was being so careful about reviewing drugs that maybe it was taking longer than it should. And the idea came up of let’s have a system of accelerated approval in which even if a drug hasn’t really been shown in a clinical study to benefit patients, if it looks promising, let’s approve it and then have the company do follow up studies so we know what we’re dealing with. That was a sensible idea back in the early nineties, because we did have no good treatments for AIDS at that point, and we did want to get anything that looked promising out there. But unfortunately, that accelerated approval program has become a loophole that has been widened and widened well beyond what anybody ever intended. And we now have drugs, you know, like for ALS or muscular dystrophy or other conditions, which are approved on the scantiest of evidence. And then the companies don’t quite get around to always doing the follow-up studies that they promised to do. And we have a lot of medications that actually should not have been approved hanging around on the market and costing money and presenting risks and not doing any good for patients. Joe 10:10-11:31 Well Dr. Avorn, you brought up a really, uh hot topic for us. Because it used to be that the FDA was very clear and it said, we will not approve any medication unless it’s proven safe and effective. And I think the FDA’s definition of safe and effective is obviously quite different from what the average citizen would define as safe and effective. And all you have to do is turn on the television and watch one of the uh commercials for for pharmaceuticals where they say this drug can cause heart attacks and strokes and severe infections and cancer, and even death, and uh uh it’s like, well, how could that medicine be considered safe if those are potential side effects. And then when it comes to the effectiveness side, we have drugs that are barely better than placebo, as you’ve sort of alluded to. And in particular, I’m thinking of the FDA’s approval of the most recent Alzheimer’s drugs that uh don’t actually do very much. So tell me about safe and effective and what that means to you versus what it means to the FDA versus what it means to the average citizen. Dr. Jerry Avorn 11:31-13:51 Boy, is that a good question? Yes. Let me say something encouraging for starters, and that is all of those adverse effects that we see rattled off on the TV commercials that you can’t possibly avoid if you want to watch the evening news, um, are there because they are required to be there by the FDA. But you know, if you were to look at the adverse effects of, you know, aspirin or Tylenol, uh it would be a pretty scary list as well. What we have relied on the FDA for is to say, in effect, over the years: Every drug can cause side effects, some of which are very scary, but we want some assurance that it’s been looked at carefully. And that the good that the drug does is overwhelmingly better and more common and more useful than the rare side effects that it can cause. Because there is no drug, as you both know so well. that doesn’t have side effects. We just want that balancing to be done by the FDA and then by the prescribing doctor or other healthcare professional. That’s the ideal. Where things have really gone off the rails is with FDA paying less attention to the real does it help patients question And then frankly, as you mentioned for the Alzheimer’s drug, the worst of which was this drug called Aduhelm that did not benefit patients at all. Was approved kind of over the objection of the outside advisors and the FDA’s own staff, and turns out to actually have some substantial side effects And it was initially priced, uh, as you know, at $56,000 a year for getting an infusion intravenously every other week. to achieve no important clinical benefit. You know, that was really kind of the low point of of FDA’s recent history and it got pulled off the market a couple of years ago because it was such a stupid drug. But so I think where FDA has gone astray is that it has really lost its uh value system or a sense of balance. and has really lowered the standards of, okay, if you can make a lab test look a little better, then we’ll let you have approval. And even if you’ve not been able to show benefit to patients. And that that’s really not what the FDA was designed to do in the modern era Terry 13:49-13:59 Oh well Dr. Avorn, how did the FDA get to the point where it was willing to lower its standards so much? You do write about that in “Rethinking Medications.” Dr. Jerry Avorn 13:59-15:02 Well, you know, as as you both know so well, this is a half a trillion dollar a year industry in the US alone, probably more than that by now. And that brings with it an enormous amount of political pressure. And it used to be that the FDA would kind of rise above political pressure and just do what the science said. But over a number of years, the pharmaceutical industry became the most powerful and richest lobbying entity in Washington, and they’ve got more lobbyists than there are people in Congress. And there’s a lot of pressure both on Congress people from both sides of the aisle and on the administration under Democrat and Republican presidents. To, you know, have the FDA kind of go easy on industry and just approve stuff that hasn’t really been shown to pass muster. And the more dollars go into medications and the bigger business it is, the more firepower there is behind that political pressure. And the political pressure has been sort of winning out over the science more and more in recent years. Joe 15:02-15:39 Dr. Avorn, when you started your career and when we got started, there were no prescription drug ads on TV. You know, there were you know Anacin ads and Alka-Seltzer ads, but there there weren’t ads for Jardiance. And for um oh you go down the list, there’s so many that it’s almost takes your breath away these days and they come on every other every other commercial. Can we get your perspective on the direct-to-consumer prescription drug advertising that’s everywhere? Dr. Jerry Avorn 15:40-18:03 Yes. As your listeners will know, and as you both know very well, we are the only country on earth that allows drug companies to advertise prescription drugs direct to consumers. And every other country, with the one exception of New Zealand, which is kind of an asterisk, but every other kind of wealthy industrialized country that we often compare ourselves to has said, no, these are too complicated issues. They are not something you can boil down into a 60-second commercial with people dancing around and singing songs and having the adverse effects flash by quickly on the screen. Everybody knew that this is not something you can condense into a quickie commercial and then get the patient to go to their doctor and say, gimme this. And actually the industry was pretty the drug industry was pretty okay with that for many, many years because ads to consumers, especially the kind that are on prime time, are very, very expensive to buy airtime. and they’re expensive to produce. And as long as uh the industry felt it was okay not competing with shampoos or cars or toothpaste or any of the other things you see ads for, they were willing to go along with that ban. And then in the 90s, with the rise of managed care and health maintenance organizations that said, no, this drug is not on our formulary. It’s way overpriced. It’s not particularly good. We’re not going to cover it. The industry said, hey, wait a minute, we gotta try to get around that prohibition. And they said to themselves, we can make every patient into a potential sales rep. And by, you know, having releasing our our our self-imposed w unwillingness to have drug ads. Let’s have the FDA say it’s okay because we need to get to the patients to make them into agents of sales to go to the doctor and say, I want Ozempic because I saw a commercial for it. And so in 1997, for the first time ever, the FDA said, okay, it’s all right for there to be direct-to-consumer drug ads, again, alone in the entire world. I don’t think we can say that this has somehow benefited the public health or made prescribing of medications better or safer or more effective, but it is something which billions of dollars get spent on. by the companies. And of course those billions of dollars just get added on to the drug price. Terry 18:04-18:21 You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. Doctor Avorn is the author of Rethinking Medications Truth, Power, and the Drugs You Take. Joe 18:21-18:28 After the break, has the FDA been captured by the industry it’s supposed to regulate? Joe 21:03-21:07 Welcome back to the People’s Pharmacy. I’m Joe Graedon. Terry 21:06-21:08 And I’m Terry Graedon. Joe 21:08-21:20 Today we are putting the FDA and the pharmaceutical industry under a microscope. Should we be rethinking how our medications are regulated, priced, and advertised? Terry 21:20-21:52 Our guest is Dr. Jerry Avorn. A professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System, he built a leading research center at Harvard to study medication use, outcomes, costs, and policies. Dr. Avorn is the author of Powerful Medicines, The Benefits, Risks, and Costs of Prescription Drugs. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 21:52-23:00 Dr. Avorn, the cost of prescription drugs has skyrocketed, and in particular for something called orphan drugs. Now, I have to be honest with you, I visited Dr. Marion Finkel at the FDA shortly after the Orphan Drug Act was passed, because she had led the Committee on Drugs of what were called limited commercial value. I wonder what happened to those ideas about kind of facilitating the development of medications for rare conditions, because the FDA thought, you know, no drug company is going to make money from medications for these so-called orphan drugs. That is not the way it turned out, and I Fear that Marion is turning over in her grave. Your thoughts on drug prices for orphan drugs and drugs in general. Dr. Jerry Avorn 22:59-25:52 Well, as you both know, Americans spend twice per capita what citizens of other wealthy countries spend on medications. Whether it’s uh Canada or England or um Japan, Australia, all of Europe, um, they pay literally half of what we do for the same drugs made by the same companies in the same factories. And orphan drugs are one important example, but it really is across the board. Even Ozempic, which we’ve talked about in the last segment, is a drug which in the uh in most of Europe costs half of what it costs Americans. Why is that? It’s because America is the only country on earth that says to the drug companies, set your price at any amount you want, and that’ll be the price. Not only is that weird, it’s also not the way we pay for anything else in our economy. It’s certainly not the way the federal government pays for anything. They don’t um you know, go to a um airplane manufacturer and say, charge whatever you want uh for this new fighter plane and we’ll pay whatever you ask. It’s up to you. That’s a crazy way to do business. For people who are fans of a functioning marketplace, you know, it’s not a marketplace. It’s just this weird arrangement that is only there because we have legislated it into being. And in fact, when the Medicare program started paying for drugs in the early 2000s, the guy that shepherded the program through Congress. Passed a law that said that no company can be negotiated with over the price of its drugs in the Medicare program. And then he promptly left Congress and took a job at a million bucks a year to head the pharmaceutical lobbying group. So he was well rewarded for that legislation. And we then are left with this crazy system where, you know, there was there was a one drug company CEO when he raised the price of a drug by thousands of percent when he bought the rights to it, and they said. How can you possibly do that? And his answer was, because I can. And sadly, although that was more crude and he ended up doing some jail time for some fraudulent activity in other ways. He was he was ruggedly honest. Yeah, because they can. So when you have companies that understandably want to please their shareholders and they’re allowed to charge anything they want, why wouldn’t they? And and we’ve in our group at Harvard have talked to folks from other countries where they have a much more thoughtful process for looking at what a medication is worth. Drug companies ought to earn handsome profits on the work that they do. And if they discover a new drug, they ought to be richly rewarded for it. But if they’re just taking a same old, same old little modification and they say it’s a new molecule and we want our own patent and then charge whatever they damn please, that that really shouldn’t be allowed, as it isn’t most everywhere on earth. Joe 25:53-26:54 Dr. Avorn, I had mentioned orphan drugs and you know there are now designated orphan drugs for cancer, for example. That cost literally hundreds of thousands of dollars a year per patient. And there are some other rare diseases, muscular dystrophy, et cetera, where the cost can be, you know. uh close to a million dollars a year. Uh and these were supposed to be drugs of limited commercial value. Um It’s not unusual for some of these so-called orphan drugs to bring in billions of dollars a year for the manufacturer. I, I’m I’m just wondering what will happen if there is truly an effective drug for Alzheimer disease. The company could easily charge couple hundred thousand dollars a year and say, hey, it’s a bargain keeping people out of nursing homes, and yet that would break the bank on Medicare and break the bank of insurance companies almost overnight. Dr. Jerry Avorn 26:54-28:52 Absolutely. And of course, Alzheimer’s would not be an orphan condition because it is so appallingly common, but other conditions, and you you mentioned cancer drugs. If a company says this drug is going to attack a particular kind of mutation or a particular kind of receptor or a particular kind of pathway in a particular kind of cancer, they can manage to narrow it down to the point where that condition affects less than 200,000 Americans a year. And that is the legal definition of an orphan drug. But, you know, we think of cancer as a relatively common condition. But if they’re able to structure the application to the FDA for a particular kind of a particular kind of lung cancer. They can say, oh, this is now an orphan drug, so we get to have all the goodies that come with it, which is much uh more generous research and development money and much more freedom to get it approved uh with perhaps lower standards. And so that that’s a particular um anomaly for drugs that are for conditions that are uncommon. You mentioned muscular dystrophy. That has got to be one of the more egregious examples of companies. There’s one company here in the Boston area called Sarepta that got through on not the orphan drug pathway primarily, but on the accelerated approval pathway. And they said, look, we’re changing the level of a certain protein in muscle. And that’s you know by just a tiny bit, but I bet that’ll help patients It didn’t help patients, but the FDA said, well, you did change that level a little bit. Maybe that might work, even if you didn’t show any benefit. And that company then went on to not just market that drug, but several other drugs of exactly that approach with tiny modifications, none of which have been shown to be very helpful. And the FDA’s excuse was they wanted to bring cash into the company because that will help them to do more research to find a cure. Terry 28:52-28:53 So wait a second. Dr. Jerry Avorn 28:53-29:14 That’s not FDA’s job to bring cash into companies. And B you, it actually had the opposite effect. It said to the companies. Hey, you can get by with a drug that has a trivial change in a lab value and you’ll get yourself a drug. So that’s why we now have multiple ones of these drugs, each of which cost hundreds of thousands of dollars per person per year, and none of which work hardly at all. Terry 29:15-29:55 All right, so Dr. Avorn, this really brings up the issue of the FDA is supposed to be reviewing drugs and the research that has been done on these drugs to make sure that they’re safe and effective. And we we haven’t really talked about how do you tell if a drug is safe enough. We have talked about the fact that every drug that we know of has some side effects for some people some of the time. But has the FDA actually changed its objectives? Has it, in fact, been captured by the industry it’s supposed to be regulating? Dr. Jerry Avorn 29:53-32:54 I think that’s a great question, and the quick answer is yes, they have. To look separately at effectiveness and safety. The effectiveness, as we’ve discussed, if you are going to be willing as FDA to now accept a tiny change in a lab test as your replacement for this helps patients, then you know the horse is really out of the barn. And we’ve seen that with the accelerated approval of these muscular dystrophy drugs, the Alzheimer’s drugs and so forth. So they’ve lowered the bar so low that you almost, you know, it’s kind of rubbing on the ground. So that’s on that’s on the effectiveness side. And that’s not what the nation had in mind in the 1960s when they said for the first time anywhere, The government can require a company to show that a drug works before you can sell it. That was a revolutionary advance in 1962, and we’ve really bit by bit backed away from that. Safety-wise, I think there’s a somewhat happier story, but it followed a kind of tragedy, and that is the drug that you both know well. which is Vioxx, which was made by Merck as a treatment for arthritis and pain. And it appeared that it was likely to cause heart disease. And we actually did a fair amount of research uh on that question in in our group at Harvard. And it turns out that we found, as did other groups, around the country that yeah, it if you take this drug, it’s going to increase your risk of heart disease. And is that worth it, you know, to get a little bit better pain relief or a little bit gentler on your stomach? And the company said no, no, no. They said we should not publish our research because we would become laughing stocks. And they denied it up until the moment, after five years on the market. That a randomized trial that they themselves at Merck had funded showed that the drug doubled or tripled the risk of heart attack and stroke. And then once that data was available from a randomized trial, they kind of had to take the drug off the market and they ended up spending the next several years paying out five billion dollars or so to patients who had had heart attacks and strokes after taking Vioxx. So the good news, if you can to come back to your question and How is this leading to good news? Is that there were congressional hearings right after that drug was withdrawn? Because after all, 20 million Americans had had taken the drug. Medicaid spent a billion dollars on just that one drug. And Congress said, essentially, to Merck and to the FDA, how the hell did you let this happen? And that unleashed a program that many of us had been advocating for years. which is FDAs performing more proactive surveillance of side effects for drugs that are in widespread use so that they get claims data. anonymized from people all over the country so they know who took which drug and who had what side effect. And so the the happy outcome of that tragedy is that uh we are now much better able to spot a side effect of a drug while it’s on the market before it’s affected millions of people. Joe 32:55-34:48 We’ll talk a little bit about the MedWatch program in a moment and how firings at the FDA may have affected that, but I want to go back to the issue of effectiveness first. Because I don’t think the average patient, and maybe even the average physician or prescriber Understands the difference between relative risk reduction and absolute risk reduction. And our favorite example is atorvastatin. And the commercial for the brand name Lipitor. There were ads in magazines that showed Lipitor lowered the risk of MI, myocardial infarction, heart attacks, by 36%. And I think a lot of people thought, oh, that sounds terrific. You know, 100 people take Lipitor. 36 of them out of 100 will avoid a heart attack. Wow, that’s impressive. But there was a little asterisk next to that, and it said three percent of the people on placebo experienced a heart attack after five years. Whereas two percent of the people on Lipitor experienced a heart attack after five years, so the absolute risk reduction was actually one percent, not thirty-six percent. And I I think this idea of absolute versus relative risk gets hidden because drug companies love to talk about relative risk reduction. How does the average physician understand the difference between absolute and relative risk reduction when it comes to, for example, statins? Dr. Jerry Avorn 34:49-37:23 To answer your question, we often don’t understand it as well as we should. Uh my view of how we train doctors is that while we do fill the heads of our very smart students with a lot of important facts, and we gotta do that, What we do a less good job at is helping them think about data in the way that you just described. And the fact that we are always, whenever we prescribe a medication, not only balancing risks and benefits, but also needing to think about the magnitude of those risks and those benefits. And that’s something which, you know, I’ve often felt that The facts that we cram into students’ heads, um, half of them may turn out to be wrong in ten years, but giving them the ability to think in the way that you were just describing about, you know, it still may well be that a statin is if it’s if it’s as safe as they are, is still, you know, for a high risk patient a good thing. But you want to come to that conclusion or not, based on thinking carefully about that issue of absolute risk reduction and relative risk reduction, and also about the the magnitude of the risks that are involved with taking any drug. And that’s where FDA could do a much better job. And that’s where we doctors, frankly, and we medical educators need to also do a better job. FDA’s standard has been If you have a drug that works better than placebo, unless it’s unethical to do a placebo-controlled study, like for AIDS or cancers. But if you have a drug that works better, which was the standard for that awful Alzheimer’s drug, Aduhelm, it it changed the level of amyloid in the brain a little bit tiny bit more than a placebo did. That’s not a comparison that I as a prescriber want to hear about. I want to hear how well does it work compared to other alternatives that we might want to offer? And then of course the the big granddaddy question is is whatever change it causes worth the exorbitant amount that we might be asked to pay for it. And that’s a level of analysis that is tricky to do. And you can’t just tell patients, Or doctors for that matter, go do your own research, you know, look up the papers and decide for yourself. We need to say this is a public good kind of question. And just as we don’t ask everybody to build their own section of roadway or make sure that you know, the water in their tap is you know clean and forget about where it’s coming from. These are things societies need to provide to their citizens. And it’s something we need to do a much better job of as a society. Terry 37:24-37:53 And we certainly have not done that very well for uh prescription medications. Consumer Reports uh offers you evaluations if you’re going to buy a car or a computer. You can take a look at the various categories in which you might rank such a consumer product, there is nothing like that for prescription drugs and they’re more important to our lives than uh a car or a computer, one could argue. Dr. Jerry Avorn 37:54-38:40 Mm-hmm. Absolutely. And I’ve tried to provide people with lists of reliable websites that you can go to without feeling like you’re being barraged by advertising or or just scammery. And you know those sites do exist and I tried to make that list available to people because While I’m not encouraging people to always just figure out for themselves what they need to take for their diabetes, it does help for to kind of even the playing field so that when a patient does go to the doctor, they at least can come equipped with questions like You know, is this drug just better than a placebo or is it really effective? What about the newer drugs? Is this affordable? Are there generics? And the kinds of things that everybody needs to be able to think about when they’re talking with their doctor about a prescription. Terry 38:39-39:07 You’re listening to Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He developed the educational outreach approach known as academic detailing, providing evidence-based information about medications to prescribers. Dr. Avorn’s new book is “Rethinking Medications: Truth, Power, and the Drugs You Take.” Joe 39:07-39:11 After the break, we’ll talk about side effects. Terry 39:11-39:16 All medicines have some side effects. How do we learn which ones to watch out for? Joe 39:16-39:27 Dr. Avorn did a groundbreaking study comparing the side effects of placebos in antidepressant studies. What lessons can we take away? Terry 39:27-39:33 We’ll also get tips on the questions we should ask before we start taking a medication. Joe 39:34-39:39 And what should you know about stopping your prescription? Joe 40:59-41:01 Welcome back to the People’s Pharmacy. I’m Joe Graedon. Terry 41:02-41:04 And I’m Terry Graedon. Joe 41:04-41:18 One of the fastest-selling drugs in the pharmacy is semaglutide. You’ve probably seen commercials for its brand names, Wegovy or Ozempic. Why are the side effect rates for the same medicine so different? Terry 41:18-41:35 Our guest today is Dr. Jerry Avorn. He’s a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. His most recent book is Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 41:36-42:10 Dr. Avorn, we’d like to segue a little bit into the side effect profile of medications. and how drug companies do their data collection. And we were so impressed with a study that you did many, many years ago. comparing placebo rates of an old-fashioned antidepressant category called tricyclics, drugs like amitriptyline. versus the side effects in the placebo group of the so-called SSRI. Terry 42:10-42:24 So comparing placebo to placebo So first explain please to the listeners why you compared placebo to placebo. Dr. Jerry Avorn 42:22-44:55 Well, one of the best inventions of all time is not a thing, but is a concept, the randomized control trial. Because it in the old days, um, people you know used to say, like if you were a doctor, in my experience this drug works well, or in my experience this one causes side effects. And it turns out As most of your listeners will know, you can’t figure that out from the perspective of any one doctor or any one patient. You’ve got to look at this systematically. And the beauty of a randomized control trial, which simply means that patients are given a new drug or a dummy pill, a placebo, And they look exactly alike, and they are randomly allocated to who gets the new drug and who gets the placebo. And neither the patient nor the doctor knows who got what. That is a very, very effective way of getting a handle on moving beyond this, in my experience, this drug works, you know, because if it doesn’t come across in a randomized controlled trial, then you got to wonder what in the world is is going on. But then we introduce the other really interesting issue of what some people call the nocebo effect And most listeners will know about the placebo effect, which is you give somebody a dummy pill and they say, thanks, Doc, that made me feel much better. There is the opposite um effect called the nocebo, which is from the Latin word for noxious, which is you give somebody a dummy pill and I mean I I don’t encourage ever doing this in practice, but in research, and they say, boy, that that pill really made me have side effects. And you know it’s not the pill because the pill just had, you know, some lactose powder in it. And so this has been a real boon to thinking about research studies because it gives you a handle on what is from the pill and what is just the patients. expectation that either they’re going to feel better or that they’re going to sometimes feel worse. And so what what we’re talking about in comparing Well the placebo rate of side effects is there shouldn’t be any difference if you have ideally people getting a dummy pill. in one study or another, if the patients are similar enough, you shouldn’t have it vary based on what the studied drug is that you’re testing. But we do see this, and it uh reminds us that an awful lot of the effects that people report from meds, both for good or for ill, may be not from the med, but may actually just be from the patient’s expectations or or perceptions. Joe 44:56-46:14 And one of the things that we think we’ve discovered is that drug companies have become ex- Extraordinarily skilled at influencing the reports of side effects. So let’s just compare two identical drugs Semaglutide is the ingredient in ozempic, which is a drug that was approved for diabetes, followed by Wegovy, the same exact drug that was approved for weight loss. In the clinical trials that the drug companies performed, 20% of the people who got Ozempic reported nausea. Forty to forty-four percent of the people who got Wegovy reported nausea, so almost twice as many on the same exact drug, but more interestingly, the people who were given placebo, that is to say, a dummy injection, 6. 1% reported that they experienced nausea on the dummy shot, whereas 16 to 18 percent of those getting the placebo shot complained of nausea. How did the drug company create those kinds of numbers? Twice as many. Dr. Jerry Avorn 46:12-47:45 Well, I think that they were probably as surprised as you were when they looked at those numbers because in principle, giving somebody a dummy shot should not create nausea or diarrhea or any other side effect. And so the reason it’s so important that we as prescribers and and the FDA have access to well-done randomized placebo-controlled studies is that we can look for things like that, and then we can say, well, gee, maybe there was there is a dose difference in the active drugs in those two examples. But the placebo doesn’t have a dose because it’s basically salt water. Why is this going on? And that makes me think as someone who evaluates drug evidence. Maybe there was a difference in the underlying patient populations, maybe because one was mostly for obesity and one was mostly for diabetes, or maybe there was some difference in the way they elicited the um symptoms. That is, you know, if they said, did you have any queasiness in the last week, as opposed to were you severely nauseated and vomiting? You know, you’re going to get very different answers depending upon how you ask the question. Now, ideally, the randomization should take care of that. And when you see a difference, you know that the difference is from the ingredient and not from any kind of expectation by the patient or the doctor. But it’s it’s a little hard to explain why it would be. And it must come down to either the underlying patient population and or the way they asked about the nausea, the vomiting, the diarrhea that created that. Joe 47:45-48:30 I am a bit cynical and I do think it has something to do with the way they asked the question because when they asked about diarrhea, the people on placebo had ten times the diarrhea rate if they were in a uh trial for Wegovy compared to a trial with Ozempic. But I I know we’re now in the weeds. And I guess what I’d like to do is segue quickly to the questions that patients should ask their doctor. whether it has to do with benefits or whether it has to risks, so that a patient will really have some substantive data to be able to evaluate whether they should be taking this medicine or not. Dr. Jerry Avorn 48:31-50:38 Absolutely. And as both of you have advocated for many, many years, patients need to be informed consumers and informed um patients when they go to the doctor. And that’s getting harder and harder every year because doctors are more and more rushed than ever. You know, it’s not their fault, but they’re asked to see more and more and more people. And it makes it hard for them to find time to actually sit down with a patient and talk about meds. But, you know, a as you both know, this is some of the most important conversations that we doctors can possibly have with our patients. And what I used to say was if your doctor doesn’t have time to that to do that, find another doctor. That was before it became impossible to find another doctor because we’ve so depopulated the field of primary care in our healthcare system. But still, I think the patient needs to advocate for him or herself, and come in with a list of questions. Because I know when I go to my doctor, I forget half the things I wanted to ask him before the visit, unless I write it down. And then I forget half the things he tells me and that’s, you know, and I’m a professor. So um people should go in knowing that you’ve got to advocate for yourself. Uh and in the book I try to give some questions that people should go in and ask their doctor, like, what is this medication for? Do I take it forever or until my symptoms are better? You know, in some drugs we say Take as little of this as you can and stop as soon as you can, like an opioid. Other drugs like drugs for high blood pressure or diabetes, we say you’ll take this probably for the rest of your life. And patients aren’t born knowing the difference between those categories. So how long will I need to take it? Is there a more affordable alternative that will work just as well? What side effects should I be on the lookout for? And what is the goal here? Is it to get my blood pressure down to a certain number? Is it to make me feel better? Is it to get rid of a target symptom? And you know, unless you know what the doctor is is going for, uh you’ll not be able to tell if you’ve gotten there or not. So it’s hard to extract that amount of time from a doctor, but I think patients really do need to use those, that list of questions of that they can ask their doctor. Terry 50:38-51:11 I think that idea of goal is really important and it’s not one that’s always incorporated into the conversations that we have with our doctors. Um and especially important, how will I know when I have reached the goal? Uh because If if you aren’t clear on the metric, you’re not going to know that, oh, okay, that’s that’s all I needed to do. And now I can look at something else that might be uh getting my attention. Joe 51:12-51:24 Well you know, Dr. Avorn, there’s another question that is rarely asked, and uh we think it’s really important, and that is how Should I stop this medication? Terry 51:24-51:25 And when? Joe 51:25-51:58 Because you know, there are a lot of Americans, literally tens of millions of them, taking antidepressant medications. uh, like Prozac, Paxil, and sertraline and we go down the long list. And you just can’t stop cold turkey Because this quote-unquote sudden discontinuation syndrome can be quite devastating. So finding out how to discontinue a medicine may be almost as important as how to start it Dr. Jerry Avorn 51:56-53:49 Exactly correct. And there has been an interest in the last number of years in this relatively new term of deprescribing. And seeing all these people that and I’ve I when I was in active practice people would come in with these long lists and I would ask them to please bring me a list or even better, a bag of all the drugs you’re taking. And, you know, things I would say, gee, you know. I thought I stopped that two years ago. Or who gave you that? Or, you know, all sorts of things that your doctor may not No, despite their being diligent because maybe it’s somebody else prescribed it or they thought it had long since gone away. So this issue of deprescribing is useful. However, there was a period where it was almost I would consider kind of a fad that, you know, let’s get everybody off of everything as much as we can. And it turns out there have again been, you know, the the answer for me to everything is rigorous clinical research. Studies where people were randomly assigned to stop a drug, and particularly antidepressants, was one of the drugs studied. Or keep going, but it was done as a placebo-controlled trial where neither the doctor nor the patient knew who was still getting a placebo and who had been switched over uh who’s still getting an antidepressant and who is switched over to placebo. And the answers are not always what one would expect from one’s armchair. That is, there are some people that um really when you stop their antidepressant, even if you do it carefully, really get worse and really get depressed. And then there’s others who don’t have any problems at all, might even feel a little bit better, but you can’t know that without really having good research data. And that’s not a topic that, you know, the drug industry is keen on funding clinical trials of stopping medications. But we do need more than more information on that because it comes up, you know, like millions of times a day in medical practice. Terry 53:50-54:20 Dr. Avorn, I’d like to turn a little bit to the topic of uh current events, as it were. I’d I’d like to ask you for your thoughts on what is going on with the FDA currently. Is the agency going to have the personnel it needs to carry out the functions we expect of it? What reforms if the FDA were to be reformed, what reforms would you see as beneficial? Dr. Jerry Avorn 54:20-57:46 Okay, I’m glad you asked that because I am scared out of my mind at these dramatic cuts that are being made wholesale. Not just at FDA, but at CDC, the Centers for Disease Control, and at the National Institutes of Health, that seem to be getting made without a whole lot of attention to are these cuts a good idea? We know that FDA has been understaffed for many, many years. And a solution that was proposed decades ago was that the drug industry said, gee, Congress doesn’t want to give you enough money to hire the people you need to review our drugs, FDA. Why don’t we just pay you to review our drugs? And the so-called User Fee Act, which was put in place in 1992 and has been renewed every five years ever since, has gotten us to to a situation in which the drug industry is now paying for about half of the salaries that FDA spends on the scientists who review the drug company’s products. Which does not seem like an ideal plan, but FDA was not able to get the money it needed from Congress going back many decades, many administrations, many different parties in power. They just never got the staff they need and they were all too willing to let the FD the uh drug companies pay for fifty percent of their salaries. So we were already starting from a bad place. And then these draconian cuts that do not seem to be getting made in a thoughtful way. And we know that because they were done so abruptly, have put the whole drug evaluation activity at risk. They’ve also put at risk apparently the people who are trying to figure out how to negotiate lower drug prices, which was a reform put in by the prior administration. Many of them have let have been let go, so the government is kind of down on its staff who are supposed to be negotiating with the drug companies But what scares me the most is these draconian cuts in the National Institutes of Health funding who are funding the research that, as we all know, leads to the drugs of tomorrow. The drug companies do research themselves, to be sure, but our our group at Harvard has shown that an awful lot of the best drugs we’ve got came from NIH funded research in universities or or academic medical centers. And then when the product is kind of ready for prime time it comes to be owned by a drug company that then charges whatever it wants for the drug. But what nobody is really talking enough about is if we stop that pipeline of discovery of basic biological insights as we are doing now at NIH. And my own institution, Harvard, is being hit with all kinds of billions of dollars of cuts by the administration. It’s not like we are all driving around in limousines and, you know, taking six-month vacations in the Caribbean. You know, most of us earn way less than we would earn in the private sector, and are doing this work because we really believe in it and then to find out that active grants are being just absolutely canceled with stop work orders going out. Is really going to come to a head, not in the next month or two, but in the next couple of years, where all the basic research that led to the development of new drugs will have been shut down or at least crippled. And then so sometime around 2027, people might say, hey, where’s all these new pharmaceutical wonders that we were expecting? You know, they’re not going to be there and that’s going to be a tragedy. Joe 57:47-58:22 Dr. Avorn, a lot of our medications now come from abroad. It’s been reported that over 90% of our generic medications come from places like China and India. And I do worry about the FDA’s ability to monitor the manufacturing process. D do you have any thoughts about A: the drug manufacturing abroad, and uh and B: the drug shortages that have resulted over the last couple of years. Dr. Jerry Avorn 58:22-01:00:40 And if I may add a C, which is what is going to happen to drug prices when tariffs kick in, given that so many of our drugs, as you just said, come from India and China. And if there are huge tariffs slapped on any imports from those countries, that is going to make not only make drugs harder to afford. But it also, I think, is gonna make our shortage problem worse, because a lot of generic manufacturers, and we’ll we’ll get back to the inspection thing in a second, a lot of generic manufacturers based in India and China operate on very, very thin margins, because generics are very, very cheap. That’s one of the great things about generics for the consumer. But if they find that their thin margins are now being essentially erased by these crippling tariffs, They’re just gonna say, hey, I’m gonna lose money with every pill I make. I’m just gonna stop making these pills. And that is gonna, and we’ve seen that before with cancer drugs and and other medicines. That is going to get exponentially worse because of the tariffs if they are handled in as careless a way as many of us worry that they might. But to come back to your earlier question, which is so important about inspection. Yeah, this is another thing that I referred to before as a public good. You know, it’s it’s the right of every citizen to know that their tax dollars are going to be used by government agencies working on behalf of everyone to make sure that somebody’s inspecting the meat, and that the water in your tap is is pure, and that the drugs that you are getting that come from another country–that those factories are being inspected adequately and are passing muster. And FDA has had a very hard time keeping up with that. And they’ve not had enough budget to do it. And as a result, uh particularly if the cuts at FDA extend to this part of their mission, we’re not going to be able to be as sure as we want to be that our blood pressure pill, diabetes pill, cholesterol pill, whatever, that may have been made in India or China, leave aside the unaffordability and leave aside the shortage, is that factory being inspected as well as it should be, especially if FDA has gotten staff cuts that it’s getting, and they don’t have the people to do that work. So it’s it’s pretty scary. Terry 01:00:41-01:01:34 Dr. Avorn, I’d like to ask about primary care. You mentioned during our interview that uh at at one point at least you were doing brown bag reviews with your patients in which They would put everything they’re taking into a brown bag and bring it in so that you could review everything they’re taking, including over-the-counter stuff and dietary supplements. And I think more and more patients are anticipating that they will be seeing specialists. So they’ll see the cardiologist, they’ll see See the podiatrist, they see the ophthalmologist, they don’t see one person who is looking at the whole patient. Can you give us some idea of the difference between the practice and the effect on the patient of primary care versus these very siloed specialist cares? Dr. Jerry Avorn 01:01:35-01:04:14 That that’s a really important point. I did my residency in in Boston when in in the 70s when we thought this is now the era of primary care. And you know, we’re going to train people particularly to be general internists who will deal with most everything that walks in the door and once in a while you’ll need a specialist to help with particularly complicated problems. But we’ve really, as a healthcare system, been beating up on primary care doctors mercilessly for the last several decades. They get paid much less than the specialists. The hours are not compatible with having a life. The emotional and intellectual responsibility of taking on whatever walks in the door, which is I think what most of us would like to have as patients as our first stop in the healthcare system really takes stall. I think primary care doctors ought to be, you know, rewarded the most and made their lives as easy as possible, but that’s quite the opposite has happened. So as a result, as you’re pointing out, somebody might be getting medications from their diabetes doctor and their heart doctor and their arthritis doctor. And it is not always possible for every doctor to be aware of what all the other doctors are prescribing. And uh I’ve written about how somebody may be taking, you know, Advil for headaches, and ibuprofen for their sore knee, and Motrin because they have low back pain, and aspirin because they think it’ll prevent a heart attack, and not ever knowing that those are all basically the same class of drugs, and they’re just multiplying the potential risk for for side effects. That’s where a primary care doctor can really shine. And, you know, we are an endangered species. It’s imperative. I’ve found some of the most useful time I would spend with patients. would not be listening to their heart or listening to their lungs, but actually saying, next visit, bring in a brown bag and fill it with not just what I’ve prescribed, but what you’re getting from all your other doctors and as you said in the question, whatever dietary supplements you’re taking and whatever herbal remedies you’re taking, whatever over-the-counter meds you’re taking, and dump it out on my desk and we’ll talk about every one. The reason that’s so useful is that you find stuff that actually is uh you know can kind of chill your blood about, oh my God, who put you on that? And you’re still taking that? I’s a very useful activity, and I urge all patients, if their doctor doesn’t ask to do it because every doctor is just so horribly overloaded with not enough time and too much to do is to offer to bring it in and you know include those supplements and over-the-counters and things from the other doctor and see what happens when you dump them on the doctor’s desk and see what his or her reaction is. Terry 01:04:14-01:04:59 And they may actually say, oh my God, we got to fix this. Well, one of the examples that you gave in rethinking medications, that is something we have heard from probably hundreds of people. is the idea that um you may have a chronic cough, that it doesn’t go away no matter what cough medicine you take and you’ve been worked up for allergies and you’ve been worked up for this and that, sometimes people get worked up for um acid reflux to see if that’s the cause of the cough. And if you just looked at the blood pressure medicine that the patient is taking. Exactly. If they’re on an ACE inhibitor, the chronic cough might be a reaction to their blood pressure medicine. Dr. Jerry Avorn 01:05:00-01:05:43 You said it. Right. I think the the figure I know is about 15% of people. And by the way, ACE inhibitors are wonderful drugs. They do a great job of lowering blood pressure. But as as you’re as you’re saying, about 15% of people on ACE inhibitors will develop a cough from them. And there’s ways of fixing that. You know, there’s angiotensin receptor blockers you can switch people to, you can use another category of drugs. But if it doesn’t come up in the conversation with a doctor, you know, they could, as you point out, they could get worked up for lung disease or put on meds for, you know, asthma or things that they don’t really need because it’s their blood pressure med. It may be a great med for most people, but if like one in seven people gets a chronic cough, that’s something that ought to be part of the doctor’s questioning of the patient. Joe 01:05:43-01:07:16 Uh Dr. Avorn, you’ve mentioned how important it is for patients to bring in all the medications and the dietary supplements and the vitamins and the goodness knows what they’re taking. for the physician, but I’d also suggest that it’s important for pharmacists to also be part of the process And also do these brown bag uh examinations, but there’s a a problem that we hear from pharmacists all the time. A patient comes into the pharmacy and they get a flag on their computer that says, uh, this antibiotic should not be taken at the same time you’re taking one of these blood pressure medications. It, it could cause potassium levels to go through the to the roof and it it could cause cardiac arrest. So this is a dangerous combination and the patient is waiting to g to get their antibiotic And now the pharmacist has to contact the physician. But when the pharmacist calls the doctor’s office, the receptionist says, I’m sorry, doctor is seeing patients now. And as you said, so many doctors are overworked and overwhelmed, it may be hours before that physician can call back to the pharmacist. And we hear from pharmacists who say, I never got a call back. What do I do when I’ve got an interaction and a patient sitting right there in front of me waiting for their prescription to be filled? What what would you recommend in a situation like that? Dr. Jerry Avorn 01:07:17-01:08:59 Absolutely. And as you both know from what I’ve written over over many years, I think pharmacists are one of the most potentially valuable and underused and abused healthcare professionals that we have. You know, they know so much about medications and yet most pharmacists find themselves working in increasingly in chain drugstores where the entire premium is on throughput and fill them and send them home and get, you know, make sure they pay. And the idea that a smart enlightened pharmacists can be part of the healthcare team just has not caught on as much as I had hoped because it could deal with a lot of these issues that that come up. It’s and then of course it puts the pharmacist in a rough spot. And sometimes, as you both know, some of these alerts are really not very sensible. But it you know the computer flashes a red light and then the pharmacist says, oh my God, I can’t do this. And then you can’t reach the doctor. I mean my vision, which is very naive and and probably unrealistic, is that practices would increasingly have pharmacists embedded in the practice who are part of the whole healthcare team. And that when the question comes up, first of all, they might even be involved in the dispensing of the drug. But if not, uh the outside pharmacy could call and they talk to the inside pharmacist, then he or she would be able to look at the patient’s records. They may even be able to snag the doctor as he or she walks by. Or they would have their own expertise and say, yeah, it’s okay. That’s one of those automatic computer flashes. Or they might say, holy cow, don’t fill the prescription But leaving everyone holding the bag because everyone is too busy to be able to just get their work done is not a good solution for anyone. Terry 01:08:59-01:09:05 Dr. Jerry Avorn, thank you so much for talking with us on the People’s Pharmacy today. Dr. Jerry Avorn 01:09:06-01:09:09 I’ve really enjoyed talking with you both again. Thanks for having me. Terry 01:09:10-01:09:44 You’ve been listening to Dr. Jerry Avorn, a professor of medicine at Harvard Medical School and a senior internist in the Mass General Brigham Healthcare System. He built a leading research center at Harvard to study medication use, outcomes, costs, and policies, and he developed the educational outreach approach known as academic detailing Providing evidence-based information about medications to prescribers. Dr. Avorn is the author of Rethinking Medications: Truth, Power, and the Drugs You Take. Joe 01:09:44-01:09:46 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:09:52-01:10:00 This show is a co-production of North Carolina Public Radio WUNC with the People’s Pharmacy. Joe 01:10:00-01:10:14 Today’s show is number 1443. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s interview. You can also reach us through email, radio at peoplespharmacy.com. Terry 01:10:15-01:10:38 Our interviews are available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In the podcast this week, we discuss sourcing medications from abroad. How does that affect drug shortages? How will tariffs affect costs? In addition, you’ll get the details on a brown bag review. Joe 01:10:38-01:11:13 At peoplespharmacy.com, you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe, you also have regular access to information about our weekly podcast. We are pleased to announce we are now launching transcripts for selected interviews, including our conversation with Dr. Jerry Avorn. We would be grateful if you would consider writing a review of the People’s Pharmacy and posting it to the podcast platform you prefer. In Durham, North Carolina, I’m Joe Graedon. Terry 01:11:13-01:11:48 And I’m Terry Graedon. Thank you for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:11:48-01:11:58 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism please consider chipping in. Terry 01:11:58-01:12:03 All you have to do is go to peoplespharmacy.com/donate. Joe 01:12:03-01:12:19 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you.

In this episode, our guest is a dermatologist who wants us to consider sunlight’s health benefits. That is a minority opinion among dermatologists. Dr. Richard Weller tells us why vitamin D is overrated and not the most important aspect of sun exposure. At The People’s Pharmacy, we bring you the latest research-backed insights on health, even when they challenge established views. In this episode, Dr. Richard Weller highlights how moderate sunlight may offer unexpected health benefits while placing melanoma risk in context. This content is provided for informational and educational purposes only. Always consult a qualified healthcare provider before making changes to your sun exposure habits or medical care. You could listen through your local public radio station or get the live stream at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Sept. 1, 2025. The Secrets of Sunlight’s Health Benefits: Dermatologists generally advise us to stay out of the sun as much as possible. After all, excessive sun exposure causes skin aging and skin cancer, conditions for which people frequently consult them. However, even if we could all live inside, wear protective clothing and high SPF sunscreen whenever we ventured out, would that be wise? According to our guest, Dr. Richard Weller, and his colleagues, “insufficient sun exposure has become a real public health problem” (International Journal of Environmental Research and Public Health, July 13, 2020). While this problem is more acute in Europe than the US, they still estimate that more than 300,000 Americans die each year due to inadequate sun on their skin. What is going on? How Does Sunlight Affect Skin? For decades, we have heard that the principal effect of sunlight on skin is the production of vitamin D. Therefore, the dermatologists have concluded, rather than take the risk of exposing skin to sunshine, why not just swallow vitamin D supplements? The problem with that proposal is that it hasn’t worked very well. Many studies show that people with low levels of circulating vitamin D are more vulnerable to high blood pressure, atrial fibrillation, heart disease, diabetes and infections, among other problems. However, people who take vitamin D supplements don’t always get the expected benefits.  Perhaps vitamin D is a marker for sun exposure rather than the most important outcome. Human Evolution and Skin Color: Humans evolved in Africa, where dark skin is an advantage, offering protection from the most harmful effects of ultraviolet radiation. By about 60,000 years ago, people were migrating to other parts of the world. Yet analyses suggest that although they arrived in Europe by about 40,000 years ago, genes for pale skin didn’t become common until less than 10,000 years ago. Anthropologists have hypothesized that pale skin is an adaptation to inadequate sunlight in northern regions. Because vitamin D is a well-recognized consequence of sunlight on skin, they have assumed that was the driver. Dr. Weller suggests that nitric oxide was (and still is) more important. He notes that the evolution of pale skin happens around the same time that people begin to cluster together in farming communities, where they are more likely to be exposed to infectious diseases. Is Nitric Oxide the Source of Sunlight’s Health Benefits? In 1996, Dr. Weller was the first scientist to find that human skin creates a compound called nitric oxide (NO) under sunlight. This compound is then absorbed into the skin, where it helps relax blood vessels and lower blood pressure. Here is a link to his TED talk on the topic. This is where Dr. Weller’s approach differs from that of more conventional dermatologists. With proper caveats that the US is at much lower latitudes, in general, than most of Europe, he proposes that more sunlight, not less, could lower mortality rates. (Lower latitudes get more sunshine.) His analysis was just published in the prestigious Journal of Investigative Dermatology (August 2024). The data underpinning this claim are from an analysis of the UK Biobank, a remarkable treasure trove of information. Dr. Weller and his colleagues have found that in the UK, people who get more sunlight are less likely to die within a specified time frame. We call that lower all-cause mortality. You can read the research report here (Health & Place, Sept. 2024).  It was discussed in this article in The Economist (Aug. 12, 2024). This Week’s Guest: Richard Weller, MD, FRCP(Ed), is Professor of Medical Dermatology at the University of Edinburgh. He holds the Personal Chair of Medical Dermatology in the Deanery of Clinical Sciences.  He is also Honorary Consultant Dermatologist at NHS Lothian and Principal Investigator at the Centre for Inflammation Research. Dr. Weller serves as Programme Director for the M Med Sci at the University of Edinburgh and is President of the Scottish Dermatology Society. He is the Clinical Lead for the Dermatology Speciality Group at NHS Research Scotland, the Global Health Academy and Edinburgh Imaging. Listen to the Podcast: The podcast of this program will be available Monday, Sept. 1, 2025, after broadcast on Aug. 30. You can stream the show from this site and download the podcast for free. Learn More: Dr. Weller kindly shared links to some research by his colleagues that he mentioned during the show. Here is an article by Joel Gelfland showing the benefits of home phototherapy for psoriasis. This article by Adewole Adamson presents evidence that dark skin is not susceptible to UV-induced melanoma. Download the mp3 of the show, or listen to the podcast on Apple Podcasts or Spotify. Transcript of Show 1397: The Surprising Secrets of Sunlight’s Health Benefits A transcript of this show was created using automated speech-to-text software (AI-powered transcription), then carefully reviewed and edited for clarity. While we’ve done our best to ensure both readability and accuracy, please keep in mind that some mistakes may remain. This transcript is copyrighted material. All rights reserved. No part of this transcript may be reproduced, distributed, or transmitted in any form without prior written permission. Joe 00:00-00:01 I’m Joe Graedon. Terry 00:01-00:05 And I’m Terry Graedon. Welcome to this podcast of the People’s Pharmacy. Joe 00:06-00:27 You can find previous podcasts and more information on a range of health topics at peoplespharmacy.com. Do you avoid the sun? We’ve all heard that we should wear sunscreen all the time and stay inside from 10 till 2. This is the People’s Pharmacy with Terry and Joe Graedon. Terry 00:33-00:45 Are there hidden health benefits from sunlight? Is it all about vitamin D? Why don’t supplements protect people against heart disease, cancer, diabetes, or depression? Joe 00:45-00:52 New research suggests that some sun exposure may be helpful. Our dermatologist guest has done fascinating research. Dr. Richard Weller 00:53-01:04 We have showed in Britain that after accounting for confounding factors, other factors, the more sunlight people have, the longer they live. Joe 01:04-01:10 Coming up on the People’s Pharmacy, the surprising secrets of sunlight’s health benefits. Terry 01:14-02:31 In the People’s Pharmacy Health Headlines, following a Mediterranean-type diet may help lower the risk of dementia in vulnerable people. People who carry a gene called APOE4 are particularly susceptible to developing Alzheimer disease. But an analysis of the Nurses’ Health Study and the Health Professionals Follow-up study published in Nature Medicine shows that those who come closest to a Mediterranean eating plan are less likely to come down with Alzheimer’s disease. There were more than 4,000 women and nearly 1,500 men included in the analysis, which covered three decades of data. People with two ApoE4 genes lowered their risk by 35% if they followed a Mediterranean diet high in vegetables, fruits, whole grains, fish, and olive oil. The lead author, Dr. Yuxi Liu, told CNN, “Not only did following a baseline Mediterranean diet reduce the probability of developing dementia by 35% in people with two APOE-e4 genes, but higher adherence to the diet further reduced their risk.” Joe 02:30-03:36 The anti-vax movement has been gaining momentum, but there’s growing evidence that the shingles vaccine offers benefit far beyond protection against shingles. Several studies have demonstrated that the shingles vaccine can reduce the risk for dementia. A new study published in the journal Clinical Infectious Diseases reports that the recombinant herpes zoster vaccine Shingrix can reduce the risk of heart attack, stroke, and herpes zoster ophthalmicus, a potentially vision-robbing eye infection. The researchers compared over 100,000 vaccinated patients to over 400,000 unvaccinated patients. The median age was 68 years old. The average follow-up was two and a half years. The investigators concluded that two doses of Shingrix vaccine “were effective in preventing herpes zoster ophthalmicus in adults over 50, and were associated with significantly reduced risk of hospitalized acute myocardial infarction and stroke compared to unvaccinated individuals.” Terry 03:36-04:27 The FDA has just approved a new and far more general indication for evolocumab, known by its brand name Repatha. Back in 2015, the agency approved this powerful injectable medication for lowering LDL cholesterol. At first it was used primarily for patients at high risk who couldn’t tolerate statins, or who didn’t respond adequately to statins for lowering cholesterol. Then the use was expanded to cover people with cardiovascular disease. Now, doctors can prescribe this medicine for any adult at risk for heart attacks, strokes, unstable angina, or other cardiovascular complications. Occasionally, people react to evolocumab with angioedema, which can be life-threatening. Such individuals will not be able to use it. Joe 04:28-06:18 At one time, x-rays were the only tool doctors had to see inside the body. Since then, MRIs and CT or CAT scans have become widely available. Computed tomography imaging is performed on over sixty million patients annually. That number has increased by over thirty percent since 2007. Such images can be extremely helpful in making a diagnosis, but there are risks that many patients may not realize. The name CAT scan sounds innocuous, but in fact it represents ionizing radiation similar to X-rays. An investigation published in JAMA Internal Medicine projected the number of future cancers due to this radiation exposure. The researchers used data from the University of California, San Francisco International CT Dose Registry and modeled the effects of the radiation. They estimated that approximately 103,000 cancers are likely to result from the 93 million scans conducted in 2023 on 60 million people. The risks are highest in children and adolescents, but many more adults undergo CT scans. The scientists conclude that if current practices persist, CT associated cancer could eventually account for 5% of all new cancer diagnoses annually. And that’s the health news from the People’s Pharmacy this week. Joe 06:15-06:17 Welcome to the People’s Pharmacy. I’m Joe Graedon. Terry 06:18-06:35 And I’m Terry Graedon. For decades we’ve been told to stay out of the sun, especially in the summertime. If we venture out, we need to be wearing protective clothing, including a hat and high-SPF sunscreen. If we’re good, we’ll never get a tan in the summer. Joe 06:36-06:51 Dermatologists worry about sun exposure because ultraviolet radiation is damaging to the skin. It causes premature aging and is linked to various forms of skin cancer, including the most dangerous, melanoma. Terry 06:52-06:57 But could sunlight be more complicated? Does it have hidden health benefits? Joe 06:58-07:24 To learn more about this very controversial topic, we turn to Dr. Richard Weller. He is a professor at the University of Edinburgh College of Medicine and Veterinary Medicine. He holds the personal chair of medical dermatology at the Deanery of Clinical Sciences. His research interests include eczema, psoriasis, and the effects of sunlight on human skin. Terry 07:24-07:28 Welcome to the People’s Pharmacy, Dr. Richard Weller. Dr. Richard Weller 07:29-07:32 Hello, it’s very nice to be talking to you today. Joe 07:32-07:40 Dr. Weller, there’s a rumor that you are a dermatologist. Do I have that right? Dr. Richard Weller 07:41-07:52 I am. I’m perhaps not a conventional dermatologist in some of my views, but those have really developed over the years as a consequence of my research. Joe 07:53-08:43 Well, speaking of your research, it kind of contradicts what American dermatologists have come to believe, which is: If you could just live in a cave, that would be ideal because that way you would never be exposed to ultraviolet radiation. In other words, sunlight. And the only time you’re allowed to go out in the sun is if you have slathered on a high SPF sunscreen, 50 or above. And definitely avoid being outside between 10 and 2 because sun is your enemy. It’ll cause cancer, it’ll cause wrinkling, it’ll mess up your life. Terry 08:42-08:43 You are exaggerating. Joe 08:44-08:44 Of course. Terry 08:44-08:46 But not by very much. Joe 08:46-08:58 So you’ve kind of come up with a different perspective, Dr. Weller. Can you tell us a little bit about your time in Australia and why that started you down this path in part? Dr. Richard Weller 08:59-10:30 Sure. I mean, I think you’re you’re pretty accurate about the American dermatology view to sunlight. And I think what I really want to say is we need a more nuanced view on sunlight. And of course, the second thing to say to you is that I’m speaking to you from Scotland, and people forget how much further north Europe is than Scotland [Scotland is than the US]. So you know, the further away you are from the equator, the less sunlight there is. And as an example, if you live in the cold woolly fringes of Maine or New England, you’re actually at the same latitude as the Côte d’Azur, as Cannes, right down on the Mediterranean coast of France. And if you live in Florida, you’re on the same latitude as the Sahara. So the amount of sunlight Americans are getting is way more than we North Europeans are getting. So I’m speaking to you with someone from Scotland and probably what I see is different from what my American colleagues see. Nonetheless, sunlight has significant health benefits, as my research and that of other colleagues around the world is now showing.  There has to be more to the message we give than just ‘sunlight is bad’ because that’s becoming outdated. And that’s really the message I’d like to get across. Terry 10:31-10:38 I wonder if you could summarize for us, Dr. Weller, what some of those benefits of sun exposure might be. Joe 10:38-10:45 And in particular, can you tell us a bit about Australia and cardiovascular disease? Dr. Richard Weller 10:46-11:46 Sure. So yeah, I mean so look, I I suppose a bit about my career. I’m an academic dermatologist. I’ve been a dermatologist for about 30 years. Before I became a dermatologist, I did an internal medicine training and as part of that I worked in Australia, in Northern Australia and Queensland for a year. And Australia is much sunnier than the UK. So in Cairns, where I was living- the UV index is seven or above every single day of the year. So in mid-winter, the UV index, which is a measure for the burning ability of the sunshine, hits about seven, you know, for an hour or so around midday, and it rises to fourteen in midsummer. So in Scotland last year, the UV index hit seven for ten minutes. It was just after lunchtime on the 24th of June, if you want to know exactly when. Terry 11:47-11:47 Okay. Dr. Richard Weller 11:48-13:58 And yet we are given sunlight protection advice copied directly from the historical Australian advice. Designed for white Australians, you know, Australians of North European heritage who’ve moved to somewhere hugely sunnier and that is inappropriate [in Scotland]. You know, skin color is an evolutionary adaptation to sunlight. So, you know, Homo sapiens, that’s us, we’re about 160, 200,000 years old as a species. Non-African humans are the descendants of people who left Africa about 60,000 years ago And what is interesting is those humans who’ve moved to high latitude, so Europe and China, modern China have independently evolved pale skin repeatedly on moving to low light environments. So the pale skin gene variants that we see in Europe, um SLC 45A2 in particular, arose about 8,000 years ago. Independently pale skin gene variants arose in humans who had moved to high latitude modern China. So skin color determines your response to sunlight. That’s that’s what it’s about. And what’s happened is repeatedly humans who’ve lived in low-light areas have there’s been an evolutionary fitness advantage to getting to to developing pale skin which allows you to get more of sunlight’s benefits. But at the same time, if you fly down to or go by convict ship from Britain to Australia you’re very suddenly moving to somewhere with way more sunlight than your skin um is adapted to manage. And that’s when you see the problems of skin cancer and and sunburn and so on. Texas is the same as Australia in that sense. Terry 13:59-14:38 Now, Dr. Weller, as an anthropologist, I’m familiar with what I guess is uh the hypothesis that as you say, uh, pale skin is an evolutionary adaptation to not getting enough sunlight, and therefore when we expose our pale skin to the uh sunlight that we can get in uh you know, North Carolina or New Jersey or France or where have you, we’re able to make the vitamin D we need. Are there other considerations beyond vitamin D? Dr. Richard Weller 14:39-17:39 Yes, very much so. And of course the key question is, you know, that there must be a benefit because it keeps occurring. What are those benefits? And I and I have to say straight off, I think the benefits of vitamin D are hugely overstated. Vitamin D is less important than we have thought for much of the last hundred years. So we look, it may have played a part in the development of pale skin. We know that people with darker skin need more sunlight to get the rise, same rise in vitamin D. But you know, we don’t in Britain nowadays see rickets or problems that associate with vitamin D deficiency in African, you know, British African communities, for instance. And actually, skin color doesn’t enormously affect vitamin D synthesis. A lot of my research about sunlight has been looking at cardiovascular disease. We find that sunlight lowers blood pressure independently of vitamin D. There’s a substance called nitric oxide, which my research has shown is stored in the skin, and when sunlight hits the skin, it releases that nitric oxide, the circulation where it dilates blood vessels and lowers your blood pressure. And that has really quite a big effect at population level. So again hit here in Britain The average blood pressure is six millimeters of mercury systolic lower in summer than winter. And that appears, that’s probably a nitric oxide effect. It’s definitely not a vitamin D effect. In terms of the evolutionary history of skin, that gets more interesting. My feeling is that heart disease, blood pressure, high blood pressure related disease like heart attacks and strokes is unlikely to have been a problem in evolutionary times. You know, chasing after woolly mammoths, running away from saber toothed tigers. Pre-the invention of cigarettes, I think it is unlikely that heart disease was a big problem. What I’m looking at now with my research is we wonder if infection may have played a role. Because what’s fascinating is humans have been in Europe for about 40,000 years, been in Asia for about 60,000 years. And yet the development of those pale skin gene variants in Europe only starts about eight thousand years ago, and initially the that the that the white skin gene variants arise in in the fertile crescent, you know. Anatolia. And those white skin gene variants arise in East Asia around eleven thousand years ago. And it it arises at the time when we make the shift from being hunter-gatherers to farmers. Terry 17:40-17:57 You’re listening to Dr. Richard Weller, Professor at the University of Edinburgh College of Medicine and Veterinary Medicine. He holds the personal chair of medical dermatology in the Deanery of Clinical Sciences and participates in the Center for Inflammation Research. Joe 17:58-18:07 After the break, we’ll find out more about how farming might have contributed to evolutionary changes in skin color. Terry 18:07-18:11 Dr. Weller offers us a summary of the health benefits sunlight can provide. Joe 18:12-18:16 Lack of sun exposure is actually associated with some health problems. Terry 18:17-18:22 Studies on sunshine are mostly being done in the UK and Europe, not in the US. Joe 18:22-18:31 Dermatologists sometimes suggest we could just take vitamin D supplements to make up for lack of sunlight. Why isn’t that adequate? Terry 19:45-19:48 Welcome back to the People’s Pharmacy. I’m Terry Graedon. Joe 19:49-20:12 And I’m Joe Graedon. Terry 20:13-20:28 Why do people who live in northern latitudes tend to have pale skin? Presumably, there’s some evolutionary advantage. Anthropologists have suggested that pale skin is better at making vitamin D when sunlight is scarce. Joe 20:29-20:49 Many dermatologists encourage people to avoid the sun as much as possible. To make up for the possible lack of vitamin D, they suggest taking vitamin D supplements. But research on vitamin D pills or injections has been strangely disappointing. Why would that be? Terry 20:49-21:18 Does sun exposure have any other physiological effects beyond triggering vitamin D synthesis? Dermatologist Steve Feldman of Wake Forest University has found that Ultraviolet exposure can boost psychological mood, making people feel more relaxed. He also found it can help people with chronic pain such as fibromyalgia feel more comfortable. Our guest today has also been studying the impact of sunlight on skin for years. Joe 21:18-21:40 We’re talking with Dr. Richard Weller. He’s professor at the University of Edinburgh College of Medicine and Veterinary Medicine. He holds the personal chair of medical dermatology at the Deanery of Clinical Sciences. His research interests include eczema, psoriasis, and the effects of sunlight on human skin. Terry 21:41-21:55 Dr. Weller, how would the rise of uh domestication and farming tie in to a change in skin color? How does that make sense? Dr. Richard Weller 21:56-24:58 Yeah well this is the really interesting thing because being at high latitude, low light, by itself has not driven a move to pale skin. Because humans have been 40,000, you know, I mean if you go to the Dordogne in France, the amazing cave art, you know, the wonderful pictures of woolly mammoths and so on and ancient animals on the roofs of the caves, dates back twenty thousand years ago, when actually the people who painted that were dark-skinned. So this this move to, so it’s not just being at high latitude, because most of the time that Europe’s been inhabited, it’s been inhabited by dark-skinned people. And it’s not just being a farmer, because farming has arisen independently. I mean farming arose independently in what’s now Mexico, maize; it’s arisen independently in India; it’s arisen independently in Papua New Guinea. So either by themselves does not precipitate that move to pale skin. It’s when the two come together. It’s when you’re a farmer in a low light environment that pale skin arises. So that sort of information sets the question. It doesn’t give the answer. It is possible that part of it’s dietary, you know, we know that that Neolithic transition from being a hunter-gatherer to a farmer actually led to a poorer diet. shorter people, probably higher infant mortality. You know, it wasn’t all milk and honey when we moved to being farmers. So it could be a dietary factor, it could be related to vitamin D. Sorry, vitamin D for an American audience. My but I have to say my feeling is it may be or it is likely to be infection. Because the thing that really happens when you make that Neolithic transition shift is that’s the advent of infectious disease. Because most infectious disease comes from animals, what we call zoonotic. You know, COVID comes from bats, TB comes from cows, influenza comes, you know, most infectious disease comes from animals. And when you’re a farmer, you’re living with animals. And the other thing, of course, is when you’re a farmer, you’re living in communities, you’re living in villages close to other people, rather than being hunter-gatherer bands dispersed across the landscape. And so most infectious disease arises from that time, we think. And I suspect that there are UV-driven processes which reduce infection. And that’s what we’re really looking at at the moment. And the point about skin color is it mediates your response to sunlight. It’s not pale skin itself that prevents you get infections. It’s the fact that pale skin allows you to maximize the biological effects of sunlight. Joe 24:58-26:23 Dr. Weller, I’d like to go back and sort of summarize, if you don’t mind, all of the benefits of exposure to sunlight, because as I introduced a little bit tongue in cheek, American dermatologists believe that that sunlight is problematic, that it will cause all kinds of problems, and that we need to use these high SPF sunscreens or better yet stay out of the sun completely. So you’ve already suggested that blood pressure is affected by exposure to sunlight. You’re now alluding to the possibility that our immune system may be enhanced by sunlight, but there are a whole lot of other conditions as well. I think about inflammatory conditions like arthritis. I think about autoimmune conditions like eczema. I think about kidney disease and osteoporosis and diabetes. So can you just sort of summarize all of the potential health problems associated with lack of exposure to sunlight? How people in Australia may be quite different from people in Greenland,  in terms of their risk of heart disease? So give us that big perspective. Dr. Richard Weller 26:23-32:25 Yeah, look, I’m delighted to and of course I’ve start I’ve jumped straight into where my my current research is because that’s really exciting. So so sunlight’s got ups and downs, got a good side and a bad side. So look with my dermatologist hat on broad brimmed shady hat. Sunlight is a risk factor for skin cancer and it is a risk and it leads to skin aging. So that’s the kind of downside. But it’s also got an upside. There is a wonderful means about looking at how do these risks and benefits weigh out. And that’s what we call all-cause mortality: death from any cause. And that gives you very robustly a summation of those two factors, the pluses and the minus. So we have a paper coming out actually next week. We’re just uh arranging uh stuff with the journal at the moment. which touches on this subject, but the first person to look at it uh was a colleague and friend of mine, Pelle Lindqvist, who is an obstetrician in Sweden. And he did a wonderful study called the Melanoma or the Melanoma in Southern Sweden study. So this was set up in 1990. It was designed, as the name suggests, to find what causes melanoma, and how does it kill people. And 30,000 Swedish women, 30,000 middle-aged Swedish women in southern Sweden. So that that at the time was a quarter of the population of southern Swedish and middle-aged women were recruited in 1990 and they were asked a series of questions about how much sunlight they got. But they were also asked an extensive range of other questions asking about lifestyle factors, education, income, health, you know, other smoking habits, medical conditions. So the baseline information was taken, they were then followed for 25 years, and then the investigators went back to find out what had happened to them. And the first thing to say is that those had most sunlight were more likely to have had a case of melanoma. But Pelle’s interest and my interest is what about the deaths? I’m not interested in cases of the diseases. I’m interested in death from any cause. And there, much to the surprise of the dermatologists who set the study up, the direction was in the opposite direction to melanoma cases. They found that the women who had the most sunlight after correcting for all of these other factors, you know, income, education, smoking, etc. , etc. , those that had the most sunlight were half as likely to be dead. 25 years after the study started, as those who had the least sunlight. So that’s the first study. We have just done a much larger study looking at the UK Biobank. So the UK Biobank, uh half a million middle aged people in Britain were recruited (I was one of them) and examined in great depth over about it took about four years to recruit the whole cohort, um, all around Britain. And every subject went up to an investigation center where there was about three hours of questionnaires, investigations, measurements, you know, mass of information taken. And that was back in 2000 and uh, anyway, about about 20 years ago. And those people have followed up long term. And we have gone into that database and we’ve taken 400,000 people from that, and we have looked at measures of sunlight exposure. So the measures of sunlight exposure we have used have been how far south people live in Britain, because the further south you live, the more sunlight you get. And our other measure actually was people who use sun beds, not so much because of the sun beds themselves as because behaviorally we know that people that use sun beds sunbathe more, actively seek the sun more. Now, we then had to correct for all the confounders. You know, sun bed users are younger, more female, less educated, more likely to come from Manchester, etc etc and we had to correct for the same factors the further south people lived. And what we find is that the more sunlight people get the longer they live. They have a reduced all-cause mortality. They have a reduced cancer mortality. Melanoma is an interesting one. There was an increase in diagnoses of melanoma in those that got more sun, but no increase in mortality from melanoma and pretty much all the other cancers had a reduced mortality. And cardiovascular mortality was also greatly reduced. So just as Pelle showed in Sweden, we have showed in Britain that after accounting for confounding factors, other factors, the more sunlight people have the longer they live. Now one big caveat I’m gonna throw in for your audience is these are North European studies. And our sunlight levels here are much lower than your levels in America. You know, white skin has developed in Europe because we don’t have much sunlight. And this data applies here. I’m not sure how much it’s going to apply in America. And of course the studies haven’t been done because all people have thought about sunlight is oh gosh, it’s dangerous, it’s bad. But really interesting. Certainly for us in northern Europe, I think a really important, really important finding. Terry 32:26-32:46 So you’re not aware of any American colleagues who are doing anything similar? Of course, we don’t have a resource like the UK Biobank, which is an extraordinary resource of a huge amount of information, I don’t believe anything of that sort has been collected in the US. Dr. Richard Weller 32:47-35:46 No, I mean these studies can’t really be done in America. I mean most of these studies come out of Scandinavia and Britain because we have universal health systems. So if you get sick or have disease or die, you know, all our data are collected centrally.  America has such a bizarre health system and it’s so fractured and broken up into small things, it’s not really possible to do there. What America has been very good at at doing though is things like clinical trials and I need to mention vitamin D, vitamin D. Because the other thing to say here is vitamin D’s benefits have been vastly overplayed. Now we know that so sunlight is responsible for making vitamin D. Vitamin D has some important benefits, rickets, you know, it prevents rickets. And we know that when you measure vitamin D People with higher measured vitamin D levels are healthier in almost every way you can mention. Less heart disease, less strokes, less multiple sclerosis, less diabetes, etc. , etc., etc. The problem is when you give vitamin D, there are you know, it prevents rickets, which we’ve known for a hundred years. And there is an enormous rearguard action going on by the vitamin D industry saying, oh, well, what about this? What about this? What about this? Um and the vitamin D industry, I mean it’s a it’s worth, I think, it’s about two billion dollars a year. It is a huge industry. The biggest study of all on vitamin D supplementation was run in America. You’re fantastic at this, you know, NIH comes in with its funding. And there was a study called the Vital Study, run by Joanne Manson 25,000 Americans, 25,000 adult Americans were recruited. Half of them were given vitamin D supplements for five years and half of them were given a placebo, a sham control. And at the end of five years and really the study has now ended, but the patients are being followed up. And what it confirms, and it confirms the findings from lots of other smaller studies, is vitamin D has absolutely no effect on heart disease, on strokes. Probably doesn’t do much for cancers. Um, you know, the results came back negative, negative, negative. And there was an editorial in the New England Journal of Medicine 18 months ago. summarizing all this saying stop taking vitamin D supplements. You know, unless you are one of those very few people with incredibly low levels of vitamin D, it’s not doing anything. And people come up saying I’ve got vitamin D deficiency. And you say, what do you mean? Oh, I had a blood test. Doctors do not treat blood tests. We treat disease. A blood test is not a disease. You know, you wouldn’t know if you hadn’t had it done. But there is a huge industry out there pushing this. Terry 35:46-36:11 So, Dr. Weller, we actually have spoken with uh Dr. Manson and with one of her colleagues, and there was one area in which the VITAL study showed some benefit for vitamin D supplements and that was it reduced the likelihood that someone would be diagnosed with a new autoimmune condition. So you know… Dr. Richard Weller 36:12-37:16 Yes, I look I’m I am not saying vitamin D is absolutely irrelevant. I think we know about rickets, the autoimmune condition is is interesting. But the vast array of benefits that have been claimed for vitamin D are not held up by that amazing study. So what is interesting is that sunlight acts in multiple ways. Now a bit of it is vitamin D. but there’s so many other areas by vitamin D independent mechanisms. And that’s really exciting. And the problem is our focus has been so much exclusively on vitamin D. We have just ignored this. We’ve said, oh yeah, I know the fact that people are healthier. It’s vitamin D. Live in a cave, take vitamin D supplements. And those vitamin D supplements only account for some of sunlight’s benefits. And we need to move on and look for what the other mechanisms are. Terry 37:17-37:36 You’re listening to Dr. Richard Weller, Professor at the University of Edinburgh College of Medicine and Veterinary Medicine. He holds the personal chair of medical dermatology in the Deanery of Clinical Sciences and participates in the Center for Inflammation Research. Joe 37:36-37:42 After the break: Why can’t we compensate for sun exposure by taking vitamin D supplements? Terry 37:43-37:48 Well, could it be that maybe, as doctor Weller says, vitamin D is just a marker for sun exposure? Joe 37:49-37:51 What exactly does that mean, a marker? Terry 37:52-37:58 Well, it means we can measure vitamin D, and there are things we can’t measure. We don’t measure nitric oxide that well. Joe 37:59-38:02 Well, what’s a reasonable amount of sun exposure? Terry 38:02-38:10 We’ll also find out more about Dr. Weller’s research on how sunlight triggers nitric oxide formation and how that affects us. Joe 38:10-38:15 What does nitric oxide do for the immune system? Terry 38:32-38:37 You’re listening to the People’s Pharmacy with Joe and Terry Graedon. Joe 38:45-38:48 Welcome back to the People’s Pharmacy. I’m Joe Graedon. Terry 38:48-39:13 And I’m Terry Graedon, Joe 39:13-39:34 Today on the People’s Pharmacy, we are exploring the controversial concept that some sun exposure might have hidden health benefits. Of course, we want to emphasize that no one should get burned by the sun. In addition to being painful, sunburn creates the risk for melanomas. Terry 39:34-40:04 To find out more about phototherapy and how ultraviolet light acts to produce nitric oxide in the skin, we turn back to our conversation with Dr. Richard Weller. He’s a professor at the University of Edinburgh College of Medicine and Veterinary Medicine, and holds the personal chair of medical dermatology in the Deanery of Clinical Sciences. He also participates in the Center for Inflammation Research. Joe 40:05-40:59 So Dr. Weller, you have just put into perspective the fact that vitamin D is not the answer to lack of sun exposure. And I want to just quickly go back and summarize all of the benefits of sunlight And what happens when you don’t get exposed to sunlight? And you’ve alluded to things like hypertension, cardiovascular disease, cancer. You’ve mentioned kidneys, you’ve mentioned diabetes. What about autoimmune conditions such as multiple sclerosis? What about eczema, which I believe is something that you have a lot of experience with? Tell us why sunlight is so important for our body’s health. Dr. Richard Weller 40:59-45:54 Yeah, great question, thank you. And I’m delighted you bring multiple sclerosis up. So multiple sclerosis It is the classic sunlight deprivation disease. So, you know, even when I was at medical school, and that was a frighteningly long time ago, We knew that MS was a disease that was most common in people who grew up in areas without much sunlight. So I’m in Scotland and we have the highest rates of MS in the world here. And in fact, the highest of the highest is the Orkney Islands, which are just off the north of Scotland. Beautiful place. But something like I think about one in eight hundred people there has MS. Incredibly common. So a colleague and friend of mine, Prue Hart in Australia. And so and again, the classic story. people with low measured vitamin D levels are more likely to get MS. You give vitamin D you know, kinda iffy you know, the the observational effect is huge. This huge great relationship measured vitamin D. You give vitamin D supplements, not very much happens. So it’s got to be more than just the vitamin D. And I might say there’s a super company in America, Cytokines,  led by a wonderful guy John McMahon, which is setting up a phototherapy study of MS in the United States. So there’s really good preliminary work done in Australia where people who when they had their very first diagnosis of MS, their very first demyelinating episode, were randomized either to get phototherapy, the kind of stuff that dermatologists use on their offices, well established, incredibly safe treatments, They were randomized either to get phototherapy or to get a control. And there was a really strong move towards a reduction in progress of MS, and a really marked improvement in the the biomarkers that are a good indicator of whether people are going to progress or not. Really exciting. The big problem, of course, was it was done in Australia. So your control group not getting phototherapy, well, they’re still in Australia under quite a bit of sunlight. And of course the other reason there isn’t much MS in Australia. It’s a very sunny country. There’s masses in Britain. So John McMahon and his company are leading this to me really exciting trial of phototherapy for MS in America. And I am watching with huge, I mean just really exciting, because here is a disease which should absolutely go along with phototherapy. And also the narrowband UVB phototherapy that we dermatologists use to treat eczema and psoriasis. has been around for twenty or thirty years incredibly safe. I think utterly over-medicalized. I mean It’s been around for 20 or 30 years. There’s no signal for skin cancer being found in Britain for people having UVB phototherapy. So it’s sunlight. We don’t see a skin cancer signal. And yet you have to see a doctor. You have to see a dermatologist to get it. Um, I think it should be used far more widely. Great American dermatologist called Joel Gelfland, again, fantastic guy. Has just done a wonderful trial of home phototherapy, people with phototherapy lamps at home. And he’s compared how well they do to people who go to their dermatologist office to get phototherapy. And he finds people with their lamps at home do amazingly well. They do as well in terms of reduction in their psoriasis as patients receiving these biologic treatments, these incredibly expensive but highly effective monoclonal antibody treatments. Well actually phototherapy, Joel showed, is as good. And I might say a fraction of the cost and, you know, I mean basically it’s it’s sunlight in a box. And I think we greatly underuse it. And we underuse it because we’ve demonized sunlight. So here is a sunlight-based treatment. And of course, that really threw dermatologists in the quandary. Hang on. We run around saying Don’t go in the sun. And then suddenly we’ve got a treatment which is based on ultraviolet. What do we do? What are oh no, we’re gonna surround it with caveats and cautions and warning signs. I think we’ve gone completely overboard with that and it means we are not using this safe and effective and clean treatment nearly as much as we should be. So I’m delighted that people like Joel Gelflands as a dermatologist and John McMahon with his MS studies is really restoring, you know, kind of rejuvenating this wonderful and underused treatment modality. Joe 45:54-47:02 Dr. Weller, I want to come back to your research with nitric oxide, because I’ve been fascinated by nitric oxide for decades. But first, you know, w we’ve been talking about sunlight exposure, and for the most part Americans have a kind of love-hate relationship with the sun. They want to go out to the beaches, they wanna play outside, they wanna be golfing and playing tennis and going for hikes. But they wouldn’t dare go out without their SPF 50 or 100. I’m just wondering, can you give us some practical guidelines about how we can expose our skin to sunlight for a quote unquote reasonable or safe amount of time that won’t do damage, that won’t burn our skin and lead to wrinkling and squamous or basal cell carcinomas. How do we use the sun without getting into the sunbox that you were talking about a moment ago in in a safe way? Dr. Richard Weller 47:02-48:45 Yeah, I mean a really good question. I mean the really key thing is to avoid sunburn and particularly for children to avoid sunburn because it’s sunburn particularly in children which is the major risk factor for melanoma, the serious skin cancer. Sunlight is photoaging. Sunlight is a risk factor for skin cancer. And you know, non-melanoma with skin cancers in particular, the more sunlight you get, the greater your risk. Look, I uh you know I have a kind of conflict of interest in here because I have, I’ve developed a a a compound you can add to sunscreen that will release nitric oxide in the sunscreen. You know, it’s it’s sort of in development. We’d love to get it out there. I I think sunscreens could be better than they are. I mean at the moment sunscreens are all about blocking sunlight, and blocking the sunlight will reduce the aging, it will reduce the burning, it will reduce the cancer. My concern is it’s also going to block the good things. I think sunscreens could be better than they are. It certainly my, in Britain I am pretty quite relaxed about sunscreen use because we live in a much less sunny place than it than America. Um in America you do have an awful lot of sunlight. Now I suppose what I’m going to say is more research is needed. I think sunscreens could be better. I think we haven’t looked hard enough at the benefits of sunlight and how much sunlight is required to get them to be able to give a really robust answer. And the reason we haven’t done that is because we’ve purely been focused on sunlight is bad, vitamin D will make up for the absence of it. And clearly the story is much more nuanced and complex than that. Joe 48:46-49:07 Well, even if you are unwilling to make a recommendation because there’s a lack of science. What would be a reasonable amount of sun exposure, and at what time should we contemplate that sun exposure if we want to avoid sunburn and some of those damages you mentioned? Dr. Richard Weller 49:07-51:42 Well if you live in Florida or Texas you’re gonna need some protection. You’re living in an African latitude, and if you’ve got white skin, you’ve got you I think you’ve just got to be protecting your skin a great deal out around the middle of the day. If you’re farther north, you know, it gets less of an issue, but you’re still in a very sunny climate I think Americans do need more sun protection than Europeans because you live so far south. And of course the other thing is skin color. Because um so really I work in Ethiopia a lot, although sadly with the political situation there, uh not for the last three or four years. So UV-induced melanoma really does not occur in dark-skinned people. Jay Adamson, a wonderful dermatologist, American dermatologist in Texas, has really shown that UV-induced melanoma does not occur in African Americans. When I work in Ethiopia, we do not see UV-induced melanoma. On at two and a half thousand meters altitude, eight thousand feet, in the tropics in Ethiopia. Incredibly sunny is the point. Dark-skinned Ethiopians do not get UV-induced melanoma. They get these rare subtypes of melanoma, not related to sunlight, but but skin color really determines your risks of of skin cancer. And I am concerned by the way that the American Academy of Dermatology regards all skin types as the same when it comes to sun protection Because certainly the work that we have done uh in America. So we looked at how sunlight lowers blood pressure in America, a big study on three hundred and thirty thousand Americans. And we showed that African Americans need more sunlight to lower their blood pressure than white Americans. So just as skin color determines your risks of getting skin cancer, It also determines how much UV you need to get the benefits of sunlight. You know, skin color is all about response to UV. And I am concerned that by putting out the same message to everyone of every skin color, that’s not wise because that risk-benefit ratio for sunlight is absolutely determined by your by your skin color. And it needs to be a different message dependent on your skin color. Joe 51:42-51:56 Dr. Weller, we just have a couple of minutes left. I wonder if you could briefly summarize your research with nitric oxide and why it’s so incredibly important for so many physiologic functions. Dr. Richard Weller 51:56-53:20 Yeah. Well the biggest killer in the world today is heart disease. So half, basically half of deaths in the world are caused by high blood pressure-related diseases, heart attacks and strokes. Sunlight lowers blood pressure and with it the risk of having a stroke or a heart attack. And the mechanism by which it does it is release of nitric oxide from the skin into the circulation. Hugely important. If you’re a male in Scotland, you are 30% more likely to drop dead of any cause in a week in December than a week in July. I’m pretty mellow at the moment, It’s July, It’s a good time of year. I’ll get through to the end of the week. I start getting a little nervous as the year gets later. And a lot of that is driven by nitric oxide from the skin and its effects on the cardiovascular system. So it’s not sunlight has benefits as well as risks. Those benefits are not just vitamin D. There’s other mechanisms. The mechanisms include importantly for cardiovascular disease, nitric oxide, but also I suspect other mechanisms that really just started to look at, like immune function in particular. So I really think we need to be reconsidering our approach to sunlight in a more balanced way, considering benefits and not just risks. Joe 53:21-53:47 And Dr. Weller, in the one minute we have left, the role of sunlight and perhaps nitric oxide on the immune system, because goodness knows, we have certainly learned a lot from COVID-19 and the pandemic. A lot of people would prefer to reduce their risk from infection. How does sunlight help there? Dr. Richard Weller 53:47-55:33 So well so interesting. So, so we looked at so we um at at the same time as, uh as a rival group in Harvard were looking at the effects of sunlight on COVID mortality. And we found in the very first three months of the pandemic that the sunnier it was after accounting for other factors, the less deaths there were from uh COVID. And that the Harvard group showed that the more sunlight there was, the less growth in cases. Now that’s observational studies, but we uh colleagues in America ran a pilot study in Louisiana giving phototherapy or, or a control to patients admitted to hospital with COVID. And it was a small study, only fifteen in each group, but they found a trend to reduce deaths in the sunlight group. And the third bit of evidence is people with high measured levels of vitamin D were less likely to get COVID or die of it, but multiple trials giving people vitamin D supplements, it had no effect. The usual story, measured vitamin D is a marker for sunlight exposure, not necessarily causative. So look, so I think there’s some really interesting data there suggesting that sunlight is driving processes which we’re now looking at that reduce your risk um of death from COVID. And that may apply to other infectious diseases, but the work needs to be done. And I suspect in evolutionary terms, that’s what has driven this move to pale skin in humans who move to low light areas. Joe 55:33-56:04 So, Dr. Weller, you’ve described the benefits of sunlight as being more than just vitamin D. Dr. Richard Weller 55:42-55:43 Yep. Joe 55:43-56:04 That nitric oxide is also a critical factor, and it’s manufactured in the skin and then circulates in the bloodstream and lowers blood pressure and probably has a lot of other benefits as well. What else is going on? Do we know what sunlight exposure does beyond vitamin D and nitric oxide? Dr. Richard Weller 56:04-59:08 Yeah, uh well I, I strongly suspect it’s having effects on the immune system and and in fact we’ve got f Pretty good evidence showing that. And that’s what I’m actually looking at at the moment with my current PhD student. So we’re so a really good early study in this area which we’re building on now by a chap called Dopico in Cambridge. Came to I think into Edinburgh actually. And he did one of these studies where you use other people’s data um very well. And they looked at um gene expression patterns in blood. Now what they did was they used about eight studies where people had had blood, and the studies have been done for various reasons. Everybody had their blood taken throughout the year during these studies, and the gene expression pattern, what genes were turned on and off in the whole blood, um, was looked at. And what Dopico and colleagues did was they looked, they analyzed the gene expression in these data sets by the month of the year in which the blood was taken. The studies were done for different reasons, but they happened to run over 12 months. And so he went in and thought, gosh, I’ll just analyze it by month of the year. And what he showed was that 30% of all the genes in your blood, you know, which are uh immune genes are very important there, show seasonal variation. So there is a huge uh seasonal variation, possibly I would imagine sparked off by UV, uh which occurs in immune cells. And broadly what he found was that inflammatory genes were turned on in winter and anti-inflammatory genes in summer. And the the, they suggest that maybe, you know, infectious disease flies around in winter. Maybe your body turns up the immune system to be able to jump on infectious disease. That was the hypothesis. So there’s now a technique called single cell RNA sequencing where you can look at every single individual cell, and so you can take, draw blood, you can look at ten thousand different cells, and you can look at every single gene turned on in every single cell. So the experiments I’m doing at the moment we do in winter. We take healthy volunteers. We load them up with vitamin D at the beginning, so they’re full of vitamin D at the start. Take their blood, look at all of their gene expression pattern, we then give them two weeks of daily solar-simulated UV, as if they were on in the Mediterranean, and we then repeat it. And we’re early days, don’t want to talk about the results yet, but we’re getting very interesting effects on gene expression patterns in in immune genes, T cell genes in particular. So it looks as if sunlight has significant effects on the immune system. And we’re really we’ll see where it takes us, but but really exciting stuff. Joe 59:08-59:53 Dr. Weller, if we were to dial back, what, 100, maybe 150 years to a day when tuberculosis was rampant and a terrible killer around the world. There were sanatoriums where people would go and they were often exposed to sunlight. Even in the winter, they would take people outside, bundle them up and exposed them to the sun, they somehow thought that exposure to sunlight could help people dealing with tuberculosis recover or at the very least survive better. Did they know something we didn’t know? Dr. Richard Weller 59:53-01:02:34 Yeah, I mean it’s really interesting and and I think sadly they never did, they had not yet invented robust, placebo-controlled clinical trials as we would understand them. But they weren’t fools. And of course, places like Davos, now an expensive ski resort and uh financial center. Davos was set up initially as a heliotherapy center, a center where people would go to get the sunlight for their tuberculosis. I I gave the opening address at the meeting of the Swiss the annual meeting of the Swiss Dermatology Association last year. And I pointed out and I was talking about the work we’ve been discussing today, and I pointed out to them that had I been there a hundred years ago, I would have been going as a disciple of the great Rollier, you know, the Swiss doctors who developed heliotherapy to treat tuberculosis. And instead, here I was a hundred years later, coming along to remind them of what they’d done previously. So absolutely, you know, we had it, you had it in America, we had it here in Britain. That was before antibiotics, the treatment for tuberculosis. And of course, and then for tuberculosis of the skin, a chap called Finsen in Denmark, developed ultraviolet lamp treatment for treatment of lupus vulgaris, tuberculosis of the skin. And he actually got the Nobel Prize for Medicine for this in I think it was 1904, really one of the very early Nobel Prizes for Medicine. So there is actually a history of UV having been used to treat infectious disease. And certainly since then we’ve had antibiotics and vaccines and we’ve had sewers and we’ve had clean airs, you know, we’ve had all of these measures that have reduced infectious disease death now. You know, the miracle of vaccination has basically eradicated infectious disease from our day-to-day life. So COVID was, I mean it was very tragic. It was also scientifically very interesting because suddenly you had a new infectious disease against which we had none of our usual defenses. You know, before the vaccines came, it was us and the virus. And you began to be able to see what happens to populations with a new virus. And it certainly looks as if those that had more sunlight had less deaths from COVID. And that for me was really very interesting. What the mechanisms are, we don’t yet know, and that’s what we’re looking for now. Terry 01:02:34-01:02:41 Dr. Richard Weller, thank you so much for talking with us on the People’s Pharmacy today. Dr. Richard Weller 01:02:41-01:02:44 Well thank you. I’ve enjoyed the conversation. Joe 01:02:44-01:03:15 You’ve been listening to Dr. Richard Weller, professor at the University of Edinburgh, College of Medicine, and Veterinary Medicine. He holds the personal chair of medical dermatology in the Deanery of Clinical Sciences and participates in the Center for Inflammation Research. The show notes for today’s show have a link to the recent article in The Economist about his research and a link to his paper in the Journal of Investigative Dermatology. Terry 01:03:15-01:03:26 Lynn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B. J. Leiderman composed our theme music. Joe 01:03:26-01:03:32 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:03:57-01:04:12 Today’s show is number 1397. You can find it online at peoplespharmacy.com. That’s where you can share your comments about today’s show. You can also reach us through email radio at peoplespharmacy.com. Terry 01:04:12-01:04:32 Our interviews are available through your favorite podcast provider, and now you can find them on YouTube as well. You’ll find the podcast on our website on Monday morning, and this week it’ll have some extra information about Dr. Weller’s research on sunlight, vitamin D and nitric oxide. Joe 01:04:32-01:04:50 At peoplespharmacy.com you can sign up for our free online newsletter to get the latest news about important health stories. When you subscribe you can also have regular access to information about our weekly podcasts so you can find out ahead of time what topics we’ll be covering. In Durham, North Carolina, I’m Joe Graedon. Terry 01:04:50-01:05:24 And I’m Terry Graedon. Thanks for listening. Please join us again next week. Thank you for listening to the People’s Pharmacy Podcast. It’s an honor and a pleasure to bring you our award-winning program week in and week out. But producing and distributing this show as a free podcast takes time and costs money. Joe 01:05:25-01:05:34 If you like what we do and you’d like to help us continue to produce high-quality, independent healthcare journalism please consider chipping in. Terry 01:05:35-01:05:39 All you have to do is go to peoplespharmacy.com/donate. Joe 01:05:40-01:05:53 Whether it’s just one time or a monthly donation, you can be part of the team that makes this show possible. Thank you for your continued loyalty and support. We couldn’t make our show without you. Citations

A randomized controlled trial published in the New England Journal of Medicine confirmed what some cancer specialists have long hoped: physical activity can prolong cancer patients’ lives. Last week, we heard from the senior author of that study, medical oncologist Christopher Booth. In this episode, we hear from an exercise physiologist who has been helping cancer patients with exercise prescriptions. The goal was for them to feel better. Many also lived longer. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 23, 2025, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Aug. 25, 2025 Who Needs Exercise Prescriptions? We start our conversation with exercise physiologist Claudio Battaglini, PhD, by asking about his career trajectory. How did he go from playing soccer in Brazil to studying how to coach Olympic-level athletes to providing exercise prescriptions tailored to cancer patients’ unique needs? You will want to hear his story. What Is the Cancer Gym? Dr. Battaglini describes how he initially resisted working with young cancer patients. How did that experience affect him? He eventually ended up setting up the cancer gym at the Rocky Mountain Cancer Rehabilitation Institute at the University of Northern Colorado (UNC for those in Greeley). After earning his doctoral degree there, he began teaching and research at a different UNC (the University of North Carolina at Chapel Hill). He established the Get REAL & HEEL Breast Cancer Rehabilitation Program and credits the breast cancer patients for pointing out the benefits of group exercise training. In addition to positive physiological effects, participants experience emotional support. This also helps motivate patients to continue their physical activity consistently. How to Motivate People to Exercise: Let’s face it: most of us could benefit from exercise prescriptions. But would we follow through? It turns out that personal relationships are hugely important in helping to motivate people to show up. That could be with their personal trainer who is expecting them for their appointment. It could also be one or more friends counting on them to participate in the activity. If others are holding you accountable, you are far more likely to get with the program. Another important factor is matching the right kind of exercise to each patient. Most people are motivated to do what they enjoy. Do you love pickleball or swimming? Dancing or hikes in the woods? If the recommendation is right, staying motivated is far less of a problem. Physical Activity for Young People: Decades ago, physical education classes were mandatory in public schools. In recent years, some school boards have been tempted to drop them as too expensive. (North Carolina and some other states have statewide policies requiring all students in grades K-8 to have the opportunity of 30 minutes of exercise daily.) How important is it to encourage youngsters to be physically active? Do they need exercise prescriptions? Practical Advice for an Exercise Program: For those of us writing our own exercise prescriptions, we discussed the pros and cons of counting steps. Where can you find exercise programs suited to you? The YMCA might be one place to start. Dr. Battaglini also mentioned online resources and qualities to look for in a personal trainer. Above all, whatever you choose to do should feel like fun. This Week’s Guest: Claudio L. Battaglini, PhD, FACSM, is a Professor of Exercise Physiology and the Director of the Graduate Exercise Physiology Program at the University of North Carolina at Chapel Hill. He is Co-Director of the Exercise Oncology Laboratory in the Department of Exercise and Sport Science at UNC Chapel Hill. Dr. Battaglini is also a member of the UNC Lineberger Comprehensive Cancer Center. Listen to the Podcast: The podcast of this program will be available Monday, August 25, 2025, after broadcast on August 23. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. In the podcast for this episode, you’ll find information about walking speed and how much it matters. We also discuss swimming or cycling as ways to protect your joints if walking is difficult. Does cross-training become more important as you grow older? What kinds of activities can slow osteoporosis? Be sure to tune in if you are interested in the importance of family and friends supporting our exercise goals. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Physical activity, aka “exercise,” is a cornerstone of good health, just like adequate sleep and a balanced diet. No one questions the benefits for people who are already healthy. But doctors may assume that cancer patients are too debilitated and demoralized to exercise. They may think physical activity wouldn’t be much help to patients who have just suffered through radiation or chemotherapy. Such assumptions are wrong and could be harmful, as a recent study shows. In actuality, structured exercise can help cancer patients survive and even thrive. How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 16, 2025, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link  so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Aug. 18, 2025. Does Exercise Belong in Cancer Treatment? An exciting study published in The New England Journal of Medicine demonstrates that a personalized exercise program can be an important component of the treatment for colorectal cancer (New England Journal of Medicine, July 3, 2025).  We spoke with the senior author, Dr. Christopher Booth, who explained that originally he and his colleagues wondered if exercise can help cancer patients feel less fatigued while undergoing chemo. Then they decided to design a trial that would go much further. They intended to answer two questions: can cancer patients exercise during treatment? And does that improve their likelihood of survival? Increasing Physical Activity Can Help Cancer Patients Survive Longer: The study, known as the CHALLENGE trial, hit a home run. The investigators recruited 889 people who had just had surgery and chemotherapy for their colorectal cancer. They randomly assigned half of them to get a health education booklet urging them to eat right and stay active. The other half got the booklet (usual care) PLUS a personalized exercise prescription designed to increase the amount of moderate to vigorous physical activity people did over the week. How Did This Challenge Work? The exercise prescriptions were devised by personal trainers who met with the “intervention” patients every two weeks for a year. Half of the meeting was devoted to motivational coaching and the other half to moving. Patients loved it. Increasing their fitness also improved their quality of life. In addition, patients in the exercise intervention group had better immune function and lower inflammation and less insulin-like growth factor, which can contribute to tumor expansion. Both men and women participated in this trial. During the follow-up period, women who were active were less likely to develop breast cancer than those in the control group. Similarly, men in the intervention group had a lower chance of a prostate cancer diagnosis. The most exciting part of the story, however, is about their colorectal cancer treatment. Not only did patients in the physically active group have longer overall survival, they also had longer disease-free survival. Remember, these two groups have the same type of cancer and got the same kind of treatment, except for the exercise prescription. The overall 8-year survival was 90.3% in the exercise group and 83.2% in the health education control group. That means the exercisers lowered their chance of dying during those eight years by 37%. The Number Needed to Treat (NNT) was 14 exercisers to prevent one death. That is a remarkable statistic. How Did Cancer Patients Get Motivated to Move? If you’ve ever started an exercise program only to drop it a few weeks later, you are not alone. Keeping ourselves motivated to stay active isn’t always easy unless you really love what you are doing. (Joe needs no extra motivation to show up for tennis.) Consequently, it is impressive that a very high proportion of the cancer patients in the CHALLENGE trial kept exercising. Part of that perseverance might be due to the motivational coaching. No doubt another big part was the relationship with the personal trainer. Meeting with a person every two weeks for a year can help build friendships and creates a relationship in which accountability is a factor. After the first year, patients and trainers met every month for the next two years. Being able to increase physical activity was empowering for patients, giving them a sense of control that can otherwise be missing in a cancer patient’s life. What Did Cancer Patients Do? The exercise prescriptions were personalized, so people undertook a wide range of activities. Jogging and walking were popular, but some people swam, and others kayaked. There were patients who bicycled, and possibly some who rode horses. (Dr. Booth does not mention that.) The point was to find an activity you love and stick with it religiously, which they did. The most popular activity by far was also the simplest: walking. The idea was to walk at a pace so you looked like you were late for a meeting. Is It Feasible to Help Cancer Patients Survive & Thrive? One of the most exciting aspects of the CHALLENGE trial was to see that people responded to coaching. Personalized exercise prescriptions with accountability could be instituted into many cancer treatment programs. After all, if insurance pays for cardiac rehab, why shouldn’t it pay for cancer rehab? The cost of a personal trainer is about $3,000 to $5,000 over three years. That is a lot less than the next-level chemotherapy drug is likely to cost, and unlike chemo, the side effect is that the patient feels better. Not only is it feasible to help cancer patients survive through targeted exercise, it should be a part of most cancer treatment protocols, In Summary: Dr. Booth offered us this explanation of how the treatment works: “Exercise is inducing physiologic, hormonal, inflammatory, immunologic changes in the body that are helping the body eradicate a proportion of these cancer cells. ‘ Learn More: Dr. Booth is a medical oncologist. To complete this trial, he called on the expertise of a lot of colleagues, including exercise physiologists. Next week, we will speak with Claudio Battaglini, PhD, to get the exercise physiologist’s perspective on this important approach. This Week’s Guest: Christopher Booth, MD, is a medical oncologist and health services researcher at Queen’s University in Kingston, Ontario, Canada. • Director, CCE Division, Queen’s Cancer Research Institute (QCRI) • Medical Oncologist • Clinician-Scientist, Cancer Centre of Southeastern Ontario • Professor, Departments of Oncology and Medicine, Queen’s University • Canada Research Chair in Population Cancer Care https://scri.queensu.ca/faculty-staff/christopher-booth Christopher Booth, MD, Queen’s University Listen to the Podcast: The podcast of this program will be available Monday, August 18, 2025, after broadcast on August 16. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

We may not often stop to think about it, but our water, food, furniture and other ordinary items are frequently contaminated with toxic chemicals. In this episode, Dr. Aly Cohen describes these threats to our health. You may have heard of compounds that can disrupt hormonal balance (endocrine disruptors). Everyday toxins like these can also interfere with the ability of the immune system to function properly. What can you do to reduce your exposure? How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 9, 2025, at 7 am EDT on your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Aug. 11, 2025. Doing an Environmental Assessment: As a rheumatologist, Dr. Cohen frequently treats patients whose immune systems have turned on them to produce conditions like lupus or rheumatoid arthritis. As an integrative medicine practitioner, she has learned to look at the patient’s environment for clues about the toxic compounds that may be causing the problem. The first environmental assessment she conducted was actually for her beloved family dog, Truxtan. When he developed autoimmune liver disease, she tried to figure out why. How Everyday Toxins Disrupt the Immune System: Dr. Cohen wasn’t able to save her dog, but the experience made her realize just how many potentially toxic chemicals we are exposed to in the course of our daily lives. If you look around your kitchen, you may discover that most of your food containers might be suspect. Plastic is incredibly convenient, since it is lightweight, break-resistant and cheap. But it often contains plasticizers such as bisphenols or phthalates that are endocrine disruptors. Some can disrupt the immune system as well. After all, immune system cells interact with the endocrine system on a regular basis. The two are tightly linked. Other food packaging can also contribute undesirable compounds such as PFAS. Exposure to these may lead to chronic inflammation. Dr. Cohen tells about a patient, Massimo, who ran a pizza shop. A young man, he had troubling fatigue. Changing his routine so that he wore nitrile gloves while handling pizza boxes helped a lot. So did bicycling to work. Everyday Toxins in Our Water: How safe is your water? One of Dr. Cohen’s patients had moved to New York from a Latin American country. Although she had filtered her water in her home country, she believed the tap water in New York was safe. It turned out the old plumbing in her building was contaminated with lead. In addition, she was relying on rice as a food staple, and it was contaminated with arsenic. Lead and arsenic are well-recognized as toxic chemicals. Filtering her water and washing her rice helped her feel much better. How do you make sure your water is free of everyday toxins? Dr. Cohen says several types of filtration devices can be useful, if they are used according to instructions. That means changing the filter medium on the recommended schedule. Any filter is better than no filter, but by far the best approach is known as reverse osmosis. This results in clean water you can trust to be free of toxins. Can You Avoid Plastic? The topic of water is almost inextricably linked to the question of plastic. Much of the water sold for consumption away from home is bottled in plastic. In addition to environmental considerations, this can expose us to plasticizers such as phthalates or even to tiny bits of plastic known as microplastics. These are accumulating in our bodies and may be harming our immune system. Bottles are not the only source of plastic in our food supply. Most cans are lined with a resin to prevent corrosion. This frequently contains BPA, bisphenol A, as a plasticizer. Some manufacturers have switched to another bisphenol instead. Thus, they can claim that the can is BPA-free, but it isn’t necessarily safer. Don’t Use Plastic Containers in the Microwave! One simple rule that can cut down on a lot of exposure to immune-disrupting plasticizers is don’t microwave food in plastic containers. Heat tends to speed leaching of plasticizers from the containers into the contents. Yes, we know a lot of frozen meals come in plastic containers that are supposedly microwave-safe. Don’t believe them. Instead, transfer the food to a glass or ceramic dish or bowl and heat it in that. That way you know you’re not getting any extra plasticizer in your snack. Prioritize! Dr. Cohen points out that to get the best results from efforts to avoid everyday toxins, we need to figure out where the exposure is greatest. That’s why she usually likes to start with cleaning up the water supply, since for most of us that is our top exposure. Analyzing your diet and focusing on foods you eat often is another way to prioritize. Those are the foods that should be free of toxins if at all possible. She recommends using the EWG (Environmental Working Group) lists of the “Dirty Dozen” foods that often contain pesticides and the “Clean Fifteen” foods that are generally safe.  For the Dirty Dozen, it makes sense to purchase USDA Organic produce whenever possible. Removing Pesticides: Dr. Cohen offers some simple, inexpensive ways to wash your produce and get the pesticide off. Add 1 part vinegar to 3 parts filtered water and let the fruit or vegetables soak in that for several minutes. Then rinse it off well with filtered water. The 21-Day Plan: To make it easier for people to implement the changes and avoid everyday toxins, Dr. Cohen offers a 21-day plan. It offers steps to avoid lots of harmful chemicals including obesogens (chemicals that make us fat). One simple way to take the first steps, after filtering the water you drink, is to carry a metal spoon and fork. That way you won’t have to resort to using plastic utensils to eat hot food, especially soup. Another step is to be cautious with skin care products. Using the online EWG guide SkinDeep can help you find sunscreen or moisturizer that is mostly free of undesirable agents. When shopping, make it a habit to seek out USDA Organic certified products for those items you eat most. Learn More: Dr. Cohen is not the only doctor concerned about toxic exposures. A summary of research into the “exposome” was published in JAMA last spring. Here’s a link. This Week’s Guest: Dr. Aly Cohen is a board-certified rheumatologist and integrative medicine physician. A member of the faculty of the Academy of Integrative Health and Medicine, Southern California University of Health Sciences, and the University of California, Irvine, she is a leading medical and legal expert in environmental health. Dr. Cohen is creator of TheSmartHuman.com social media platform, and the co-author of the bestselling consumer guidebook Non-Toxic: Guide to Living Healthy in a Chemical World. Her latest book is Detoxify: The Everyday Toxins Harming Your Immune System and How to Defend Against Them. Her website is https://alycohenmd.com/ Aly Cohen, MD, author of Detoxify The People’s Pharmacy is reader supported. When you buy through links in this post, we may earn a small affiliate commission (at no cost to you). Listen to the Podcast: The podcast of this program will be available Monday, August 11, 2025, after broadcast on August 9. You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

In this episode, our guest, Dr. Andrew Armstrong of Duke University, discusses recent advances that men should know to overcome prostate cancer. We ask about former President Joe Biden’s diagnosis. What does it mean to have Stage IV prostate cancer and a Gleason score of 9? News outlets have reported that Mr. Biden’s previous prostate screening test was in 2014. How often should men be tested for this common cancer? What does the PSA (prostate specific antigen) test really tell us? How You Can Listen: You could listen through your local public radio station or get the live stream on Saturday, Aug. 2, 2025, at 7 am EDT on your computer or smart phone (wunc.org).  Here is a link so you can find which stations carry our broadcast. If you can’t listen to the broadcast, you may wish to hear the podcast later. You can subscribe through your favorite podcast provider, download the mp3 using the link at the bottom of the page, or listen to the stream on this post starting on Aug. 4, 2025. How Do We Detect Prostate Cancer? Prostate cancer affects one man out of every eight in the course of a lifetime. Fortunately, if it is caught early and treated appropriately, most men do not die of this disease. They die of something else, even if they may still have prostate cancer cells. For years, the mainstay of prostate cancer screening has been the level of PSA, prostate specific antigen. Although it is specific to prostate, it is not really specific to prostate cancer. All prostate cells make it, so doctors watch for unusual increases in PSA. That suggests a rapid growth of the prostate, which could be caused by prostate cancer. Not every prostate cancer produces large amounts of PSA, though. That’s why urologists watch for changes rather than using a threshold number. Men with a family history of prostate cancer are at higher risk for developing it themselves. Ideally, they would start screening at a younger age and possibly have it done more frequently. In men who have a limited life expectancy, doctors may not recommend prostate screening. PSA alone is just the first step. If PSA is elevated or if it is rising, men will need further workup. What Is Next to Overcome Prostate Cancer? Often the next step is imaging. Magnetic resonance imaging of the prostate can be very informative. If there is a suspicious area on the MRI, the doctor will schedule a biopsy. Current practice is to use the MRI and ultrasound to guide the biopsy, so that the tissue examined is from the area thought to harbor the tumor. Grading the Tumor: The tissue removed during the biopsy will be examined by a pathologist. That expert will use the characteristics of the cells in the tissue to assign it a Gleason score. These range from 6 (not very worrisome) to 10 (the most aggressive). Former President Biden’s cancer had a Gleason score of 9, which is serious. Doctors also want to know if the tumor has spread beyond the prostate gland itself. To find out, they may conduct a PSMA PET scan. This picks up prostate-specific membrane antigen (hence PSMA) wherever it may be in the body. Stage IV, like former President Joe Biden’s cancer, has spread outside the prostate to other parts of the body. In his case, the cancer has metastasized to his bones. In some cases, prostate tissue will be sent for genetic testing. BRCA2 is associated with breast and ovarian cancers, but men who carry this gene are more vulnerable to prostate cancer as well. Approaches to Preventing Prostate Cancer: The risk of prostate cancer appears to be roughly half hereditary and half environmental. That means there are things that men can do to reduce their risk. Avoiding environmental toxins is crucial. Plastics and plasticizers don’t belong in our food or our bodies. Diet matters, of course. Not everyone loves broccoli, Brussels sprouts, cabbage and cauliflower, but getting plenty of these cruciferous vegetables can help reduce the risk of prostate cancer. Another important step is to focus on exercise. Not only can regular vigorous physical activity reduce the chance of developing prostate cancer, it also is very useful in counteracting the side effects of the powerful drugs used to overcome prostate cancer. Options for Treating Prostate Cancer: Blocking Testosterone: Often the doctor prescribes leuprolide (Lupron) to shut down testosterone production. That part of the protocol is referred to as “androgen deprivation therapy” or ADT for short. An even more powerful androgen blocker such as abiraterone (Zytiga), apalutamide (Erleada), darolutamide (Nubeqa) and enzalutamide (Xtandi) may be added. These drugs can help men overcome prostate cancer, which seems to thrive on testosterone. Blocking the androgen receptors with one of these medicines has made treatment for prostate cancer more effective. Androgen blockers stop testosterone formation even further and thus discourage the growth of the cancer. That’s the benefit. The downside is that men suffer the effects of “low T.” Here is where exercise stars, helping men feel better even when their testosterone levels are nonexistent. Other Treatments for Prostate Cancer: There are nonhormonal approaches to treating prostate cancer that may be used in conjunction with androgen blocking or in some cases independently. One is surgery, in which the prostate is removed. That used to be the standard treatment. With new approaches available, it is one option among many. Another is radiation. Dr. Armstrong describes some of the different types of radiation, which can be very effective when used together with androgen blocking medication. There are also immune therapies. One exciting new therapy, called Pluvicto uses radioligands that seek out and attach to PSMA. Because it can find prostate cancer cells wherever they are in the body, it is being considered for treating metastatic prostate cancer when ADT may no longer be working well. What to Know to Overcome Prostate Cancer: Dr. Armstrong wants men to know that prostate cancer can be detected early; when it is, it is often curable. Even in the case of advanced disease, there is hope. He urges men to ask for second opinions on treatment and take advantage of a multidisciplinary team when possible. Above all, he says: “The good news is that treatment can extend life often dramatically, and that many men, most men in fact with prostate cancer, don’t die of prostate cancer. They die of other stuff.” This Week’s Guest: Andrew J Armstrong, MD, ScM, FACP, is Professor of Medicine, Surgery, Pharmacology and Cancer Biology at Duke University. He is Director of Research at the Duke Cancer Institute Center for Prostate and Urologic Cancers. His appointments are in the Division of Medical Oncology in the Departments of Medicine and Urology at Duke University. Dr. Armstrong is one of the country’s leading prostate cancer researchers. Andrew Armstrong, MD, Professor of Medicine, Surgery, Pharmacology and Cancer Biology at Duke University. Listen to the Podcast: The podcast of this program will be available Monday, August 4, 2025, after broadcast on August 2. In this week’s podcast, Dr. Armstrong describes how to find trustworthy information online. We discuss diet, exercise and natural approaches that can be helpful in preventing and recovering from prostate cancer treatment. When will medical centers recognize the value of personalized, structured exercise for cancer rehab, as they already do for cardiac rehab? You can stream the show from this site and download the podcast for free, or you can find it on your favorite platform. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.