euthymiclabs's comments

This is not at all what the article says. The argument is that the current classifications don't work, and that consensual sex should never be considered paraphilic.

This funding campaign is questionable. Investors should have some access to profit and loss information before investing. I don't have a major problem with unaccredited investors jumping in and losing money, but I do think that they deserve at least minimal transparency.

I'm not far above the accredited investor line and have a few AngelList investments. They've always provided cash flow, burn rate, projected revenue goals, and how they plan to hit them. I know I can't perform due diligence and know I'll probably lose the 1-2% of my portfolio in angel investments, but I would run from any company that doesn't offer real information.

I'm a big fan of Substack and hope that I'm wrong. I just hope that trying to reach venture expectations doesn't tank what could be a fantastically lucrative SMB.

It's provocative in rats, but there's lessons from similar attempts that need to be considered. Cocaine-specific vaccines have been in development for years, and they haven't been successful. The biggest problem is that you need people to maintain an enormous concentration of antibodies against the drug so that even minute quantities are captured within seconds of entering the blood stream. Even if you can achieve an initial therapeutic levels, you need to constantly boost the vaccine to maintain high antibody titer. All of these attempts have targeted people with cocaine use disorder and are able to focus on shots every few weeks to months. We're nowhere close to developing something that would work as a routine preventative vaccination.

We do have a once a month injection of naltrexone that can block all opioids, which can be effective in the right person. A targeted approach to fentanyl alone would probably work in people who don't have an opioid use disorder (and therefore wouldn't be as prone to substitution with an alternative opioid). This is an interesting step, but our understanding of immunology is far too limited to make this realistic in the near term.

Maybe so, but I'm struggling to think of any trait that wouldn't moderate mental illness when manifest in its extreme.

I can't say enough good things about my induction cooktop. It's as responsive as gas, but puts out more power than a home gas stove. Plus, it's incredibly easy to clean. Love it.

Which is how people think clinically. Schizophrenia spectrum disorders are the most common forms of lasting psychosis. Psychopathy isn't related.

Correct, dehydration-related complications are possible during opioid withdrawal, and I agree that it's hard to put a number on cases. The other significant risk is suicidality, which is very common during opioid withdrawal. In general, I tend not to recommend full, rapid, medically-supervised (or unsupervised) withdrawal from opioids, as the best option for most people is a transition to opioid agonist therapy with buprenorphine or methadone--which have profound mortality benefits. There are always exceptions--especially in people who prefer antagonist therapy with long-acting injectable naltrexone--but agonist therapy has the most data.

Psychiatrist here. This is true, and most people find recovery eventually without a formal program. Working with a doctor can make it much less comfortable in many cases--and in the case of opioids, can offer several options that can be lifesaving by preventing return to use and overdose.

Agreed. This paper https://www.nejm.org/doi/10.1056/NEJMra1602872 (which isn't available open access, unfortunately) argues that the brain changes in substance use are more likely normal learning associated with very strong stimuli than actual disease processes. I find this to be a more helpful, optimistic, and accurate interpretation of the data than the disease model. (And it really complements the other evidence-based interventions for substance use disorders we have!)

Psychiatrist (and addiction psychiatrist in training) here. I agree that calling substance use disorders a disease is highly problematic. However, I think that while the majority of people who use substances don't have a problem, there are many people who use substances in a maladaptive (or disordered) way that dramatically impacts their ability to function, and we need a name to describe that. Substance use disorder is a pretty neutral term, and much better than the older "abuse" and "dependence" terminology for a number of reasons. The wording isn't intended to suggest that personal responsibility isn't required--and any treating clinician would quash that idea right away. It's a way to describe patterns and determine what might be helpful for an individual. It's certainly imperfect, but a much better description than past nomenclature.

More accurately, I might say it's a protestant Christian app, whereas Mormonism considers itself restoration Christianity and may not fit as well here.

Saw this on 3/31, and got really nervous for a moment that I'd have to pay to copy and paste. (I tend to only copy and paste syntax that I can't remember. Anything more complex tends to be risky.)

Modern psychology is heavily driven by both theory and empiric techniques. The theories themselves are rich and generally cohesive, but without empirical validation, they are essentially bare philosophy. Of course they aren't as water tight as the theories and observations of physics, but if you spend any time in the core psychological literature, you'll find a ton of theoretical work.

Agreed. Blind trust is always a serious risk.

In psychiatry, we've thankfully replaced the term "Munchausen syndrome by proxy" with the much more accurate "medical child abuse." Parents hurting children by creating medical illness is an important problem to monitor for--not a medical disease.

I'm not sure recruiters are that malignant. But understanding their role, their incentives, and what you can rationally do about this is an important discussion.

Love this! I was just trying to search for studies on weight gain in a very uncommon medication. I'll have to pester my institution about this.

I'm really excited about this. United States policy has typically been more restrictive of addiction treatment than to much more dangerous medical practice.

For example, on day one of residency, I was allowed to prescribe unlimited quantities of intravenous opioids to people with no additional training. Those were DEA schedule 2 substances--the classification that is deemed most dangerous but which may have appropriate medical use. This classification includes fentanyl, oxycodone, hydromorphone, methamphetamine, and even intranasal cocaine.

But to provide a life-saving treatment for opioid use disorder with a schedule 3 substance like buprenorphine (which by definition would be considered less dangerous than fentanyl or hydromorphone[1]), I had to have an additional 8 hours of training and other reporting requirements that wouldn't be required to run an opioid pill mill.

Buprenorphine isn't perfect, and it isn't for everyone. But the molecule itself is generally safer than alternatives like methadone[2]. It's made a huge difference to so many of my patients. (That's just anecdote: mortality studies suggest it reduces overdose deaths by 70% and all-cause mortality by 55% [3]. That's much larger than almost any other treatment for a chronic disorder in medicine).

---

[1] The scheduling system is a little silly. Schedule 1 substances have no approved clinical use, and so things that are highly unlikely to kill people like marijuana are rated as higher risk. But schedules 2-5 are in a very rough rank-order of risk when misused.

[2] The way methadone is regulated may make it's mortality benefit better than buprenorphine despite it being a riskier substance. Initial dosing is in-person 6-days per week for at least three month, and then incentives allow people to bring home more doses with continue success in recovery.

[3] https://pubmed.ncbi.nlm.nih.gov/28446428/

Note that "antidepressant" is largely a marketing term. The drug in particular is fluvoxamine, a potent selective serotonin reuptake inhibitor (SSRI). This doesn't mean that other antidepressants will work (if fluvoxamine really does work in larger trials).

Believe it or not, fluvoxamine isn't even approved by the FDA for depression. It probably works, but it's only labeled for OCD (https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/02...). Usually, we'll preserve it for more refractory cases of OCD since it tends to have more side effects and interactions than other SSRIs.

Not surprising, unfortunately. Our "call room" in one hospital during residency was a utility closet. There are mandates of what to do, but hospitals routinely ignore them. Who will report problems? No resident wants to have their program lose accreditation.

Our program director (in psychiatry) always pointed out that psychiatry had one of the highest rates of people going over the 80 hour-per-week limit in the health system. It was much more uncommon for us than for most of our colleagues, but we tended to report it on the rare occasion it happened. My surgical colleagues who went over the limit were asked to meet with their program director when it happened, and it was much easier just to "round down."

Glad I did a residency, but mine was relatively easy. I probably wouldn't have made it through some programs.

This really isn't true. (Source: I'm a psychiatrist who treats some forms of chronic pain, while also treating people with opioid use disorder who started with prescription pills).

Good psychotherapy for chronic pain explicitly acknowledges that pain is real and not just in the patient's head. Chronic pain is thought (at a grossly oversimplified level) to be due to nerve sensitization rather than acute trauma, but experience, co-morbid health problems, and life stressors all interact to influence this.

Psychotherapy for chronic pain helps people identify maladaptive behaviors that could be worsening chronic pain, and then help to set goals and learn skills to improve their overall function. On average, it's only modestly effective, but it's better than many alternatives.

Some people might say that opioids are a placebo. A more nuanced statement would be that most trials can't distinguish between opioids and placebo for chronic pain. That doesn't necessarily mean they don't work for an individual, it just means that it's an intervention based upon low-quality evidence. On the other hand, opioids come with significant (and occasionally catastrophic) risks, and so the decision to pursue a high-risk/low-benefit treatment is discouraged. There are always exceptions, but I've been really pleased with the results I've seen as we've moved further away from opioids for chronic non-cancer pain.