This week, Dr. Sydney Spiesel discusses a potential link between smaller elementary school class sizes and better health, a safer way to give painkillers, and treatments for ADHD.
Smaller classes, better health?
Question: An extraordinarily provocative article in this month's American Journal of Public Health ties together two seemingly unrelated phenomena: the size of school classes and the health of students. Could smaller class sizes be a good investment not only for educational reasons but for medical ones?
New study: Peter Muennigof the Columbia University School of Public Health and Stephen Woolf of Virginia Commonwealth University in Richmond drew their data from Project STAR, which began in 1985 and randomly assigned almost 12,000 Tennessee kids to classes of different sizes in kindergarten through third grade. Some of the kids were in classes of 22 to 25 students, and others were in classes of 13 to 17 students. Teachers were also randomly assigned. The children were then tracked to determine the effect of class size on educational attainment.
Model: The educational effects were considerable. Now Muennig and Woolf are making use of the findings in a whole new way. They used Project STAR's statistics about educational attainment to build a computer model of a hypothetical group of 5-year-olds exposed for four years to small classes (of 13 to 17) and then followed until the age of 65. The researchers calculated projected earnings, welfare payments, and crime costs based on what we know about the relationship between these outcomes and educational attainment. They also drew on statistics relating degree of education to quality-of-life scores and age-specific mortality. And they accounted for the cost of maintaining smaller class sizes.
Findings: Based on their model, the authors project that reductions in class size would generate a lifetime net cash return of almost $200,000 (presumably in the form of taxes collected) for each additional low-income student who graduates from high school as a result of early placement in a small class. In addition, they project that four years of small classroom size will lead to improvement in health and longevity. These benefits, they calculated, would on average add up to the equivalent of an additional 1¾ years of life in perfect health.
Conclusion: It's important to point out that these numbers are based heavily on assumptions that might not hold true for the future or for places outside Tennessee (kudos, by the way, to that state for supporting this bold experiment). But these are plausible assumptions, at least. And the numbers they generate are astonishing, because they suggest that investment in reducing elementary school classes is better, in cost-benefit terms, than money spent on antibiotics, or hospital buildings, or even vaccines (long thought to be one of the most cost-effective interventions for health care). Perhaps I would do better for my patients if I gave up pediatrics and became a member of my local school board.
How to give more morphine for pain relief
Question: Do the risks of using narcotics to help chronically ill people with pain outweigh the benefits? Morphine, a natural opioid made from the unusually beautiful opium poppy, is a tremendously powerful painkiller. It's much better for almost every medical use than, say, Demerol. But when given in a high dose to a patient who has not been previously exposed, morphine is likely to cause respiratory depression. A patient's drive to breathe dwindles, which can easily be lethal. Fears that this may happen can discourage doctors from prescribing adequate amounts of opioids to fully control a patient's pain.
Treatment: While initial treatment with an opioid carries a real risk of respiratory depression, repeated dosing creates tolerance. Patients become far less sensitive to respiratory depression, yet are still able to get the pain relief, as the medication dose is raised. However, many doctors are unaware of this transformation, and so don't give the larger doses needed to fully control pain in their chronically ill patients.
New study: A study of more than 1,300 hospice patients addresses the safety of larger morphine doses for chronic patients. Conducted by Dr. Russell K. Portenoy of Beth Israel Medical Center, New York City, and his colleagues in 13 different hospice centers, the study compared the survival of patients on relatively low morphine doses with patients whose doses had been pushed up, often to very high levels, to keep them as comfortable as possible at the end of life.
Findings: Portenoy's data show that high doses of morphine create only a tiny risk, if any at all, of premature death for a patient whose body has become accustomed to the medication. This study strongly supports the use of higher doses of opioids like morphine for pain control so that doctors can do a proper job of relieving suffering.
Conclusion: Doctors also keep painkiller doses low out of fear of inducing addiction. There is actually little basis for this kind of fear. In fact, it has been estimated that the risk of addiction generated by a doctor is less than one in 10,000. And yet painkillers are still withheld, especially in developing countries, where high-quality medications may be absolutely unavailable because of the fear of generating addiction. This is especially troubling with respect to morphine, a single effective dose of which in a developing country could cost as little as 1 cent.
Condition: If you're ever looking for a fight, just say ADHD at a cocktail party. One person will insist that it's a phony diagnosis that allows—maybe even encourages—poor behavior. Another person will say that her child has it and it's very real, and now the kid is getting treatment and can finally function in school. Then someone else will say, "How can you give those addicting, dangerous medicines to your kid?"
Question: So, what is ADHD, and should we even be treating it? The central issue in attention-deficit/hyperactivity disorder is an inadequate ability to concentrate attention, to focus. Some children with ADHD are mostly inattentive, other children are hyperactive and impulsive, and still other children are both hyperkinetic and poorly focused. The boundaries between these three subtypes are pretty fuzzy, as is the diagnosis, frankly. Still, about 5 percent of children worldwide are thought to be affected, and in the United States, a large majority of them are given medication. That's a lot of kids and a lot of medicine, which leads to a lot of concern that not all of it is as rational or thoughtful as it ought to be.
Recommendations: In response, a committee assembled by the American Academy of Child and Adolescent Psychiatry was charged with bringing some order to the diagnosis and rational management of ADHD. The committee's recently issued report (along with a distillation of its contents for parents) makes clear that ADHD is a real medical condition that often seriously impairs children's functioning. The cause remains unclear, though the report asserts a neurobiological mechanism. The report's greatest contribution is to lay out a series of guidelines that should lead to a more orderly and sensible evaluation and treatment.
New medications: Meanwhile, two new forms of slow-release stimulant medications for ADHD have recently gone on the market. Daytrana is a patch that is applied to the skin that feeds the medication in at a constant rate and stops fairly quickly after the patch is removed. Vyvanse is reported by some patients to be easier to tolerate than other stimulants, though other children don't find it particularly helpful. With any ADHD medications, getting the dose just right seems to be the most important factor.
Risks: In general, all the stimulants have similar (sometimes troublesome) side effects. One of the benefits of the slow-release versions is that they smooth out the seesaw changes children experience if they take several doses of the short-acting products. ADHD children who take stimulants aren't at greater risk for later substance abuse. (Actually, there is evidence that this treatment lessens the risk.) The risk of significant adverse medical effects is also extremely low.
Conclusion: Treatment can convert a child from a space cadet who hates school to an avid learner who loves school. It can change a child who is shunned by peers into one who is enthusiastically included. Doctors, parents, and teachers who witness this kind of transformation are rarely ambivalent about treating ADHD.