Pain is an important warning signal, helping you protect your body from damage. That’s why we can view acute pain as an asset. Chronic pain, though, can be debilitating. In this episode, a pain psychologist offers a roadmap for managing chronic pain. 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 EST on Saturday, June 13, 2026, through 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 June 15, 2026. Managing Chronic Pain Nobody likes feeling pain. Joe remembers that as a child, he would ask the doctors and nurses if the procedure was going to hurt. They always lied and told him it would not. As a result, he ended up not trusting them. We often think of pain as located in the body part that hurts (hence, tell me where it hurts). In actuality, though, pain is a complex phenomenon the brain and its interpretation of the situation at least as much as the body. That is why Dr. Rachel Zoffness maintains that pain is biopsychosocial–the result of three overlapping circles in a Venn diagram: biological, psychological and sociological. The biological circle includes our genetics, tissue damage, diet, sleep and movement. Psychological factors are never just psychological. The brain uses the same limbic system to process emotions and pain, so our feelings about our situation have a major impact on our pain experience. In the sociological realm, we find access to care, a history of trauma, and factors like racism or poverty. One result is that pain is incredibly subjective, varying from one individual to another and even from day to day. Another example of the power of the brain to generate pain is phantom limb pain. You may have heard of someone whose foot hurts even though the leg was amputated. Dr. Zoffness tells us about a boy with hand pain after a fireworks accident that resulted in his arm being amputated. The hand wasn’t there, but the pain was real. What Is Your Pain Recipe? In managing chronic pain, it helps to know what your pain recipe is. What factors contribute to a bad pain day? A few common ones are poor sleep, too much junk in the diet, lots of stress, too little movement. Once you have the recipe for a bad pain day, you may be able to turn that around to find the recipe for a low pain day. If you get enough sleep, does that turn down the pain dial? How about diet? We also discuss the power of self-hypnosis and biofeedback. If you can practice warming your hands up, as Dr. Zoffness has learned to do, you can also practice making yourself more comfortable. She shares another story of a teenager who suffered from crippling migraines, social anxiety and generalized body pain. He had not been to school in years, but taking very small steps at first–just standing in the sun on his front porch–he was gradually able to build himself a low-pain recipe. Taking the dog to the dog park helped him move his body and his brain started producing chemicals like dopamine and serotonin. Eventually Sam was able to return to high school, even graduating. Using Pain Medicines in Managing Chronic Pain Physicians have often learned that managing chronic pain is something of a prescription puzzle. Which drug will work best for this patient? A decade or more ago, the answer was frequently opioids. That’s no longer the case. As a result of the overdose epidemic, doctors usually try to prescribe some other type of medication. Two of the most popular are gabapentin and tramadol. When our listeners tell us about their experience with gabapentin, the results range widely. For some people, it seems to be a life-changing medication. For many others, it is lackluster at best, and for some, the side effects of brain fog, dizziness, breathing problems, edema and an increased risk of dementia are too much. Dr. Zoffness has heard similar reports about gabapentin. Her guideline for pain medicine is to try it for three months and see if it makes a (positive) difference. If not, ask the prescriber to help you taper off. Stopping any pain medicine suddenly could be a mistake. For managing chronic pain, people need a healthcare professional who can help them create a personalized pain management plan. For improving sleep, which is often a key ingredient in the pain recipe, she recommends cognitive behavioral therapy for insomnia (CBTI). The sleep hygiene protocol she suggests can also be helpful, dimming lights and gearing down as the day comes to a close. The Roadmap for Managing Chronic Pain The last section of Dr. Zoffness’s book is a detailed pain protocol. She reminds us that there is no quick hack for pain. If trauma is part of the pain recipe, addressing the trauma will be useful. Medications are important tools, but they are not a permanent fix for chronic pain. She wants us all to remember that if the brain can change, pain can change. It is in our power. This Week’s Guest Dr. Rachel Zoffness is a leading global pain expert, pain psychologist, speaker, author, and thought leader in pain medicine. She is faculty at the UCSF School of Medicine, teaches pain science at Stanford, and is a winner of the prestigious Mayday Fellowship. Dr. Zoffness is the author of Tell Me Where It Hurts: The New Science of Pain and How to Heal. Her website is www.zoffness.com Dr. Rachel Zoffness, pain expert at UCSF 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, June 15, 2026, after broadcast on June 13. 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.

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 may have heard this interview when it was first broadcast on Saturday, Sept. 27, 2025. If you did not, you can download the mp3 using the link at the bottom of the page, or listen to the stream on this post by clicking on the little triangle in the green circle. We have added extra information to these notes, but not to the interview itself. 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. Wait–MEN Can Get Osteoporosis? Q. My husband and I have two friends with significant disability largely due to spinal fractures as a result of osteoporosis. One man was always an avid exerciser, including running marathons. Both men are over six feet tall and have always appeared to be muscular. My husband is shorter and is physically active, playing tennis and going to the gym regularly. Because of our friends’ bone issues, I advised him to request a DXA scan to assess his bone health. The nurse practitioner told him that it was not recommended for men. I am still concerned that he may be at risk for osteoporosis. Are there medical studies that determine the risk factors for men? A. The nurse practitioner was mistaken. Men can develop osteoporosis, as your friends discovered. Many medical guidelines recommend that men over 70 be tested with a DXA scan to assess bone health. If your husband has low testosterone levels or has taken medications such as prednisone, he could be at increased risk for a fracture. He would be prudent to have the assessment. 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.

You may think of allergies as causing sniffly noses and congestion in the spring or fall. But allergies can go far beyond that. As Dr. Kari Nadeau points out in this episode, allergies can affect us from head to toe, including eyes, nose, throat, lungs, sinuses, skin and gut. In the most dangerous instances, the whole body is threatened with an anaphylactic reaction. That’s a medical emergency! One in three Americans will develop allergies at some point in our lives, so it’s important to know what works to control them. 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 EST on Saturday, June 6, 2026, through your computer or smart phone (wunc.org). Here is a link so you can find which stations carry our broadcast. (Welcome, Huntsville, Alabama!) 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 June 8, 2026. What Are Allergies? We begin our discussion of your allergy survival guide with an explanation of what is happening during an allergic reaction. The immune system perceives some foreign compound, usually a protein, as dangerous even though normally it would not be. So it reacts by trying to flush the invader out by producing extra mucus. The turbinate sinuses can make one to two gallons of mucus a day, and naturally, it has to go somewhere. That’s why you might be congested. Having all that mucus in the sinuses can also encourage bacterial growth, so if the allergic reaction persists, some people have to deal with sinus infections. Emergency Treatment In determining what works, you need to know the nature of the reaction. If you have two or more organs involved, if you are having trouble breathing or if you feel dizzy, you may be in the midst of an anaphylactic reaction. What works for that is an epinephrine injection and immediate medical attention. This is potentially life-threatening, so you will want to figure out what triggered the reaction so you can avoid it in the future. Once someone has suffered one anaphylactic reaction, they should keep epinephrine with them at all times in case of another episode. Epinephrine comes as a self-injector pen or a nasal spray (neffy). Can You Spot Drug Allergies? In the warnings that are rattled off as part of a TV ad for a pricey new drug, we often hear viewers cautioned not to take the medicine if they are allergic to it. That sounds like simple common sense, but it also has a Catch 22 quality. How do you know you are allergic to a medication unless you take it–and experience an allergic reaction for which you might need treatment. Most of these presumably are immune system-mediated reactions, in which the body produces IgE. That is how allergies to penicillin or sulfa drugs work. Some drugs cause a different type of reaction, not IgE-mediated but dangerous nonetheless. Lisinopril is the most commonly prescribed blood pressure medicine in this country. Like other ACE (ACE is short for angiotensin-converting enzyme) inhibitor medications, lisinopril can trigger angioedema. This swelling can affect the face, lips, tongue and throat, where it can compromise breathing. The most insidious aspect of this reaction is that it can occur after the person has been taking the drug without problems for weeks, months or even years. “Red man syndrome” or infusion reactions in people taking vancomycin can likewise occur without warning. The last type of drug reaction is not actually an allergy at all, although people occasionally use that terminology. It is better described as sensitivity. For example, a stomachache is a common reaction to the antibiotic erythromycin. Some people are disabled by this abdominal pain and try to limit their exposure to erythromycin thereafter. What Works and What Doesn’t? Since the immune system is acting inappropriately to cause allergic reactions, treatment should involve immunotherapy. Eye drops can help eyes feel less itchy and irritated. Likewise, OTC nose drops or nasal sprays can often help the nose. The corticosteroid Flonase (fluticasone) and the antihistamine Astepro (azelastine) are good examples. During allergy season, some people find that a daily nasal wash (with a neti pot or NeilMed device) can help reduce the mucus and remove the allergens such as pollen causing the reaction. There are also oral antihistamines and inhalers for asthma. For decades now, allergists have offered their patients shots to help desensitize them to the allergen causing their trouble. Joe had these as a child and teenager and has been largely free of allergies since. Not everyone gets such lasting relief. Complications from Current Therapies Medications have side effects, and that is true of allergy medicines as with other drugs. Antihistamines, especially the older ones like Benadryl (diphenhydramine), are notorious for causing drowsiness. That’s one reason it is often included in nighttime pain relievers as the “PM” in drugs like Advil PM. We worry about regular use of such antihistamines because it has been linked to a greater risk for dementia. A second-generation antihistamine such as Allegra (fexofenadine) is much less likely to make someone feel sleepy. However, Dr. Nadeau has seen patients on antihistamines suffer worse allergies if they stop suddenly. The People’s Pharmacy has received hundreds of reports from people who experienced unbearable itching upon discontinuing Zyrtec (cetirizine) or Xyzal (levocetirizine). This can last for weeks. Doctors don’t usually worry much about steroid nasal sprays like Flonase because they are topical. Presumably, nasal tissues pick up most of the dose. Just the same, using such a nose spray day after day for a long time could result in systemic steroid exposure that is not trivial. Stronger Medicine Dr. Nadeau is enthusiastic about the benefits of two potent prescription medicines. One is Xolair (omalizumab). It was originally developed to prevent asthma, but is now approved for chronic sinusitis, food allergies and chronic hives. Paradoxically, Xolair is one of those medicines that could cause a severe allergic reaction even on the first dose, so the FDA warns that the initial injection should be given in a healthcare setting prepared to treat anaphylaxis. This is uncommon, though, occurring in 0.1 to 0.2% of patients. The other medication Dr. Nadeau is prescribing for allergy patients who don’t respond well to other treatments is Dupixent (dupilumab). The FDA has approved this medicine to treat a wide range of conditions, including eczema, asthma, chronic sinusitis, allergic reactions affecting the esophagus and chronic hives, among other things. Most insurance companies will not cover this pricey injection unless the patient has failed all other therapies. Fighting Air Pollution: What Works Air pollution makes allergy symptoms worse, so using an effective air filter inside the home is a good step. A HEPA (high-efficiency particulate-arresting) filter is ideal, especially as part of the air-handling system. If that’s not possible, utilizing a MERV 13 in the part of the home where you spend the most time is a good second choice. Sonu One new option for treating allergies is acoustic resonance therapy with the SoundHealth Sonu headband. It uses vibration from sound to loosen mucus from the sinuses so that they can clear. The FDA has approved its use for children as well as adults. New research was just published demonstrating its helpfulness in treating children with nasal congestion (Oto-Open, April-June 2026). SoundHealth has underwritten The People’s Pharmacy podcast. Dr. Nadeau has also been compensated for her role in conducting studies of this device (International Forum of Allergy & Rhinology, Dec. 2025). Since it does not employ medications, there are no drug side effects. This Week’s Guest Kari C. Nadeau, M.D., Ph.D., is Dean of the UCLA Fielding School of Public Health ( starting July 1 2026). Until then, she holds many other positions. At Harvard T. H. Chan School of Public Health she is: John Rock Professor of Climate and Population Studies; Chair of the Department of Environmental Health; and Director of the Allergy, Extreme Weather, and Exposomics Lab. Dr. Nadeau is Professor of Medicine at Harvard Medical School and serves in the Division of Allergy and Inflammation at Beth Israel Deaconess Medical Center. She is an Adjunct Professor at Stanford Medical School. Dr. Nadeau is also the co-author of The End of Food Allergy, which provides strategies for treating and preventing food allergies in children. Here is a link to the research underway in her Harvard laboratory. PHOTO CREDIT: STACY GEIKENTaken in April 2017 at Kari Nadeau’s professorship dinner The End of Food Allergy: The Science-Based Plan That Turns Food into Medicine 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, June 8, 2026, after broadcast on June 6. You can stream the show from this site and download the podcast for free. This episode has additional information about Nasalcrom (cromolyn sodium nasal spray) and its effect on mast cells; alpha gal allergy to red meat; and the latest thinking on preventing peanut allergy among young children. Download the mp3, or listen to the podcast on Apple Podcasts or Spotify.

Over the years, we have spoken with scores of healthcare experts about chronic illness. Many of them attribute the problems to inflammation, which is after all a natural response to infection or injury. But not everyone has a system for locating and addressing the source of the inflammation. If you want to treat the cause, not just the symptoms of your disease, you might want to consider functional medicine. 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 EST on Saturday, May 30, 2026, through 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 June 1, 2026. What Is Functional Medicine? Many people have heard of integrative medicine. We asked our guest, Dr. Susan Payrovi, how this differs from functional medicine. (She practices both.) According to Dr. Payrovi, while both approaches embrace lifestyle therapies, integrative medicine may focus on individual organ systems, just as conventional medicine does. Functional medicine, on the other hand, is more likely to focus on how the body works. What functional systems are involved when a person experiences fatigue, for example? If there is a problem with the way the body produces energy, how could that be resolved? If you are dealing with a problem caused by underlying inflammation, you could prescribe a potent anti-inflammatory or even a medicine that counteracts the immune system’s response to danger by blocking interleukins, for example. Or you could search upstream for the disturbance that is causing the immune system to overreact. Going upstream to find the cause is the functional medicine approach. Sending the Body Safety Signals If inflammation is a response to a danger signal, how can we let the immune system know that the body is safe? Lifestyle therapies offer some powerful interventions, even though they may sound very ordinary. Getting adequate sleep can make a huge difference for the immune system and lower inflammation dramatically. Stress management is another potent non-pharmaceutical approach. Consuming a diet rich in anti-inflammatory foods or even medicinal herbs could also contribute to a sense of safety and reduced inflammation. The Silo Problem of Modern Medicine We have spoken with many people who have struggled with a disease that manifests in multiple symptoms. They end up seeing a variety of specialists who don’t seem to communicate with each other. NO tool manages every condition. Too often, specialists pay attention only to the specific organ that they are assigned, and as a result, nobody puts the big picture together for a long time. The hope is that functional medicine would do a much better job for such patients, including those whose suffering has an emotional, psychological or spiritual aspect. Functional Medicine and Chronic Fatigue Syndrome One example where patients are demanding more of their medical care is chronic fatigue syndrome. Conventional medicine has a notoriously difficult time treating such patients. Coaching patients on small but important lifestyle changes is one approach that functional medicine can offer. Pacing and learning to prioritize are vital skills for such patients. Dr. Payrovi learned a lot about the value of such approaches in dealing with her own illness, multiple sclerosis. Finding a Functional Medicine Practitioner People looking for a functional medicine practitioner can consult the Institute for Functional Medicine. The organization lists practitioners on its website, ifm.org. So does the Academy of Integrative Health and Medicine, aihm.org. This Week’s Guest Susan Payrovi, MD, is a physician practicing Integrative and Functional Medicine at Stanford’s Center for Integrative Medicine. Dr. Payrovi is board certified in Anesthesiology, Hospice and Palliative Medicine, as well as Integrative Medicine. She has additional training in Functional Medicine and acupuncture. https://med.stanford.edu/profiles/susan-payrovi. Her website is drsusanpayrovi.com. Susan Payrovi, MD Listen to the Podcast The podcast of this program will be available Monday, June 1, 2026, after broadcast on May 30. 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.

What do you conjure up when you think of music? Perhaps you imagine a singer-songwriter telling her story. On the other hand, you might imagine a parade with a marching band, an orchestra playing an outdoor concert or a mother singing her baby to sleep with a lullaby. Regardless of the format, music acts on the brain in unique ways. Neuroscientists are learning how music heals and why healers around the world have integrated music into their rituals for millennia. 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 EST on Saturday, May 23, 2026, through 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 May 25, 2026. How Music Heals Dr.Elizabeth Margulis directs the Music Cognition Laboratory at Princeton University. This scientific endeavor is devoted to understanding how our brains react to music. One discovery is that music has a lot in common with infant-directed speech. It is highly repetitive with exaggerated pitch modulation. When people talk to babies, they may slow their words down a bit and raise the pitch of their voices. All of these properties make infant-directed speech a lot more like music than the rest of our everyday utterances. Caregivers around the world adopt this sort of “baby-talk” because babies pay attention longer when they do. Is music tapping into the same primal brain responses? Another characteristic of music is that it can trigger emotional responses. These are culturally conditioned; bagpipes do not have the same effects as Tibetan singing bowls. Howe er, the reminiscence triggered by music can be remarkably complete, putting us back in time not only to the place where we heard it before, but even to the bodily sensations that we experienced at that moment. Musical memories are exceptionally persistent. Older people with dementia who can no longer remember important facts about their own lives can often join in singing a popular song from their youth. The Downsides of Music Music may have social and political ramifications. Just imagine a chorus singing “We shall overcome,” and you will probably make assumptions about the singers and their values. As a result, we should not be surprised to learn that people may fight over music. Frequently entire generations have genre preferences such as hip hop or rock that are not shared by adjacent generations. How do we approach the music we love to hate? Can we understand how music heals even if we don’t like it very much or at all? Musical Daydreams Help Us Understand How Music Heals Dr. Margulis has studied and written about musical daydreams. What does she mean by this? As you watch a movie, you may appreciate the score. But even if you don’t notice it at all, the sound track influences how you understand the action on the screen. Likewise, when most people listen to a piece of music, they may create a visual to go with it. Dr. Margulis offers us an example of a snippet of music by Liszt that evokes for many people an image of a cartoon cat chasing a cartoon mouse. Needless to say, that is not what Liszt was thinking when he composed it, since cartoons did not exist at the time. Choosing Music for Healing Joe mentioned the unobtrusive but soothing music playing in the background when he has an acupuncture treatment. Dr. Margulis suggested that music activates motor areas of the brain, and that might help explain the benefit in this setting. We are still learning more about how music heals. This research may some day guide healthcare professionals in choosing music for their practices, even in the hospital. This Week’s Guest Elizabeth Margulis,PhD, is Professor and Acting Chair in the Department of Music, with affiliations in Psychology and Neuroscience. Dr. Margulis directs the Music Cognition Lab at Princeton University. Her research pursues questions that lie at the intersection of the humanities and the sciences. She was also trained as a pianist. Her most recent book is Transported: The Everyday Magic of Musical Daydreams. Her website is https://www.elizabethmargulis.com/about This link takes you to the publisher’s page. Elizabeth Margulis, PhD, Princeton University 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, May 25, 2026, after broadcast on May 23. 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.

In this episode, a renowned neurosurgeon shares what he has learned in decades of working to restore ailing brains. His new book covers a vast range of neuroscience. Our dilemma was what to pay attention to in all those options. In a sense, that is always the human situation. We are capable of conscious processing of approximately 200 bits per second (bps) of information. Our unconscious brain deals with as much as 11 million bps. 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 Saturday, May 16, 2026, 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 May 18, 2026. (This show originally aired April 25, 2025.) The Power of the Unconscious Brain Our senses feed us a tremendous amount of information all the time, but we don’t have the bandwidth to pay attention to more than a small fraction of it. That’s where the unconscious brain is so valuable, juggling millions of bits of information while we focus our conscious attention on what seems important. One surprising outcome of the research on how our brains function is a re-assessment of what is going on when people are unconscious. For centuries, doctors thought there was really no brain activity while a person was comatose. Then, a few decades ago, a scientist was recording the brain waves of a patient in a coma. The activity was very peculiar, as if the person were watching a ball being lobbed back and forth across a tennis court. In actuality, a television set in the room was broadcasting a world championship match between Roger Federer and Rafael Nadal. The neuroscientist recognized that this individual was following the match and was not nearly as deeply unconscious as had been thought. Further research showed that this kind of unconscious brain activity is not uncommon. It may hold keys to determining who has the best potential for recovering from their coma. Freud and the Unconscious Brain If you hear the term the unconscious mind, you may think of Sigmund Freud. He really popularized the concept that some very important brain activity takes place outside of our conscious awareness. It still has a powerful influence on our behavior. By the way, if we recognize that our conscious attention is indeed a limited resource (200 bps, remember), we won’t try to multitask. Humans actually aren’t very good at multitasking; instead, we switch our attention from one thing to another. Some people can do that fairly easily, but for most of us, it is less effective than staying focused. Three Stages of Brain Development Evolution likes to build on what it’s already got in place, so it shouldn’t surprise us that we can track three different evolutionary stages to our human brains. The reptilian brain came first, of course, and is there as a base, operating mostly on reflex. It’s definitely an important part of the unconscious brain. The mammalian brain brings in emotions. The hormone oxytocin is relevant for this discussion. It is critical for birthing and nursing young. As it turns out, oxytocin can also be put to other uses, such as bonding mates together and creating friends. Finally, we have the primate part of our brain. We humans, like other primates, can exercise empathy because our mirror neurons allow us to relate to another creature’s experience. In fact, mirror neurons were discovered by scientists studying macaques and eating gelato. Listen for a great story! Speaking of empathy, we wondered about empathy fatigue. We started hearing about empathy fatigue during the COVID pandemic, when healthcare providers were overwhelmed by extreme demands with inadequate support. Research shows that “constant, repetitive exposure to the pain of others leads to empathy fatigue.” Lack of empathy can lead people to do terrible things. Wonders of the Unconscious Brain Our brains are full of clocks. To some extent, these are shaped by how we use them. Musicians who play percussion instruments can perceive time differences of just a few hundredths of a second. All of us are entrained to a 24-hour a day cycle, whether we observe sunrise and sunset or not. But if we are deprived of connection with that cycle, our internal clocks can’t keep good time, and our brains may get far off track. What About Premonitions? Some people think premonitions are a fantasy. Yet this is another area where our unconscious brain may be more capable than we imagine. Dr. Hamilton describes an experience in the Swiss Alps where he and his wife had a choice of which path to take down from the summit. One appeared to be a shortcut, and they did have some time constraints. But as soon as they had taken a few steps that direction, he had a premonition of something terrible. They took the other path and learned later that there had been a landslide on the shortcut that would have swept them helplessly down the mountain. According to Dr. Hamilton, some people have the ability to influence the output of random number generators. Those of us who can’t may wish to reject that idea, but it has been documented. The Princeton Engineering Anomalies Research lab has run many studies demonstrating an impact on random number generations, not to mention remote viewing. In this way, some of the hidden power of the unconscious brain appear as cerebral entanglements, analogous to quantum entanglements at the sub-atomic level of matter. This Week’s Guest Dr. Allan Hamilton, MD, FACS, is a neurosurgeon who has specialized in treating brain tumors. His extraordinary journey from janitor to Harvard-trained neurosurgeon is just the beginning of his remarkable story. A decorated Army veteran, he now holds four professorships at the University of Arizona and has been recognized as “One of the Leading Intellects of the Twenty-First Century.” As the only American honored with the Lars Leksell Award for pioneering scientific discovery in stereotactic neurosurgery, Dr. Hamilton’s groundbreaking work has revolutionized the field. He has had a life-long interest in the application of computer technologies to enhance surgical care and reduce avoidable medical adverse events. In addition, he has served on two White House Advisory Committees under two presidential administrations. Allan Hamilton, MD, FACS His expertise extends beyond medicine, having studied creative writing under Rod Serling and serving as a senior medical consultant for Grey’s Anatomy for nearly two decades. Dr. Hamilton’s seven non-fiction books have garnered numerous awards and international translations, offering insights that have inspired leaders across various fields. Dr. Hamilton’s 7th non-fiction book is Cerebral Entanglements: How the Brain Shapes Our Public and Private Lives. 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, April 28, 2025, after broadcast on April 26. 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.

Tick season is well underway in many parts of the country. It seems that a mild winter and a warm spring have brought the nymphs out seeking blood. If that blood is yours, you may be exposed to a range of pathogens. What’s more, ticks are not the only creatures ready to bite you. Fleas are an even bigger problem when it comes to transmitting bacteria called Bartonella. That genus is responsible for cat scratch disease and trench fever. When the infection goes chronic, it’s called bartonellosis. What are the dangers of flea and tick bites? 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 EST on Saturday, May 9, 2026, through 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 May 11, 2026. You can watch us interviewing Dr. Breitschwerdt on YouTube. The Hazards of Flea and Tick Bites Ticks can transmit a dizzying number of pathogens, including viruses, bacteria and protozoa. Rocky Mountain Spotted Fever, for example, occurs when a tick injects Rickettsia rickettsii into a person through a bite. If not treated properly, it can be fatal. Fortunately, however, it usually responds to doxycycline. The NCSU laboratory has developed a reliable diagnostic test that picks it up quickly. Another tick-borne disease that has become familiar over the last few decades is Lyme disease. It is carried by deer ticks infected with Borrelia burgdorferi. If treated promptly, most people clear the disease, but sometimes it morphs into a stealth infection that is quite controversial. You may not think much about flea bites, but they too could be the source of a stealth infection. Fleas transmit Bartonella (and so do body lice, ants, pigeon mites, rat mites and sand flies). Cats can be infected (with three different species of Bartonella) and so can dogs (only two species). When people develop bartonellosis, it can cause liver disease and neurological problems such as headaches and memory loss. In some cases, infected people suffer seizures. Preventing Flea and Tick Bites Once Bartonella get into the body, it likes to hide. The bacteria can enter virtually any cell in the body and make itself at home. As a consequence, the immune system may have difficulty tracking it down and eliminating it. Antibiotics don’t always get to it, either. Treatments of entrenched infections need to be very intensive. So it is better to prevent flea and tick bites. One way is to make sure that pets are protected. Veterinarians can prescribe preventive medicine for them, either oral or topical. Another important step is to protect yourself. Wear effective insect repellent when outside or cover your long pants with permethrin-treated gaiters. And absolutely do not skip the tick check when you come inside. If you find a tick that has bitten you, remove it with tweezers, seal it in a plastic bag, date the bag and put it in the refrigerator. That could provide useful identification if you begin to feel ill over the next several days. When the type of tick is identified, it helps to point the infectious disease expert in the correct direction for what condition you may have. This Week’s Guest Dr. Edward B. Breitschwerdt is a professor of medicine and infectious diseases at North Carolina State University College of Veterinary Medicine. He is also an adjunct professor of medicine at Duke University Medical Center, and a Diplomate, American College of Veterinary Internal Medicine (ACVIM). Dr. Breitschwerdt directs the Intracellular Pathogens Research Laboratory in the Institute for Comparative Medicine at North Carolina State University. He also co-directs the Vector Borne Diseases Diagnostic Laboratory and is the director of the NCSU-CVM Biosafety Level 3 Laboratory. Dr. Breitschwerdt’s clinical interests include infectious diseases, immunology, and nephrology. https://www.galaxydx.com/about-us/meet-the-team/edward-breitschwerdt-dvm-dacvim-saim/ Dr. Ed Breitschwerdt, NCSU College of Veterinary Medicine Listen to the Podcast The podcast of this program will be available Monday, May 11, 2026, after broadcast on May 9. In this week’s podcast, we talk about developing treatments for these challenging conditions. A major focus for Dr. Breitschwerdt is prevention, so he and his colleagues are working on a vaccine that could prevent Bartonellosis. We also discuss the possibility that Bartonella might contribute to arthritis. Find out about the complications of another vector-borne infection, Babesiosis. You can stream the show from this site and download the podcast for free. This episode of our podcast was sponsored in part by MUD\WTR. Start your new morning ritual & get up to 43% off your @MUDWTR with code PPOD at mudwtr.com/PPOD

Americans often boast of having the best health care in the world. It is certainly the most expensive health care. We pay twice as much as people in many other industrialized nations. Are we getting our money’s worth? Some population statistics, such as life expectancy, suggest we could be doing much better. How can we make sense of the complexity of American health care? 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 EST on Saturday, May 2, 2026, through 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 May 4, 2026. Why We Pay Twice as Much for Health Care One reason Americans pay twice as much is the complexity of our health care services. We often call it a health care “system,” but it often doesn’t feel as coordinated as a system ought to be. Many other countries have universal health insurance coverage in one form or another (and there are many). That means the government has an incentive for keeping costs down. With so many different payers and players in the US, the incentives frequently go in the other direction. You may notice this if you examine an explanation of benefits from Medicare or a private insurance company. There may be a sizable gap between what the provider charged and what insurance approved. Who pays the retail price? Only people who don’t have insurance, who are usually those least able to manage a big bill. If you find yourself faced with a hospital bill and no insurance coverage, it is important to talk with the billing department. Nonprofit hospitals should have a mechanism for patients without coverage to negotiate a lower total or a longer time frame in which to pay. Even some for-profit hospitals and medical practices are open to negotiation, but starting the negotiation as early as possible is key. How Much Does an Emergency Cost? Nobody plans for a medical emergency. That is the nature of emergencies–they are unexpected. If you need an ambulance to get you there, if you have to be transferred to another hospital with a better ability to care for your problem, if the doctors must do multiple tests to make a diagnosis will all influence your bill. As a result, emergency visits could cost from tens of thousands of dollars to a million or so. With high-deductible health insurance, a person or their family could end up owing more than they can pay. That is how some cases of bankruptcy are rooted in high healthcare bills. We Pay Twice as Much Because Providers Make More In the US, doctors were once in the same category of professionals as teachers or firefighters. Those days are long gone. Healthcare providers here are compensated more generously than providers in many other places, such as Canada, Japan or Israel. Moreover, just as there are middlemen in the prescription insurance business (called pharmacy benefit managers, PBMs), health insurance has its own middlemen. The result is a great deal of complexity, very little transparency, and a lot of parties trying to make money on each transaction. That also leads to a great deal of administration, which further increases the cost. Why Don’t Market Forces Control Costs? Some analysts suggest that the free market should be able to control costs. But for market forces to work, you need competition and transparency. Over the last decade or so, there has been increasing consolidation in every sector of health care. Competition is limited in most areas. Moreover, transparency is in very short supply in health care. For years we have been talking about how hard it is to do comparison shopping for health services like MRI scans or colonoscopies. If consumers cannot compare costs or value, they cannot make the rational decisions that would help moderate prices. How Administrative Costs Increase Bills Part of every insurance premium goes to paying administrative costs. Insurers pay people to review claims (and deny some). Preauthorization also adds to administrative costs. Manage the Hospital Bill So You Don’t Pay Twice as Much as You Should Years ago, we interviewed Marshall Allen, who titled his book Never Pay the First Bill. Our guest for the current episode counters always request an itemized bill. That way you can check it to make sure that simple items such as names, dates and insurance policy numbers are correct. Then look at whether the services billed are actually the services received. An estimated nine of ten hospital bills contain mistakes. The sooner you catch them and contest them, the less likely you are to have to pay them. To determine what you must pay, you may need to review the summary of benefits on your insurance policy. That lays out in detail exactly what the insurance will cover. What Can Patients Do So They Don’t Pay Twice as Much? Ask for an itemized bill and check it carefully in every detail. If you find a mistake, contest it. Sooner is better, even though you may be trying to recover from a serious illness. Ask the billing office about patient assistance or a negotiated payment plan. Check with the Patient Advocate Foundation. They may be able to help in an individual case. Find out if your state has a consumer assistance program in the department of insurance. Notify an intractable billing department that your story will appear in your social media feed. This should probably be the last step if the previous ideas don’t work. But hospitals really don’t like bad publicity, so it might give you leverage you wouldn’t have otherwise. This Week’s Guest Linda J. Blumberg, PhD, is a research professor at Georgetown University’s McCourt School of Public Policy. She is an expert on private health insurance (employer and nongroup), health care financing, and health system reform. Linda J. Blumberg, PhD, describes why we pay twice as much for healthcare Listen to the Podcast he podcast of this program will be available Monday, May 4, 2026, after broadcast on May 2. On this episode, Dr. Blumberg discusses the importance of the summary of benefits in your insurance policy in greater detail. You’ll hear about a situation in which an emergency department overcharged a patient egregiously; the summary of benefits was key in resolving the problem. 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 of Show 1471: 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. Medical bills can be mysterious or infuriating. How can you make sense of the complexity and pay a fair price? This is The People’s Pharmacy with Terry and Joe Graedon. Terry 00:34 Here in the United States, we pay more for our health care than people in any other comparable country. Despite this, our longevity statistics are worse. Joe 00:46 We’ll talk with an expert about how we got ourselves into this mess and what we might be able to do about it. Terry 00:54 She’ll help us better understand medical billing and how to challenge mistakes. Joe 00:59 Coming up on The People’s Pharmacy, why Americans pay twice as much for less care. Terry 01:15 In The People’s Pharmacy Health Headlines: An estimated two-thirds of American adults drink coffee every day. Now scientists have an idea why coffee is so popular. Researchers recruited 31 coffee drinkers and 31 people who do not drink coffee for a detailed study. They compared the composition of their gut microbiota and found some striking differences. Then the coffee drinkers abstained from coffee for two weeks. During this time, the investigators noticed changes in their gut microbiota. After two weeks, coffee drinkers were once again provided with their beverage. Half the volunteers got regular caffeinated coffee, the other half got decaf. Neither researchers nor participants knew who got which beverage. Non-coffee drinkers did not participate in this part of the experiment. Coffee-drinking volunteers reported less stress and depression whether the coffee had caffeine in it or not. People drinking decaf had improvements in learning and memory, possibly due to the polyphenols. Those getting caffeine in their mugs reported less anxiety but better attention and vigilance. The scientists note that coffee is much more than a caffeine delivery mechanism. Coffee consumption also has an effect on the immune response. Joe 02:37 Vertigo can be a disorienting and disturbing symptom. A recent overview published in JAMA describes one of the most common forms, benign paroxysmal positional vertigo, abbreviated BPPV. It’s caused when calcium carbonate crystals inside the ear move out of position. A sensation of non-spinning dizziness or lightheadedness occurs when people lie down or change position. The diagnosis of BPPV relies on observing eye movements called nystagmus that occur when the head moves. It can be treated with a set of prescribed head movements called the Epley maneuver. Although physicians often prescribe the antihistamine meclizine for vertigo, this drug is not effective for treating BPPV. Patients can also self-treat this condition by performing the Epley maneuver at home with good results. Terry 03:34 Levothyroxine is one of the most prescribed drugs in America. That’s because millions of people have a sluggish thyroid gland. The condition is called hypothyroidism. Medical experts have worried that it is being over-diagnosed, especially in older people, based solely on thyroid function blood tests. The investigators set out to examine whether de-prescribing levothyroxine is feasible. Study participants were all 60 or older and had been taking levothyroxine at the same dose for at least a year. The doctors began gradual dose reductions. Over the course of a year, 25% of the 370 volunteers were able to get off levothyroxine without having TSH or T4 levels go out of range. Joe 04:24 One of the most contentious issues among nutrition experts in recent years has revolved around fat, in particular, the benefits and risks of omega-6 polyunsaturated fatty acids, or PUFAs. The AHA has long promoted PUFAs found in vegetable oils because they’re heart-healthy. Critics suggest that an imbalance with excessive omega-6 fatty acids could be harmful. Nutrition scientists distinguished between one specific omega-6 fat, linoleic acid, and all the others. Researchers used data from nearly 274,000 volunteers registered with the UK Biobank. These middle-aged, healthy people had no dementia when the study began. Blood tests revealed the balance between linoleic acid and other omega-6 fatty acids. Over the next 15 years, 5,800 individuals developed dementia. Those with the highest levels of linoleic acid were almost 20% less likely to come down with dementia. In contrast, those with the highest levels of other omega-6 fats were about 20% more likely to have a dementia diagnosis. The scientists call for research on whether increasing dietary linoleic acid might help protect people from dementia. And that’s the health news from The People’s Pharmacy this week. Terry 06:15 Welcome to The People’s Pharmacy. I’m Terry Graedon. Joe 06:18 And I’m Joe Graedon. Have you ever received a confusing medical bill? Actually, let me correct myself. Have you ever received a bill from a hospital that was not confusing? Terry 06:30 Most of us have had, oh, maybe a moment of alarm when we’ve had to try and decode a complicated medical bill. Why is the American system so hard to navigate and so difficult to afford? We pay far more for our health care than people in any other comparable country, and we have much less to show for it. Joe 06:53 To learn more about health care in America and how it compares to other countries, we turn to Dr. Linda Blumberg. She is a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Terry 07:17 Welcome to The People’s Pharmacy, Dr. Linda Blumberg. Dr. Linda Blumberg 07:20 Thank you so much for inviting me today. Joe 07:23 We are delighted to be able to talk to you about, I think, one of the most challenging issues facing health care in America, and that has to do with our system for paying. So perhaps you can explain briefly how our payment system in the U.S. compares to most other advanced countries. Dr. Linda Blumberg 07:47 Well, it is much more complicated than in most other advanced countries, probably in all other advanced countries. And that’s because we have so many payers and so many different sets of prices that are used for providers, for insurers, for different plans, et cetera, and how employer plans work. So the variation is enormous, which causes a lot of confusion for consumers. And frankly, it often causes confusion for the providers as well. Terry 08:17 I wonder if you would explain, Dr. Blumberg, you say so many different prices, which implies that if I were to go in for a CT scan of something, I might get one price and somebody else who has the exact same procedure done maybe charge something completely different. How does that work? Dr. Linda Blumberg 08:39 That’s absolutely correct. And it all boils down to what type of insurance you have and what plan you have. So if you are somebody who is enrolled in Medicare, the program in the U.S. for those who are 65 and over or who have particular disabilities that qualify them, there are prices that are regulated by the federal government in terms of what a provider can charge for each service. If you have private health insurance, however, there is no regulation on the prices. And so a lot of it depends on what the market will bear for the particular provider that you happen to be using and the negotiations that they have completed with the particular insurance plan you have. And so you may have a United Health Insurance Plan and somebody else may have a United Health Insurance Plan, but they’re two different plans and those would pay different prices for the same procedure. Joe 09:34 Well, we’ll talk about billing in a minute, but what has always confused me is the idea that if you have insurance and you have to go into the hospital for some sort of a procedure, you would get bill X if you have insurance company Y. But if you have no insurance and have to pay out of pocket, it can be substantially greater. I mean, like dramatically more expensive, which seems like it’s just [bleep]-backwards. Pardon my language. I mean, it just seems upside down. How do they figure out these crazy prices? Dr. Linda Blumberg 10:20 Well, first of all, we do not have a rational basis for deciding the prices that an insurer is paying to a particular provider or what a particular provider is going to charge to someone who’s uninsured. And you’re right. If you walk in the door without any insurance coverage, you are likely to be charged the highest price of anybody that’s walking in the front door of a hospital. And that is because there is no insurer or third-party administrator that is negotiating any prices on your behalf. So you’re basically being charged the, you know, the retail rate, which is the highest that there is. What a lot… as you say, it makes no sense because usually people without insurance are the people with the lowest incomes, right? And they have the least ability to pay for these services. And oftentimes the hospitals, in particular, the nonprofit hospitals are required to have programs that lower prices for people with modest incomes that are coming in without insurance. However, they often don’t even advertise that these programs exist. They’re hard to find even on their websites. And so people who are walking in without insurance are being charged huge prices, and they have to know to say, “Listen, well, I have low income and I need to have access to someone who’s going to help me with whatever program you have for low income people walking in the door.” So it is a lot of hit and miss in terms of what people understand about what might be available to them and what negotiated deals a particular hospital has made with a particular health insurance plan. And it’s often a function of how much market power the insurer and the health care providers, the health system have in that particular area is going to drive whether the prices are lower or higher. Terry 12:22 Dr. Blumberg, you mentioned the retail price of a procedure or a hospitalization. And you also mentioned that Medicare prices are regulated, even though all these other prices are not. I’m going to mention, as a Medicare patient, I occasionally look at my explanation of benefits and I find them very confusing and/or alarming because what I see is that my provider, for example, might charge $355 for something. So that’s the retail price. And Medicare approves, let’s say, $128, you know, as that’s the approved payment, but it doesn’t pay that full amount. And then the supplemental, I happen to have Blue Cross, picks up usually most of what Medicare doesn’t pay on the amount that Medicare has approved. But there’s such a mismatch between that retail price and that approved price. How does that work? Dr. Linda Blumberg 13:40 Well, that shows you that when somebody who walks in the door to get the retail price is being charged much more than somebody who’s coming in with Medicare. And that is by federal government law, is that physicians who take payments from Medicare, who participate in Medicare, have to agree to take the rates that are set out in federal law. And these providers know they’ve made this agreement with the federal government. That’s why they’re participating. So this is customary for them. It’s not surprising to them that there is a disconnect between those prices. In fact, very few people end up paying the actual retail price. But if you’re walking in with private health insurance, you’re likely to pay considerably more than or your insurer is going to be paying more and you are likely to pay some more also compared to the Medicare prices. So on average, and this is just on average, hospital payments under private insurance are in the neighborhood of two and a half times what Medicare pays. And for physicians, for clinicians, it’s more on average about 25% above what Medicare pays. So the variation is large even around that. You know, for some procedures and for some clinicians, they may be getting 600% of Medicare or 900% of Medicare. It varies enormously through the system. And that’s why I say we’re not paying privately on any rational set of prices. Joe 15:17 So what has really boggled my mind is that if, for example, you need a hip replacement, as I have had, or a cataract surgery, the provider may charge thousands of dollars. Let’s just make up a number and say, you know, $3,500 for this particular cataract surgery. But Medicare may only pay a few hundred dollars. It’s like the discrepancy is so dramatic. It would be as if the sticker price for your car is $25,000, but you actually only have to pay $18,000. I mean, people are so shocked by these numbers. They seem to make no sense whatsoever. And you kind of wonder, well, how can this system function if these billable numbers are two, three, four times more than the doctor actually gets paid? It seems insane. Dr. Linda Blumberg 16:19 Except for the doctor doesn’t really expect to get paid the amount that they’re showing on the bill, they have negotiated particular rates of payment with insurance plans, and they have accepted the federal government fee schedule, which is public information. So the retail prices that you see are really pretty meaningless because the real prices are the ones that have been negotiated with whoever the insurance company is, whether it’s public or private. Joe 16:50 Unless you don’t have insurance, unless you’re not eligible for Medicare, in which case you’re on the hook for an unbelievable amount of money that you can’t possibly afford. Dr. Linda Blumberg 17:02 Absolutely. But then, you know, I always suggest to consumers when they’re in that situation, first of all, if it’s with the hospital, to explore what programs they have for uninsured people with modest incomes. Because if it’s a nonprofit hospital, they’re required by law to have some kind of program. Whether a particular individual is going to qualify for it is up to what that program looks like. But you always explore that. And absent that, or if you’re talking about care you’ve received from an individual physician, I always suggest that the consumer talk to the physician, talk to the financial manager for the practice and see if there’s some way to negotiate that rate down. Because as you said, it doesn’t make any sense and nobody with private insurance is paying for it. Terry 17:51 You’re listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Joe 18:14 After the break, we’ll ask Dr. Blumberg how much an emergency might cost. Terry 18:18 Are we getting any bang for our buck compared to other countries? How do health insurance middlemen affect the cost of care? Some people suggest that the free market should take care of the pricing problems. Joe 18:29 Why haven’t market forces brought health care prices down? Terry 18:43 You’re listening to The People’s Pharmacy with Joe and Terry Graedon. Terry 20:45 Welcome back to The People’s Pharmacy. I’m Terry Graedon. Joe 20:48 And I’m Joe Graedon. Joe 21:17 We’re talking about the high cost of health care in the United States. Are we getting our money’s worth? We pay far more than people in most other countries, but our health statistics are abysmal. Terry 21:31 Many families in America go into debt because of huge medical bills. In some cases, people have lost their life savings and their homes because of a health care crisis. Joe 21:42 Will cuts to Medicaid make this situation more challenging? Will hospitals close because of reduced financial stability? Terry 21:52 Our guest is Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. Joe 22:10 Dr. Blumberg, in the event that you had an emergency, and let’s say you had to have an ambulance and then you had to go to the emergency department, maybe you thought you were having a stroke or a heart attack, and then you’ve seen multiple specialists and you have a whole bunch of tests, CT scans and goodness knows what else. And then you have to stay in the hospital with maybe a couple of procedures for, let’s say, three to five days. How much might your bill be at the end of this hospital stay? Dr. Linda Blumberg 22:43 Well, a total bill for a hospital stay can be enormous. It depends upon the services you’ve received, how long you’re staying. But, you know, it can often be in the tens of thousands of dollars. But, you know, there are people who have inpatient stays in a hospital for a length of time in serious conditions that could be a million dollars, right? So it all varies a lot, but an emergency department is a particularly expensive place to obtain care, and hospital stays are the most expensive costs that we face in our healthcare system. Joe 23:17 I’d like to ask you about how much bang we’re getting for our bucks in the United States compared to other advanced countries, because, you know, we have done an amazing job at getting smoking down. I mean, turn back the clock about 40 or 50 years and like half of Americans, especially men, smoked. And today it’s down around 12 or 15 percent or lower, maybe around 10 percent. So we’ve made some real progress in terms of health behaviors. But that aside, our life expectancy has not improved dramatically. Other countries, for example, Japan, South Korea, Sweden, and France are all about 83 to 84 years of age. In the U.S., our life expectancy is around 78 years. We spend annually over $12,000 a year per capita per person. In Germany, it’s 8,000. In France, it’s $6,600. And in Sweden, it’s $6,400. So almost half of what we spend. And yet their longevity is much greater. I mean, substantially better. How? I mean, what? Terry 24:37 What gives? Joe 24:36 What is going on? How can it be that we’re paying so much more for so much less? Dr. Linda Blumberg 24:45 Really good question. Part of what’s going on and probably the biggest difference in terms of what we spend compared to other countries, developed countries on health care, is the prices that are paid to the health care providers from, you know, who we’re receiving our care from. So a hospital stay for the same services in the United States is typically going to cost considerably more than if those services were obtained in Canada or in Japan or in Germany or in Israel. So those are systems that… where all of the… There is regulation of the prices that are paid, are paid for medical procedures, regardless of the type of insurance coverage you have. And some of them have, you know, different plans, et cetera, not as much variation as we have here, but some variation. But all of those prices are limited in those countries by government dictate. And we are, as I said, we’re only limiting the prices that we pay for medical care if you’re in a public insurance program like Medicaid or Medicare. If you have private insurance, which most people below age 65 have a private health insurance, those prices are not regulated. In addition, when you think about longevity, we do have a more diverse population in a lot of respects than is the case in most other developed countries. But in addition, we have the issue here of still having a significant number of U.S. residents without any health insurance coverage at all, which is not the case in these other developed countries where they have at least some level of universal health insurance coverage. And sometimes it’s considerably more comprehensive than the types of coverage we have here. And so when you have a significant share of the population, even if it’s only at this point under 10%, about 10% of the population under age 65, you still have a considerable number of people who are not getting access to medical care when they need it. And that is going to affect longevity. Other things like diet and pollution and, you know, various other different issues. We have a lot of gun violence here, which is not the case in the vast majority of other countries. So all of those things go into the difference. But the difference in our spending is completely on the prices that we’re paying to our health care providers on the commercial side. Terry 27:25 Dr. Blumberg, you’ve written about health insurance middlemen. I wonder if you could explain what that is and how it affects the prices we pay. Dr. Linda Blumberg 27:35 Sure. So when we are obtaining medical care in this country, we are paying for the particular services, right? And money is going to the providers who are providing these services to us. But we’re also paying administrative costs. And those administrative costs are built into the prices that we’re paying to hospitals and doctors and other providers. And it’s also built into the premiums that we’re paying for our health insurance coverage. And increasingly in this country, we have moved our healthcare economy into a space where huge numbers of dollars are going for administrative fees that are associated with what I refer to as middlemen. People have heard a lot about prescription drug benefit managers. But the same is true on the medical side. So a hospital is spending large amounts of money on a revenue cycle management company that is trying to figure out how to send in bills and code the services delivered to increase the revenue of the hospital. Same on the physician side. You have various different types of entities that are contracting with insurance companies to do particular types of tasks that the insurance company or the third-party administrator either doesn’t want to do themselves or finds more profitable to contract out to their subsidiaries. So there is a lot of dollars that are going into making the prices higher on the claim side, on the medical service price side, and that are also being built into our insurance premiums through higher claims and through higher administrative loads that are attached by the insurer. So, I mean, we’re talking about an industry that is hundreds of billions of dollars every year that is really extractive, that’s pulling dollars out of every one of the transactions. And there’s billions of transactions that go through our system every year. And so these entities, these administrative and financial entities have figured out how to extract dollars from the healthcare economy by adding some administrative costs to every single transaction that is being processed through the system. Joe 30:07 Dr. Blumberg, I think most people have a real hard time dealing in billions and dealing with middlemen and all the other stuff, but they can relate to an office visit. So for example, if you had to go see a specialist in this country, maybe a gastroenterologist or a dermatologist or a cardiologist, those bills for just a quote unquote ‘regular visit’ could be in the hundreds of dollars. In Sweden, it’s 40 bucks. That’s the maximum a specialist can charge in Sweden. Kids are free in Sweden. I think most parents know that a pediatrician’s visit can be pricey. They have no health care premiums in Sweden. It comes off their tax bill. The average hospital bill in Sweden for a day, this, you know, being in the hospital for a day, is $11. In this country, it can be thousands. And the maximum that a person would pay for all medical appointments annually in Sweden, everything lumped together would be $160. It can cost us $160 for just one visit in this country. So I’m just wondering, when will the American public say enough is enough? Dr. Linda Blumberg 31:38 So I think one important thing to remember is that, yes, when somebody is taking their kid to a pediatrician in Sweden, they’re not paying anything out of pocket. But their taxes are higher, right? Because those providers still have to be paid for the services they’re providing. It’s a matter of how the prices are, how they’re being paid. And in those countries, much more of the dollars are flowing through their national health system, which is funded by tax dollars. And so the tax rates in Sweden, for example, are typically quite a bit higher than we face in the United States. But they, at the same time, obviously the country is regulating how much the providers can earn for providing the services that they’re provided. So there are some limits that lower the incomes, the revenue that the providers receive, but much more of the dollars are flowing through the government and from tax dollars than is the case here. We have always struggled here in the United States with balancing, number one, regulation. How much do we want to regulate prices instead of letting the market decide what a private sector person like a health care provider or hospital is going to receive? And we also struggle with increasing our taxes, right? And so we could create a system where we have greater regulation of the prices and limits on prices that are paid to health care providers to lower our total spending. We can also finance more coverage through the federal government or through state government for more people. But it is a real political struggle to convince people that while they feel like their… that health care is too expensive, they’re afraid of oftentimes of putting limits on what their particular doctor is going to make or their particular hospital is going to make. Because the hospitals and the physicians will let them will tell them whether it’s accurate or not, that their access and their quality of care is going to suffer if they do that. And there are also people in this country are very much resistant to significant increases in their taxes, even if you tell them it’s going to lower other out-of-pocket expenses because they don’t really believe it, right? Or they think they’re going to end up paying more for somebody else to have lower prices. So it is a very complicated political balance here. I think people are getting more and more frustrated with the way that the system works and the increase in the denials and the red tape and the complexity people have to jump through to obtain their medical care. But the political challenge is real in terms of more government regulation of prices and/or financing more care through the tax system. Terry 34:43 Well, you’re absolutely right. It is very complicated politically. And you mentioned that one of the alternatives that is sometimes posited is: let market forces regulate prices, which is, I think, where we are, except that market forces are only making prices higher, not lower. Why doesn’t health care in America work like a market should? Dr. Linda Blumberg 35:12 We have had a tremendous amount of consolidation in our healthcare industries. And so when we talk about hospitals being bought, you know, buying other hospitals and creating hospital systems and, you know, sometimes often now buying medical practices, insurance companies, UnitedHealthcare is now the biggest employer of physicians in this country, right? The insurers and the healthcare systems are buying up these middlemen that are making more money off of, you know, as I was saying, extracting dollars from the claims that are being processed. So there’s been a tremendous amount of complexity added in the financial relationships between all of these stakeholders, the providers, the insurers, the middlemen. Very few of them are independent at this time. Very many of them have conflicts of interest, all directed in the direction of increasing prices on the commercial side and increasing spending. Terry 36:15 Right. Lots of complexity, not much transparency. Dr. Linda Blumberg 36:18 Right. It is basically capitalism run amok. And you’re talking about a product in health care that was already from the beginning of time, much more complicated to shop for than a refrigerator, right? You know, you don’t know necessarily what you’re going to need in terms of services or what it’s going to cost before you walk in the door at the doctor’s office or in the hospital. It is not something that is easy to shop for, whereas I can, you know, spend 20 minutes and figure out what the best price I can get on the refrigerator I want is. That’s just not the way medical care works. And then when you take the consolidation and the hidden fees and the conflicts of interest that have arisen both between co-ownership in the healthcare industry and these financial deals that are being made between the insurers and the middlemen and the providers at this point, you have a situation where there is no competition in these markets or where there is, it’s extraordinarily limited. And so you’re not going to… the more this is allowed to fester and expand, which is what it is doing year in and year out, the worse it’s going to get. You’re not going to have competition driving prices down. You’re going to have greater financialization of the system continuing to drive prices up. And really the only way to interfere with that is for government to put limits on both what prices can be charged for particular services and to eliminate the financial dealings that are interconnecting all of these stakeholders with each other and encouraging higher intensity coding and hidden financial fees that are passing between different entities that are driving costs up for consumers and employers. Terry 38:14 You’re listening to Dr. Linda Blumberg. She’s a research professor at Georgetown University’s McCourt School of Public Policy, and she is an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms and examine the implications of private equity companies’ movement into health care. Joe 38:43 After the break, we’ll discuss why you need to examine your hospital bill extra carefully and with skepticism. Terry 38:52 Hospital bills are complex and they often contain errors. To really figure out the charges, you need to request an itemized bill. Joe 39:01 Surprisingly, your insurance company might not behave like an ally. Terry 39:09 How do you contest a bill that is obviously wrong? Joe 39:12 Sometimes media exposure of outrageous bills can make a big difference. Most hospitals hate bad publicity. Terry 39:31 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 39:46 And I’m Joe Graedon. Joe 40:16 Are you the kind of person who pays bills as soon as you get them? Nothing wrong with that. But when it comes to hospital bills, you may need to slow down. It turns out they often contain errors that can be tough to track down. Terry 40:33 Medical bills, especially hospital bills, can be extremely complex. And hospitals make mistakes all the time. You’ll need to scrutinize every charge. Joe 40:44 We’re talking today with Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. Dr. Blumberg’s expertise is in private health insurance, health care financing, and health system reform. She has analyzed the Affordable Care Act and studied strategies to address remaining health insurance coverage issues. Dr. Blumberg has also analyzed approaches for setting standards of affordability for insurance coverage. Terry 41:14 Dr. Blumberg, some years ago, we spoke with a fellow, I think his name is Marshall Allen, who wrote a book. He titled it: “Never Pay the First Bill.” And we found our conversation with him quite interesting. I’m wondering what you think of that advice. Dr. Linda Blumberg 41:34 Well, I think my advice is always be skeptical and look carefully at a bill. Don’t just pay it, because the vast majority of them, whether they’re coming from a hospital, much more likely from a physician, also reasonably likely there’s mistakes in them. And so you do want to approach them with some skepticism and caution. Joe 41:58 Well, actually, that’s not enough. And the reason I say that’s not enough is because most of us, when we look at a hospital bill or a clinic bill, we don’t know what to make of it. I mean, it is really confusing. And as you said, there’s like the bill that the doctor presents and the bill that the clinic presents or the hospital presents. And then there’s what Medicare might pay or might not pay or your insurance. It’s like, how in the world do we make sense of our medical bills? How do we even get started? Dr. Linda Blumberg 42:38 It’s rough and it takes a good deal of patience and time, unfortunately. Hospital bills in particular, I’ve heard estimates that nine out of 10 of them have errors. I’ve heard others say that there’s never a hospital bill that doesn’t have an error in it, right? And they’re the most complex of the bills that an individual is going to receive. My advice is always the first thing you do is request an itemized bill from the hospital, because by and large, what the hospital will send out is a summary bill, not an itemized bill. And you can’t figure out what the errors are in general from a summary. So request an itemized bill. If they don’t send it, you got to ask again, because sometimes they’re a little pokey about it because they just want you to pay. They don’t want you to look at the itemized bill. Joe 43:26 Well, let me ask you this: let’s say you get an itemized bill and it says that you had an ultrasound done on such and such a date of, you know, such and such a part of your body and you go, “No way. I did not have an ultrasound at all.” How did that happen? And then how do you contest something that’s obviously wrong? Dr. Linda Blumberg 43:53 The first stop from my perspective is to call the billing department, to call the physician’s office of the physician that you’ve seen and contest it and say, there’s a mistake. I’m being charged for a service that I never received. An insurance company, if you have an insurer, can also often be helpful when you’re talking about something you’ve been charged for that is something you have not received. But it sometimes will take multiple calls and multiple interactions to resolve a problem like that. You know, one of the most common errors that people see in hospital bills is being billed twice for the same thing or the number of, you know, something that was charged for, you know, some supply or something is, you know, somebody added a zero to it by mistake, you know, assumedly. And that needs to be corrected, and so engaging with the physician who you’ve received services from with your insurer and trying to contact the billing department directly at the hospital… Joe 44:59 Let me ask you one follow-up to that, because you would think that since the insurance company, if you’re fortunate enough to have insurance, would be an ally, would be joining you in fighting an incorrect bill or a bill that was overcharged for some reason or a service that was never provided or a medication that you never got. We’ve heard that insurance companies, they’re not as likely to be enthusiastic about challenging these bills because after all, they’re just going to pass those charges on to their customers and consumers. It’s like, well, why waste our time? Because you, you know, you, you were charged for aspirin, but you didn’t get aspirin. So how do we get the insurance companies fired up to actually challenge mistakes? Dr. Linda Blumberg 45:55 It is sometimes a struggle for sure. One of the things that people should be aware of, and what I talk about when I talk about this complex web of interconnected financial interests across stakeholders in the healthcare industry, is that insurance companies, they can make greater profit the higher the claims. Under the law, they are limited in terms of what percentage of a premium can go to administrative costs, including profit. So since that’s limited as a percentage, the higher the total spend on claims, the bigger the amount of money they have left over for their administrative costs and their profit. And so in a lot of ways, they’re disincentivized to hold down spending, which is contrary to what many people who are using, buying health insurance coverage expect of their insurer. They think their insurer is trying to get the best deal for them. That is not always the case. And so you can talk to the consumer reps with the insurer, but sometimes you’ve really got to go directly to the provider and dispute. And there’s a nonprofit called the Patient Advocate Foundation that is particularly created to help people with chronic illnesses contest incorrect bills and deal with billing issues. There are others who will do it for a fee as a percentage of what savings created. But it becomes sometimes a situation where the consumer themselves needs to do repeated calls and contacts and filing complaints in order to get a bill resolved. But I still always say contact the insurance company as well. They may be in a mindset to help out. Terry 47:52 Dr. Blumberg, you’ve mentioned that patients can and probably should negotiate with whether it’s the physician’s office billing or the hospital billing, especially if they don’t have insurance, but even if they do. Can you tell us about a time when somebody did that? What was the outcome? Dr. Linda Blumberg 48:17 Well, sure. I mean, I think it depends greatly on the health care provider, right? And if you have had a primary care physician for many years and then you’ve lost health insurance coverage or for some reason you have a gap or et cetera, you know, there are ways in which, you know, in circumstances where these providers will either set up a payment plan for you, or they’ll say, “Listen, you know, you’ve been a great patient and I want to help you through this rough spot.” And they’ll negotiate down, you know, hopefully to what at least at a minimum that the private insurer would have paid, right? But it is very much [an] ad hoc kind of decision that’s being made by these providers. Now, in the situation of a hospital, particularly for people who have modest incomes, there are programs that nonprofit hospitals have, as I mentioned before, that are there to help people in financial straits. And those programs, sometimes they’re programs that are funded by state government dollars. Sometimes it’s… parts of it, the hospital themselves, but those are programs that exist explicitly for people in tough situations. And some… but some… The problem is you have to really push to get the information about them to figure out whether you’re eligible. Joe 49:41 Dr. Blumberg, what about media exposure? I mean, every once in a while, somebody sort of blows the whistle on an outrageous bill that just blows everybody’s mind. It’s like, that’s ridiculous. And they contact their, their local TV station or their newspaper, and all of a sudden, you know, it goes, you know, wild on the internet, and it affects the hospital in such a way they say, “Oh, never mind, let’s negotiate a better bill.” Is that something that people can actually do successfully? Dr. Linda Blumberg 50:15 Yes, people have done it successfully. And there’s, you know, ‘bill of the day’ kinds of newspaper reporting, et cetera, where some experienced reporters are doing this repeatedly on behalf of people in particularly egregious circumstances. And it can be really effective at cutting through to the right people at the right moment to get a better deal created. And so, listen, if I was in that situation, I would use whatever options I had at my disposal. You know, in some states, unfortunately, it’s not all states, but in some states, state governments have what are called consumer assistance programs. They were originally funded by the federal government across the country, but that funding has not been reappropriated in many years now. But those consumer assistance programs, if you’re lucky enough to live in a state that has one, can sometimes also be helpful if you contact them, file a complaint with the state. If it’s a problem with the insurance company and it’s a fully insured product, not a self-funded plan from the employer, you can file complaints with the Department of Insurance, et cetera. So there are opportunities for going higher. And I always suggest to people, even if you’re contacting someone at the hospital, if you’re not getting any kind of satisfaction from a consumer rep, you want to escalate to a manager, to whoever. You want to just go as high as you can in the pecking order to try to get some resolution. Joe 51:50 We are concerned about pharmaceutical prices, as you can very well imagine here on The People’s Pharmacy. And we have seen pharmacies disappearing in this country at an extraordinary rate, in part because private equity firms have bought up large chains, and those large chains are now closing not dozens but hundreds of pharmacies. And so the idea of a mom-and-pop pharmacy where the pharmacist was a sole operator seems to be disappearing very quickly. And drug prices, as everybody knows, are way higher in this country than any place in the world. What do you suggest when it comes to the costs of medicine in this country, especially for people who have life-threatening conditions and their bills may be in the tens of thousands of dollars? Dr. Linda Blumberg 52:43 It’s really, really difficult. And I wish I had a good answer for you. I know some people are trying to obtain medications at more affordable prices outside of the country. That’s always challenging and a little bit risky depending upon where you’re going to get the medications. But there are some programs that particular pharmaceutical companies have that lower prices for people with modest incomes or people who do not have health insurance coverage for brand-name types of drugs that they need. And so, you know, I usually suggest to people, first stop if you can’t get satisfaction or help from your insurance company. And sometimes if it’s not on their formulary, you can get evidence from your… help from your physician about why that particular drug is so necessary to try to appeal and get coverage from your insurance company. If you’re without insurance or without good enough insurance to cover costs, I would suggest to people go to the website for the company that makes your drug and see if they have some programs that might be able to help. There are also some states [that] have particular programs for providing financial support for prescription drugs. Joe 54:04 Dr. Blumberg, we only have about two minutes left. If we were to put you in charge of the entire health care system, how would you change things? Dr. Linda Blumberg 54:15 Well, first of all, I would put back a number of the coverage cutbacks that this administration has put in place or that they will be putting in place in the near future in the Medicaid program because every person in this country should have access to affordable, adequate health insurance coverage for their medical needs. Beyond that, I would put limits in place on the prices that are charged by providers, and I would do it broadly across all prices, and hospital level, physician level. I would include prescription drug controls in that as well. I would then make sure that we are monitoring a system to make sure that everybody has the access that they need. And I would do a lot to break up the kinds of integrated financial incentives from co-owned entities in the healthcare system to separate those financial incentives, create more competition and clarity in terms of what people are paying when they obtain care. And I think we’ve also got to go a ways to your point about the prescription drug issues on the private equity side. There’s a lot of practices that private equity typically uses in the healthcare space that are extractive and damaging both to prices, quality, and sometimes the stability of the healthcare providers themselves. And we have to prohibit those kinds of high debt financing and other extractive practices that are often in place there. Terry 55:50 Dr. Blumberg, did we miss anything that we should have asked you? Dr. Linda Blumberg 55:54 No, I think we covered a lot. So, yeah, I think, you know, when people get their bills, they should always make sure that the names, the dates, you know, the insurance information is all correct. Sometimes that stops insurance companies from paying appropriately from like little minor like typo errors in addition to the kinds of things we talked about. And everybody who has a health insurance policy by law has access to what’s called a summary of benefits and coverage or an SBC. This is part of the Affordable Care Act law. It’s an English-language summary of your benefits. And so I always suggest to people to have that in hand so you can make sure that when you get the bill that says this is what your insurance company pays, this is what you owe, that you’re clear that that is really what you owe. So, for example, I had a situation where I was helping somebody and they had gone into the emergency room for urgent care that the doctor told them to go to the ER. And the hospital charged them $2,000 up front on a credit card when they walked in the door. Their summary of benefits and coverage very explicitly said that the only charge they should be charged when they walk into an emergency room for a real emergency is $200. It took me about an hour and a half or two hours and maybe three or four different telephone calls to resolve that. But it was really clear from that summary of benefits and coverage that that person was overcharged. So, you know, knowing, being really on top of what your health insurance plan is supposed to cover and comparing that to what you’re being charged is a really important line of defense. Joe 57:47 Dr. Blumberg, whenever we talk to healthcare professionals, they often complain these days. They complain that they have to see way too many patients in way too little time. They complain about the cost of their education, whether it’s a nursing school or pharmacy school or medical school, that it’s very expensive and that they had to go into debt. And then they complain about the whole fee structure and all the bureaucracy and all the time they have to spend sometimes arm wrestling insurance companies, and it’s not actually practicing medicine the way they would like to. But at the same time, we hear that people earn rather extraordinary incomes. So a, for example, orthopedic surgeon is often making $500,000, $600,000, $800,000 a year. A family practice physician may be only making $150,000 to $200,000 a year. How do the payments to healthcare professionals in this country compare to the healthcare professionals in, let’s just say, the UK or Germany or Sweden? Dr. Linda Blumberg 59:20 We are paying our specialists in particular a lot more than are being paid in those other countries. I don’t have the statistics at hand on those specific salaries, but, you know, I’m not sure we’re paying our primary care physicians, you know, any more or not significantly more than they are paid in other countries. But, you know, those are at the highest levels, you know, as you said, the orthopedic surgeons, the interventional radiologists, the folks that are being paid for procedures at really high levels are paid much more than we see in other countries. And I think my understanding is, and I’d have to look at this more carefully, but my understanding is that education in general, including education for medical professionals, is much more highly subsidized in most of these countries than we do here. And so if you’re going to pay considerably less, then we also have to think about subsidizing the education for some more medical professionals than we do. And that should be part of the thinking if we’re going to put a lot of limits on what these providers can make. Joe 01:00:38 And finally, our listeners learn from stories. And quite honestly, so do doctors. They call them case reports. But it makes the topic that we’re discussing come alive in ways that just talking in a more academic way [does not]. Have you had any experience over your career in which a patient or a family or some situation where the billing was so outrageous that it came to your attention and it was able to be modified? You mentioned spending a couple of hours on the phone because the person was billed so much on their credit card when they entered the emergency department. Is there any other story you could share about billing that would be how I would describe it as helpful for our listeners to comprehend the scope of the problem? Dr. Linda Blumberg 01:01:40 Well, you know, I am an academic researcher, right, and a policy researcher. And so I do not generally work as an advocate for patients. Every once in a while, a family member or a friend or somebody who sees a program that I’ve been speaking on will contact me and ask for help and I’ll do what I can. But that’s the most… The situation with the $2,000 bill instead of the $200 bill is my most recent case of that. But, you know, the other thing that I’ve seen a lot in terms of what’s been in the media is stories of people who go in for an emergency room visit, and it’s a reasonably modest kind of situation. They’re not in there long. Maybe it’s for a child and they were worried, but it’s really not a big medical problem. And the intensity with which that bill is coded is way out of whack with the services that were provided because emergency room visits are coded by the intensity of the situation and the services needed. And so those are situations where people can get bills in the huge range, tens of thousands of dollars for something that should have been a much more low-cost price. And seeing that and having to go back and appeal that is something that is becoming more common, I think, in emergency departments over time. So I don’t have a lot of individual stories where I have particularly intervened because that’s, you know, I’m a data and analytic person more than I am, you know, I’m not really a consumer advocate. Terry 01:03:26 Dr. Linda Blumberg, thank you so much for talking with us on The People’s Pharmacy today. Dr. Linda Blumberg 01:03:32 My pleasure. Thanks for having me on. Terry 01:03:34 You’ve been listening to Dr. Linda Blumberg, research professor at Georgetown University’s McCourt School of Public Policy. She’s an expert on private health insurance, health care financing, and health system reform. Dr. Blumberg has provided technical assistance to states in their efforts to analyze and implement federal reforms. She’s also examined the implication of private equity companies’ movement into health care. Joe 01:04:05 Lyn Siegel produced today’s show. Al Wodarski engineered. Dave Graedon edits our interviews. B.J. Leiderman composed our theme music. Terry 01:04:14 This show is a co-production of North Carolina Public Radio, WUNC, with The People’s Pharmacy. Joe 01:04:23 Today’s show is number 1,471. You can find it online at peoplespharmacy.com. That’s where you can share your comments about this episode. We’d love to hear your reports about hospital bills, interactions with the medical system. Please, you can reach us through email, radio at peoplespharmacy.com. We’re also trying to enhance our YouTube channel with videos of our interviews. If you’d like to watch our interactions with guests you hear each week on The People’s Pharmacy, why not go to YouTube and search for People’s Pharmacy? Terry 01:05:01 Our interviews are always available through your favorite podcast provider. You’ll find the podcast on our website on Monday morning. In this week’s podcast, we also discuss how easy it is for errors to creep into the bill, even through simple typos. The summary of benefits for the insurance coverage is a crucial document. It lays out exactly what the hospital can and can’t charge you for. One reason health care costs so much in the U.S. is the high cost of specialized medical professionals. How does compensation in other countries compare to what health care professionals make here? You’ll also hear about emergency room coding errors. Joe 01:05:48 At peoplespharmacy.com, you could 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 would be so grateful if you would write a review of The People’s Pharmacy and post it to the podcast platform you prefer. If you find our topics thought-provoking, please share them with friends and family. In Durham, North Carolina, I’m Joe Graedon. Terry 01:06:18 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 01:06:55 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 01:07:04 All you have to do is go to peoplespharmacy.com/donate. Joe 01:07:10 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.

If you had to name one thing that could contribute to better health throughout the lifespan, what would it be? We think exercise, or at least physical activity deserves the top spot. Yet in 2025, fewer than half of adults met the guidelines for aerobic physical activity. And less than one-quarter were doing both aerobic and muscle-strengthening exercises on a regular basis. Perhaps your doctor should prescribe exercise. What could we expect as the benefits? 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 EST on Saturday, April 25, 2026, through your computer or smart phone (wvtf.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 April 27, 2026. Would Your Doctor Prescribe Exercise for Depression? Earlier this year, the Cochrane Collaboration published a review of 73 randomized clinical trials of exercise as a treatment for depression (Cochrane Database of Systematic Reviews, Jan. 8, 2026). Most of these compared physical activity to antidepressants or to psychological therapy for depressed patients. Some of them compared the exercise prescription to no treatment or wait list. Comparing exercise to no treatment revealed an advantage for exercise, although the quality of the trials left something to be desired. Ten trials compared exercise to psychological therapy. In addition, five trials weighed exercise against antidepressant medication. Neither comparison showed a clear tilt for or against exercise as a superior intervention against depression. Exercise in the Cancer Center Dr. Claudio Battaglini of the University of North Carolina at Chapel Hill was not surprised by this finding. The exercise program he oversees for cancer patients often results in lifting their spirits as well as improving their health. That may help explain the very high adherence in his program. Will Physical Activity Reduce the Risk of Cancer? According to a review of the evidence, regular physical activity can reduce the number of people who die prematurely. In addition, it helps with weight control, quality of life and bone health. Older people are less likely to fall or experience declining cognition if they exercise regularly. The review found that physical activity improves quality of life and promotes emotional benefits (European Journal of Cancer Prevention, Jan. 1, 2025). If oncologists should prescribe exercise, don’t cancer patients deserve to have their insurance company cover the cost? Insurers rarely blink twice at cardiac rehab. Although cancer rehab is also super-helpful, insurance companies often don’t choose to pay for it. What Role Could Coaching Play in Guiding Physical Activity? Lots of doctors tell their patients to get more exercise. The patient wants to and intends to, but perhaps they just don’t know how. What activity should they choose? What is the proper technique? How often and how much do you need to move? All these questions can be answered by a coach. The coach will take into account your objectives and preferences as well as your prior experience. What do you love doing? Are there any moves you should avoid to reduce the risk of injury? That’s why when doctors prescribe exercise, they should include coaching to provide this sort of guidance. If Doctors Prescribe Exercise, Will That Help Motivation? Many of us know we should be active, but we don’t always follow through. How can we get motivated to move? According to Dr. Jordan Metzl, the first step is to find something you love doing. For Joe, for instance, having the doctor prescribe exercise of runniing a mile a day is not going to work. But he’ll cover much more than a mile–and quickly–if he is playing a competitive game of tennis. Joe loves tennis. Terry is not a runner either. On the other hand, karate club is a highlight of her week, and she has worked to achieve some skill in it. Dr. Metzl advocates for finding the activity that gets you excited and making it a priority in your life. If you are having fun, that is a great motivation. Reducing the Cost to Act Another thing to consider is overcoming the cost to act. If your activity requires a lot of preparation that feels like a chore, the cost to act is high. If you can make it easier and break down that barrier, you are much more likely to accomplish your exercise. External rewards can also play a role. Joe loves winning, so he likes to play with guys at about his same level of skill. That way, he has a chance to win if he tries. For Terry, there was a progression through belt levels in karate, from yellow to green to blue, and so on. Now, she looks forward to closing the rings in the fitness app on her watch. When Doctors Prescribe Exercise, Does That Give You a Push? For Dr. Metzl, the idea of pushing yourself and maybe your friends is a positive notion. We asked him about people who dig in their heels when pushed. What approach do they need to perceive and pursue their goals? He summarized the three ingredients of healthy motivation as knowledge, emotion and belief. That’s knowledge of the benefits of activity, an emotional response of appreciating and enjoying activity and a belief that you can achieve your goal. This Week’s Guests Claudio Battaglini, PhD., FACSM, is Professor in the Dept. of Exercise and Sport Science at The University of North Carolina at Chapel Hill. He is also Director Emeritus of the Get REAL & HEEL Breast Cancer Research Program and Co-Director of the Exercise Oncology Research Laboratory. Jordan D. Metzl, MD is an internationally recognized sports medicine physician, bestselling author, and fitness instructor who practices at the Hospital for Special Surgery in New York City. He lectures around the world and founded the first physician-led online fitness community, IronStrength, with more than 50,000 members. He created the Ironstrength Workout, a functional fitness program for improved performance and injury prevention that he teaches in fitness venues throughout the country. An elite athlete himself, Dr. Metzl is also a 40-time marathon runner and 14-time Ironman finisher. Dr. Jordan Metzl, author of Push, runs the New York City Marathon 2025 Dr.Metzl’s latest book is Push: Unlock the Science of Fitness Motivation to Embrace Health and Longevity 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, April 27, 2026, after broadcast on April 25. On this episode, Dr. Metzl talks about the joy of teaching medical students to offer an exercise prescription and the challenge of getting specialties other than cardiology to integrate physical activity into their rehab process. Dr. Battaglini discusses the contrast between cardiac rehab, which is covered by insurance, and cancer rehab, which is not. He also describes the value of swimming, especially for older people with sore joints. Walking is good exercise and easy for most people. What if the weather is bad? Perhaps an indoor walk around the mall would be a good alternative, and if you can recruit some friends to join you, so much the better. You can stream the show from this site and download the podcast for free.

Many indigenous peoples around the world have developed traditional uses for psychedelic compounds. In Western medicine, these were mostly unknown until Albert Hoffmann synthesized LSD (lysergic acid diethylamide) in 1938. He later tried to figure out how it might be used after having an extraordinary personal experience. By the mid to late 1960s, psychedelic drugs like LSD or psilocybin had become a cultural phenomenon. By 1970, medical research on such drugs was essentially shut down. A personal note: I worked in the Neuropharmacology Laboratory at the New Jersey Neuropsychiatric Institute from 1967 to 1969. My mentors were Dr. Carl Pfeiffer and Dr. Leonide Goldstein. Both were actively involved in basic research into psychedelic compounds such as LSD and psilocybin. Dr. Pfeiffer’s first paper on the topic was published on March 14, 1957 in the Annals of the New York Academy of Sciences. I tested these hallucinogenic compounds in rabbits and rats using a quantitative EEG technology that Dr. Goldstein brought to the US from France. One of our papers was published in the Proceedings of the National Academy of Sciences (Oct. 1969). I share this in an effort to provide full transparency so that you will understand I was involved in basic psychedelic research before it was unacceptable to conduct such investigations. What Scared the FDA and the NIH? After 1970, if a researcher wanted to perform research on psilocybin or LSD, the FDA was not supportive. Neither were funders such as the NIH or private foundations. The memory of the 1960s with the slogan sex, drugs and rock and roll created a no-fly zone for scientific investigation after 1970. That was when the federal government passed the Controlled Substances Act (CSA). The CSA made LSD and related compounds Schedule 1. The meant that LSD and related hallucinogens were categorized like heroin with “no currently accepted medical use and a high potential for abuse.” This made scientific research virtually impossible. But over the last decade or so, there has been increasing interest in the use of such compounds to ease the anguish of post traumatic stress disorder, the existential crisis of a cancer diagnosis, drug dependency or even schizophrenia. But the hallucinatory potential of such drugs continues to discourage many researchers from studying such compounds. President Donald Trump Signs the Psychedelic Drugs Executive Order On April 18, 2026, President Trump signed an executive order titled: “Accelerating Medical Treatments for Serious Mental Illness“ For the first time in decades, investigators will be encouraged to conduct research into the therapeutic potential of hallucinogens such as psilocybin, MDMA and ibogaine. Health and Human Services (HHS) will be encouraged to fund research into psychedelic programs. And eligible patients will able to access such compounds for therapeutic purposes under the “Right to Try Act.” Here is the dramatic reversal: “The FDA and Drug Enforcement Administration shall facilitate and establish a pathway for eligible patients to access psychedelic drugs, including ibogaine compounds, under the Right to Try Act (21 U.S.C. 360bbb-0a), including any necessary Schedule I handling authorizations for treating physicians and researchers, consistent with 21 U.S.C. 823, and any applicable waiver authority under the Controlled Substances Act.” What Does This Mean? First and foremost, it means that psychedelic drugs can now be studied without fear by researchers at prestigious medical institutions. Agencies can now fund such research. The head of the Food and Drug Administration, Dr. Marty Makary, is on the record encouraging the FDA to accelerate review of such compounds. There is growing evidence that psychedelic compounds may help people dealing with severe mental health conditions. You will see research and have access to interviews with investigators that have been studying these drugs for years. Yes, there has been research, even if it was not sanctioned by federal agencies. Current Research on Psychedelic Drugs Over the past decade or so, investigators have been conducting research on the healing potential of psychedelic drugs. Dr. David Nichols, an international authority on these compounds, describes the history of this research. His son Charles Nichols, a pharmacologist, studies the molecular and behavioral effects of hallucinogens in animal models. The Healing Potential of Mystical Experience Dr. Matthew Johnson, associate director of the Center for Psychedelic and Consciousness Research at Johns Hopkins School of Medicine, has conducted a number of clinical trials utilizing psilocybin. He and his colleagues have been exploring the possible uses of psychedelic drugs as medicines for people with life-threatening cancer. They have also examined the possible benefits of a single dose of psilocybin for smoking cessation and overcoming alcohol misuse. Their research was highlighted in an episode of the CBS television show “60 Minutes.” How Psychedelic Drugs Affect Existential Crises When people are diagnosed with terminal cancer or other life-threatening conditions, many become extremely anxious or depressed. While this reaction may seem rational in the face of a frightening diagnosis and foreshortened life expectancy, it can interfere with people actually appreciating the days, weeks or months they have left. Dr. Johnson and other scientists have found that a session with psilocybin that results in a mystical experience can alter people’s lives dramatically. They have far less anxiety and depression and seem to find more purpose in their lives, along with other positive changes. How does this work? Dr. Johnson’s most recent publication (with colleagues) explores the nature of these mystical experiences (PLoS One, April 23, 2019). Our Radio Show Guests David Nichols, PhD, is an adjunct professor at the Eshelman School of Pharmacy at the University of North Carolina, Chapel Hill. David Nichols had an active research program at Purdue University for 38 years prior to his retirement in June 2012. His research interests focused in two areas: the study of hallucinogens (psychedelics), where he was recognized as an international authority, and also discovery of novel D1 dopamine receptor full agonists, which showed efficacy comparable to levodopa in both animal models of Parkinson disease, and in human Parkinson patients. In 1993 he founded the Heffter Research Institute, which has encouraged and supported modern clinical studies of the psychedelic agent psilocybin (from “magic mushrooms”) for treatment of depression, anxiety, and various addictions. His general interests continue in the medicinal chemistry and pharmacology of CNS-active agents. Charles Nichols, PhD, is Professor of Pharmacology at Louisiana State University Health Sciences Center in New Orleans. As David Nichols’ son, he did not begin his career with the intention of studying hallucinogens. However, his current research interests include the molecular and behavioral effects of such compounds on the brain. Matthew W. Johnson, PhD, is Associate Professor of Psychiatry and Associate Center Director of the Center for Psychedelic and Consciousness Research at Johns Hopkins School of Medicine. The photograph of Dr. Johnson is courtesy of Johns Hopkins Magazine. The website is https://hopkinspsychedelic.org Listen to the Podcast: The podcast of this program is available for free. The show can be streamed online from this site and podcasts can be downloaded for free. Download the mp3 Want More? Here is our radio show # 1317: Psychedelic Compounds for Healing You can listen by clicking on the arrow inside the green circle under the photograph of Bryan Roth, MD, PhD at the top of the page. It’s super easy! You will learn about conditions that may respond to psychedelic compounds: Cluster Headaches Substance Use Disorders Depression and Distress Would You Consider LSD If There Were No Hallucinations? Investigators at University of California, Davis have modified LSD so that it does not cause hallucinations. The new compound, called JRT, appears to have some therapeutic benefit, however. That’s because it increases neuroplasticity. So far, the drug has only been tested in animals, but the initial responses appear promising. The hope is that JRT will have fast-acting antidepressant activity and may even be helpful against schizophrenia (Proceedings of the National Academy of Sciences, April 14, 2025). The authors of this research point out that current treatments of schizophrenia leave a lot to be desired. They don’t work very well: “…for addressing the negative and cognitive symptoms, and evidence suggests that they are unlikely to rescue morphological or synaptic deficits.” One of the negative symptoms of schizophrenia often includes the term anhedonia, which is described as an inability to feel pleasure or joy. It is also characteristic of depression. Another negative symptom of schizophrenia is avolition. It means an inability to get motivated to participate in goal-directed activities. That’s psych talk for profoundly disturbing blahs. People just cannot mobilized to get going or stay going. Social activities are just overwhelming. Then there are the “impairments in attention and working memory.” It is hard to function when you have brain fog, little to no motivation, and few, if any, feelings of joy or happiness. JRT and Neuroplasticity: The researchers who helped create the new compound called JRT suggest that this nonhallucinogenic compound promotes “neuroplasticity” in the brain. So does LSD. What is neuroplasticity, you ask. It is, according to Wikipedia: “…the ability of neural networks in the brainto change through growth and reorganization. Neuroplasticity refers to the brain’s ability to reorganize and rewire its neural connections, enabling it to adapt and function in ways that differ from its prior state. This process can occur in response to learning new skills, experiencing environmental changes, recovering from injuries, or adapting to sensory or cognitive deficits. Such adaptability highlights the dynamic and ever-evolving nature of the brain, even into adulthood.” The researchers who helped create JRT note that: “Effective treatments for complex neuropsychiatric diseases like depression, substance use disorders, and SCZ [schizophrenia] are likely to involve multiple targets rather than a single site of action. However, the polypharmacology of such agents must be carefully tuned to maximize benefit while minimizing unwanted side effects. The unique polypharmacology of (+)-JRT might endow it with specific advantages compared to compounds currently in use.” “Despite its lower hallucinogenic potential, (+)-JRT has demonstrated profound therapeutic effects.” It’s a long and winding road before JRT could become available as a medication to treat challenging conditions such as PTSD or schizophrenia. In the meantime, there is a lot of new and intriguing research involving drugs that do induce hallucinations. The Future of Psychedelic Drugs? There is no good answer to that question. No one should undertake treatment with a psychedelic compound on their own. This approach requires well-trained healthcare professionals who actually know what they are doing. It requires a therapeutic setting with experienced therapists. Some people should not undergo such an experience. Despite the fact that I worked in a laboratory that had one of the world’s largest collections of LSD and other psychedelic compounds, I was never interested in a hallucinogenic experience. Some people may not be helped and might be harmed by such a “trip.” That said, I am pleased that the research doors (and funding) are beginning to open. After research was halted because of the “war on drugs,” we could now be entering a psychedelic renaissance. Let’s see what the research produces. Please share your thoughts in the comment section below. If you think friends or family might be interested in this article, please send it along. 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