Essay on Field notes

Does Stress Predispose Your Body to Injury?

Sat, 18 Apr 2026 00:00:00 +0000

Photo: Apr 2, 2026; Oklahoma City, Oklahoma, USA; Los Angeles Lakers guard Luka Doncic (77) walks across the court during the first quarter against the Oklahoma City Thunder at Paycom Center. Mandatory Credit: Alonzo Adams-Imagn Images

The Injury

I recently saw this guy on Instagram Reels, Stefan Duvivier or @airduvi. His LinkedIn bio says that he is a “Movement Coach” and high jumper. He was talking about Luka Doncic, the professional basketball player for the LA Lakers, who recently suffered a season-ending hamstring injury during a game (grade 2 strain, or partial muscle tear). The hot take? That Luka’s injury had much less to do with how many minutes he was playing on the court, and much more to do with the amount of stress he was experiencing off the court.

Luka is currently one of the most valuable athletes in the entire NBA, having recently signed a $165 million dollar contract for 3 years. He has access to some of the very best doctors, physios, athletic trainers and coaches from around the world, not to mention equipment and treatments and facilities. He has been in prime physical condition, losing more than 20 lbs last summer. However, despite all that going for him, his body was still breaking down, and repeatedly. All at just 27 years old, at a time when LeBron, who is 14 years his senior, is still thriving in his 22nd season. So what gives?

Maybe it’s just plain old bad luck. Sometimes the stars don’t align. Or maybe it has something to do with Luka’s whole world flipping upside down in the past year.

The Stressors

He was traded from the Dallas Mavericks back in February 2025 in a trade he didn’t see coming. His partner of 10 years and fiancée leaves in May back to Slovenia and takes their daughter with her. His second daughter is born in December, and apparently the police were called during a disagreement at the hospital. He then returned to the US on his own and since then has called off the engagement and is now embroiled in a bitter and very public custody battle over the two kids, who he hasn’t even seen since December.

Maybe his nervous system was activated in ‘fight or flight mode’, Stefan posits. As a result, maybe his deep hip flexors including his psoas muscles were chronically tense and tilted his pelvis forward, lengthening his hamstrings and putting them at a higher risk of injury at baseline. Maybe they’ve been building up tension with every step he took, until a big enough disruption finally overwhelmed the ability of the muscle fibres to keep it all together, and the muscle tore.

“Your hamstring doesn’t just randomly tear. It tears because the tissue has been under siege for months from a nervous system that never got to calm down.”
― Stefan Duvivier

Stefan argues that in chronic states of stress, cortisol is elevated, muscles are more tense and slower to recover, and that no amount of physiotherapy or adjustments or exercises are going to resolve the injury until the underlying cause is addressed and dealt with.

“When the nervous system doesn’t feel safe, when the ground underneath your life is unstable, the [muscles] grip and try to create stability that the rest of the system up top can’t provide for you.”
― Stefan Duvivier

When I heard this, I was quite struck by how powerful, poetic, and intuitive this felt.

The Research

This is not a new idea. These two sports psychology researchers from the University of Arizona wrote a landmark paper all the way back in 1988 called “A Model of Stress and Athletic Injury: Prediction and Prevention”, and this is also now known as the “Williams and Anderson model”.

This diagram from the original paper summarizes it well: when there is a potentially stressful event for an athlete, there is first a “stress response” – that is influenced by non-physical factors like personality, history of stressors, and coping resources, and modulated by interventions –> resulting in increased muscle tension, narrowing of the visual field, and increased distractibility –> that finally then leads to a physical injury.

Of note, this was largely a theory, a framework of hypotheses for future research direction rather than actual cold, hard, empirical data. Decades later, we have slightly more research to back this up, but overall still not a lot compared to, for example, research in cardiology.

Stefan cited in his video a paper published in 2024 called “50 Years of Research on the Psychology of Sport Injury: A Consensus Statement” that nicely summarizes the field of the psychology of sport injury over the past half-century. Seven experts from across the globe (one of whom was Canadian) came together to review the literature, and collectively had “over 130 years of academic experience, and over 150 peer reviewed publications, book chapters and books on the psychological aspects of sport injury” – certainly quite impressive. They broke it down into three domains: risk factors for sport injuries (both acute and overuse injuries), rehabilitation after sport injury, and return to sport, and also came up with some recommendations for applied practice of these principles for athletes, coaches, and sports medicine practitioners.

I took a deeper dive into the research on psychosocial risk factors for acute sports injuries, which highlighted a 2016 systematic review and meta analysis titled “Psychosocial Factors and Sport Injuries: Meta-analyses for Prediction and Prevention”. The study references the Williams and Anderson model and refers to it as a “path model” (A affects B affects C, as opposed to direct correlation A causes B), and essentially tries to find some hard numbers to support the model.

The researchers took 48 published studies that looked at psychosocial factors and injury rates, and found that the predictors with the strongest association with injury rates was stress response (r=0.27) and history of stressors (r=0.13).

In psychology, r values between 0.2-0.3 are considered medium-to-large effect sizes, and between 0.1-0.2 considered small-to-medium. Other factors upstream in the path, like coping and personality traits, had much smaller and almost negligible effect sizes (r=-0.07, and 0.01 respectively), although this to me is still encouraging, because it’s a lot easier to do mindfulness meditation than it is to change your entire personality or coping mechanisms.

Overall they found that the path model as a whole explained about 7% of the variance in injury occurrence, suggesting that 93% is explained by other things, such as biomechanics, training load, sport type, and bad luck. So while a stress response may have a medium to large effect on whether you get injured, it certainly doesn’t explain everything. Looking at the numbers directly, it seems like there were only 4 studies that actually measured stress response, probably because it is so multifactorial and difficult to measure. One of these was a 2007 study by Swanik et al, which looked at whether athletes who suffered noncontact ACL injuries had decreased baseline neurocognitive performance, that might suggest loss of neuromuscular control and higher stress response. The computer test that was used tested verbal memory, visual memory, reaction time, and processing speed. Unsurprisingly, the athletes who had ACL injuries had significantly worse performance on all of the above categories (p = 0.045 or lower).

What is perhaps more interesting is that psychosocial interventions studied (such as stress management), was associated with fewer injuries (r=-0.31), which corresponded to an equivalent number needed to treat (NNT) of 4.3. This means that for roughly every 4 athletes who go through a stress management or mindfulness-based program, one injury that would have otherwise happened could have been prevented. That being said, there were only 7 studies included that looked at preventative interventions. These ranged from 25 to 120 minute sessions spanning 4 weeks to 1 year in duration, and covered cognitive behavioural content such as self-regulation techniques, stress management, relaxation, goal setting, self-confidence, cognitive thought stopping, imagery, mindfulness, and emotion control. Populations studied included soccer players, gymnasts, rugby players, football players, and even ballet dancers.

The Mechanisms of Injury

OK, but why exactly did Luka’s hamstring tear, and how much of that really was due to life stress? We don’t and likely will never fully know. The authors of the meta analysis propose that strong stress responses are likely to reduce an athlete’s decision making capacities and leave them more vulnerable to errors, collisions, and compromised motor control, which is supported by the findings of neurocognitive testing such as described in the Swanik paper. Although not mentioned in the 50 Years consensus statement, we also know from other studies that stress responses (namely life-event stress and hardiness) are associated with peripheral vision narrowing (basically tunnel vision), which may decrease an athlete’s in-game awareness.

Stefan also mentioned decreased proprioception (the body’s sense of its own position in space) due to stress, although I wasn’t able to find any literature on this. The reality is probably multifactorial and complex, and may even involve factors we haven’t even thought of. The expert researchers say this under future directions for research, looking ahead to the next 50 years:

“We also advocate moving beyond traditional biopsychosocial approaches to sport injury, to include a nuanced understanding of institutional (physical environment, psychosocial architecture), socio-cultural (e.g. norms, collective values, cultural narratives) and policy (e.g. national, governing sport-body policies) level factors.”
― Tranaeus et al, 2024

What we do know is this: that athletes who are well supported by their coaches and teams, who are well-rested and get good quality sleep, and are in a social environment and culture where they feel safe reaching out for help rather than a culture of risk and playing through pain and injury, those athletes are less likely to get injured.

What we also know is that athletes who are motivated, have less fear of reinjury, and adhere to recovery regimens are the most likely to rehabilitate after an injury to pre-injury functioning and ultimately return to sport and competition. Individual factors are certainly at play, as athletes who have severe pain catastrophizing, a strong athletic identity, or perfectionistic tendencies tend to have prolonged and more distressing rehabilitation. Mindfulness, acceptance-based practices and cognitive behavioural therapy all help, as does gratefulness, as exemplified by my personal favourite player, Nikola Jokić.

I found this passage about perceptions around re-injury super interesting and a good example of the mind-body connection:

“Re-injury concerns typically involve reductions in perceived competence (e.g. ‘I’m no longer sure my body can handle the demands of competitive sport or if I get re-injured it will be even more difficult to attain desired levels of athletic proficiency’), autonomy (e.g. ‘I no longer feel in control of my body’s ability to stay healthy or to avoid re-injury’) and relatedness (e.g., ‘If I get re-injured I’ll once again be removed from the sport environment and people I care about and/or who reinforce my identity as an athlete’). Re-injury concerns delay or prevent a return to sport, increase attentional distraction, and negatively affect athletes’ post-injury performances.”
― Tranaeus et al, 2024

My Own Back Pain

I’ve always been interested in stuff like this, like how trauma shows up in the body and mind with the writings of Gabor Maté and Bessel van der Kolk, but also the idea of the mind-gut axis and IBS, or how the brain perceives pain in complex regional pain syndrome or fibromyalgia. Take the idea of total pain in palliative medicine: how stressors, existential suffering, anxiety, and mood can all modulate the (very real) physical pain that we experience, and which aren’t always fully treated with pain meds and pharmacology alone.

Watching Stefan’s video and learning about Luka’s life stresses made me think about my own chronic back pain. It all started in undergrad, first year of college. I was on the varsity novice men’s rowing team, which is a development team for people who haven’t rowed before. I was the weakest guy who barely made it on the team from tryouts, after some other guy got injured. The guys on the team were all these high level athletes in other sports like track and field or volleyball who wanted to try rowing, and from the beginning, I always felt like I had to prove myself, to get stronger and (literally) pull my weight on the boat.

We had morning practices on the water at 5AM three or four times a week, which I wasn’t entirely unused to from doing competitive swimming as a kid growing up at the club level, but combined with living away from home for the first time, keeping up with my medical science courses, and navigating a college social life, my nervous system was overwhelmed, even though I might not have known this at the time.

I weighed 150lbs (at the time lol) and I was told by coach that I needed to gain 20 or 30lb ideally, which despite all the late night snacks available on campus, I could never really do. So there I was, an insecure 18 year old kid trying to literally become someone else, bulk up and become stronger to earn my place on the team and be respected on a team I felt like I didn’t belong on, to forge an identity that I didn’t have. So I did the only thing I knew how to, which is to put my head down, and pull harder. I remember once I collapsed off the erg (rowing machine) after a tough workout, limped to the trash can nearby, and barely made it to puke my guts out. Another time, I had popped a blister on my thumb from pulling the oar so hard, and only realized when I noticed a blood stain on my shirt. At team huddle I brought this up and remarked that the bloodstain looked a bit too low and that I should be pulling a bit higher toward my chest instead, and everyone laughed.

UWO Men’s Novice Team - on the water practice. I am in the 7th seat, and yes Coach is telling me to reach more

And thus the back pain started. I’m sure there are a million other factors at play, such as the amount of time I spend sitting at a desk at work, my poor posture, and how I have a relatively long torso and short legs. But after dozens of massages, physio appointments, cable pull workouts, and even dry needling, what I can tell you is that I can’t remember the last time I didn’t have back pain.

And I’m not complaining. Sure, on some days it is really bad and majorly sucks, but overall it’s manageable, and I know I’m hardly the first person in history to complain about back pain.

I also don’t regret signing up for rowing at all, because I got to experience one of the best feelings in the world: sliding along the calm surface of the water, the sun just rising, birds flying by, the refreshing cool autumn breeze in your face, and the sound of 8 guys (and a girl coxie) sitting in silence, breathing in unison, and the feeling that anything was possible.

Would it have been nice to have that without lifelong back pain? Of course. But I have to be optimistic, and grateful. Because according to the research, that will give me the best chance of recovery.

Capitalism, culture and chronic pain

Wed, 14 Jul 2021 00:00:00 +0000

As published in The Hamilton Spectator newspaper, Opinion

For the original unabridge version, click here

North Americans are the highest opioid users per capita in the world.

A 2019 research study found surgical patients in the U.S. and Canada had a sevenfold higher rate of opioid prescriptions filled compared to similar patients in Sweden who undergo the same surgeries. There is no evidence to show that North Americans experience more pain than people from other countries, so why the substantial discrepancy? The answer seems to lie somewhere between capitalism and culture.

Morphine, the original opioid, is isolated from the opium poppy plant and has been used for millennia in Middle Eastern societies by ancient priests and physicians. Today, we have developed synthetic opioids such as fentanyl which are a hundred times more potent than morphine. Opioid drugs are listed by the World Health Organization as an essential medicine, indicated for the treatment of acute pain, pain caused by cancer, and palliative care. However, in North America, many patients with chronic non-cancer pain are prescribed opioids, and sometimes this has resulted in opioid dependence and subsequent illicit opioid use. A 2019 research study published in the Lancet describes the problem:

“From the 1990s to around 2011, aggressive promotion, under-regulation, and over-prescribing of pharmaceutical opioids caused a substantial increase in opioid dependence and overdose deaths.”

In fact, in January 2020, the CEO and founder of the pharmaceutical company Insys Therapeutics was convicted of engaging in a racketeering conspiracy to increase the profits from his company’s sublingual fentanyl spray, including the bribing of doctors to prescribe the medication to patients beyond the approved use for cancer pain. In November 2020, OxyContin maker Purdue Pharma pleaded guilty to three criminal charges including paying doctors a kickback to encourage them to prescribe more painkillers, as well as impeding the U.S. Drug Enforcement Administration.

The worst part of it is this: although opioids are powerful, they have not been shown in the literature to be superior to nonopioid analgesia (Tylenol and Advil) for chronic non-cancer pain. Ironically, opioid use may even cause more pain, a phenomenon called “opioid-induced hyperalgesia.” The longer patients are on opioids, the more likely they are to experience more pain, and consequently need more and more opioids — a neverending deadly cycle.

The other factor that contributed to the opioid crisis was the American, and by extension, North American culture. America has always been an innovator in instant gratification. For example, fast food is a staple of American cuisine, and with Amazon Prime Now, customers can get items delivered to their door within just a couple hours of clicking a button online. As a society, we want things now, and we would rather pay than have to wait. In medicine, both patients and doctors tend to look for a pill to solve every problem, which is often easier than doing the less glamorous and difficult work of long-term preventive lifestyle changes. The same concept applies to pain and pain control.

Opioids, like all drugs, carry risks. Mild, tolerable side effects include constipation, nausea and vomiting, but more serious risks include addiction, dependence and death. There were more than 19,000 opioid-related deaths in Canada in the past five years, according to the Public Health Agency of Canada. Many families were torn apart by opioid addiction that first began with a seemingly harmless postsurgical prescription; stories about family members finding their loved ones dead from unintentional overdoses are unfortunately too common.

I once read a New York Times piece titled, “After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea.” The author, an American who immigrated to Germany, writes about how she was surprised she was only offered ibuprofen (Advil) for pain control after her hysterectomy, and recalls her anesthesiologist explaining:

“Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.”

The opioid crisis was created due to aggressive and unethical pharmaceutical marketing, as well as the North American culture of instant gratification and “hacking” away inconveniences such as pain. It has resulted in patient deaths and addictions, a growing illegal trade, and finally in 2020, the criminal convictions of pharmaceutical executives. If more doctors were brave enough to recommend rest over opioids, and more patients willing to accept it, maybe, just maybe, the opioid crisis could have been avoided.

We Can Hack Pain — But Should We?

Sun, 14 Jun 2020 00:00:00 +0000

Red opium poppy plants. Photo by Marten Bjork on Unsplash

I learned recently that Americans are the highest opioid users per capita in the world. That was no surprise. However, this next fact made me stop and think: there is no evidence that Americans experience any more pain than people from other countries.

A 2019 Lancet study found that the use of opioid analgesics (painkillers) in the USA far exceeds its use in other nations. The US population consumed 68% of the world’s prescribed opioids between 2011 and 2013, despite only making up 4.25% of the global population. What’s going on?

s-DDDs=standardised defined daily doses, or the average dose of opioid per day. The USA leads the pack in both opioid usage and the growth of usage in the last few decades. Degenhardt et al., 2019

Origins of the Opioid Crisis

Morphine, the original opioid, is isolated from the opium poppy plant and has been used for millennia in the middle eastern societies by ancient priests and physicians. Today, we have developed synthetic opioids such as fentanyl and carfentanil, which are 100 and 10 000 times more potent than morphine respectively. Opioid drugs are listed by the World Health Organization as an essential medicine, indicated for the treatment of acute pain, pain caused by cancer, and palliative care.

Relative potencies of opioids. Image by Author. Data: CDC.

However, in North America, many patients with chronic non-cancer pain are prescribed opioids, and sometimes this has resulted in iatrogenic (from the Greek for “brought forth by the healer”) opioid dependence and subsequent illicit opioid use. The authors of the aforementioned Lancet article write:

“From the 1990s to around 2011, aggressive promotion, underregulation, and overprescribing of pharmaceutical opioids caused a substantial increase in opioid dependence and overdose deaths.”

In fact, in January 2020, the CEO and founder of the pharmaceutical company Insys Therapeutics was convicted of engaging in a racketeering conspiracy to increase the profits from his company’s sublingual fentanyl spray, including the bribing of doctors to prescribe the medication to patients beyond the approved use for cancer pain. He was sentenced to 66 months in prison. Criminal charges against other pharmaceutical executives tied to the opioid epidemic are underway.

It wasn’t until 2010 that rules and regulations were put into place, but unfortunately it was too little too late. Demand stayed high, and the illicit market profited from the mandated decreases in supply. In a sense, we had tasted the forbidden fruit and opened Pandora’s box. Now we can never go back.

The Efficacy of Opioids

The worst part of it is, opioids aren’t even that much better at controlling pain in the first place. In 2018 a systematic review of 96 randomized clinical trials and over 26 000 patients with chronic noncancer pain found that although the use of opioids was associated with less pain and improved physical functioning compared to placebo, the result did not meet the “minimally important difference”, or the smallest amount of improvement in a treatment outcome that patients could recognize as important. The incidence of vomiting, however, was significantly higher in the opioid group.

The 2018 SPACE Randomized Clinical Trial showed that for patients with moderate to severe chronic back pain, or hip or knee osteoarthritis, opioids did not improve pain-related function, and pain intensity was actually better controlled in the nonopioid group (with Tylenol or Advil). Adverse symptoms, however, were significantly more common in the opioid group.

Besides chronic pain, opioids are often prescribed for post-surgical pain. The 2019 PANSAID Randomized Clinical Trial looked at patients after total hip replacement surgery and showed that among the most common nonopioid analgesic regimens, ibuprofen (Advil) alone was the best, and significantly reduced morphine requirements.

A 2019 cohort study of just under 130 000 patients undergoing the same surgeries in the USA, Canada, and Sweden studied postoperative opioid usage. They found that after surgery in the United States and Canada, patients had a 7-fold higher rate of opioid prescriptions filled than patients in Sweden. Could it be that North Americans felt more pain or had more painful surgeries? No, because the patients shared similar characteristics across the three countries, including age, comorbidities, and type of surgery. While the irresponsible promotion of opioids by pharmaceutical companies play an undeniable role, I believe the discrepancy is also due to our deeper, more systemic cultural relationship to pain that allowed them to propagate their criminal marketing in the first place.

Differences in opioid prescriptions filled after surgery between the three countries. Error bars represent 95% confidence intervals. Ladha et al., 2019.

‘Hacking’ Culture — A Pillar of the American Economy

America has always been an innovator in ‘fast’ things. In other words, immediate gratification. Fast food is a staple of American cuisine with international icons like McDonald’s, Wendy’s, and Kentucky Fried Chicken. The Chinese take-out container was invented in Chicago in the late 19th century. With Amazon Prime Now, customers can get stuff delivered to their door within just 1–2 hours of clicking ‘order’. Americans want things quickly, and they don’t like waiting.

During my undergrad, I was an avid hackathon attendee. Hackathons (a portmanteau of hacking marathon) are typically weekend-long events where computer nerds get together to collaborate intensively on software projects. The culture can loosely be described as sweaty, chaotic, and intense. Sleep and hygiene are quickly sacrificed for the excitement of creating something awesome, and the chance to win some big prizes. Startups often sponsor these events, and it was at a hackathon where I first had a taste of Soylent.

Soylent in different flavors. Photo: Soylent.

Soylent is a meal replacement drink created in 2014 by a Silicon Valley software engineer. It was a fascinating concept: food was a time-consuming hassle that was only necessary for survival, and it could be solved as an engineering problem. Soylent was also cheap ($1.50/meal for the powdered version) and could even be a solution to food insecurity around the world. The idea caught on, and the founders raised $2.1 million via online crowdfunding, and then an additional $1.5 million of private funding right afterward. I bought into this idea too, and I purchased a couple of boxes of Soylent to use during exams when I was busy reviewing (read: cramming) semester-worths of notes to regurgitate them on the exam.

It was great. Meals became a 5-minute affair, the taste was tolerable, I felt full, and I had no dishes to do. However, by the end of the two-week exam period, I felt like I had lost something: the ability to taste, the ability to cook, and the ability to form solid stool.

When Soylent first came out, a big criticism was that in “hacking away” the “tediousness” of cooking and eating, you also hack away the human pleasures that come with preparing food and sharing a meal with others. Food has always been a centerpiece in human social behavior from the dawn of time. When was the last time you willingly hung out with someone in a setting that didn’t involve food or drink? We are so lucky to exist in a time when we have access to all the delicious cuisines on Earth, via both the restaurants that serve us these dishes and the ingredients and online recipes to make them ourselves. Taking that away is like stripping away a bit of makes us human. It’s a similar argument with pain.

Humans and Opioids

Opioids, like all drugs, are useful for a reason — they help us control acute pain, tolerate surgery, and provide symptomatic relief to cancer patients. But they also carry a lot of risks including addiction, dependence, and death.

The Opioid Chapters is a website that features interviews with patients and healthcare workers who have lived experience with opioids. One interviewee injured his back while working as a paramedic, and after trying many treatments, found that opioids were the only drug that dulled his pain. “The opioids worked,” he says. “They are about the only thing that has worked. But my tolerance increased and I needed more. So then it was like, ‘Okay, this is going in the wrong direction.’” At the same time, he is worried that doctors are being pressured to not use opioids at all, even when they are the only thing that works for some patients. Another interviewee talks about waking up one morning to find his wife slumped over, dead from an unintentional fentanyl patch overdose.

Ironically, opioid use may even cause more pain, a phenomenon called “opioid-induced hyperalgesia”. While we don’t fully understand why this happens, scientists believe it has to do with brain neuroplasticity and neurotransmitter modulation upon long-term exposure to opioids. This is another reason why Pandora’s box is next to impossible to close. The longer patients are on chronic opioids, the more likely they are to experience more pain, and consequently need more and more opioids — a never-ending deadly cycle.

Another interviewee, a family doctor, talks about the difficulty that came with taking over a high-opioid-prescriber’s family medicine practice and trying to taper down her patients’ opioid dosages. She reflects on how they got onto the high dosages in the first place and admits that the ‘hacking’ culture spills into medicine as well.

“More and more,” she says, “physicians are being trained to find a pill for every problem, instead of looking at the underlying root causes of disease and actually offering something that is a bit more holistic and durable.”

Dan injured his back working as a paramedic. Opioids are the only thing that dulls his pain, but his tolerance has increased. The Opioid Chapters.

Pain is a Part of Life

I came across an excellent New York Times opinion piece a couple of years ago titled, “After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea”. The author, an American who emigrated to Germany, writes about how she was surprised she was only offered ibuprofen (Advil) for pain control after her hysterectomy (surgical removal of her uterus). She wanted Vicodin (a combination of acetaminophen and hydrocodone, an opioid) instead. The author recalls her anesthesiologist explaining:

“Pain is a part of life. We cannot eliminate it nor do we want to. The pain will guide you. You will know when to rest more; you will know when you are healing. If I give you Vicodin, you will no longer feel the pain, yes, but you will no longer know what your body is telling you. You might overexert yourself because you are no longer feeling the pain signals. All you need is rest. And please be careful with ibuprofen. It’s not good for your kidneys. Only take it if you must. Your body will heal itself with rest.”

If more doctors were brave enough to recommend rest over opioids, and more patients willing to accept it, maybe, just maybe, we might not have had nearly as bad of an opioid crisis.

The opioid crisis was created due to aggressive pharmaceutical marketing, physician greed, and the North American culture of ‘hacking’ away inconveniences such as pain. It has resulted in patient deaths and addictions, a growing illegal trade, and the criminal convictions of pharmaceutical executives. It also resulted in a large discrepancy between the opioid use by Americans compared to use by the rest of the world, despite no good evidence showing opioids are more effective at controlling pain and restoring function compared to non-opioid painkillers.

Technology has come a long way in pushing the frontiers of human possibility. Silicon Valley startups and modern medicine have undoubtedly improved the quality of life for a lot of people. However, as the old saying goes, with great power comes great responsibility, and we should be careful before hacking away the last parts of us that make us who we are.

COVID-19 and Climate Change

Mon, 06 Apr 2020 00:00:00 +0000

I attended an online webinar the other day organized by the Canadian Association of Physicians for the Environment (CAPE). The session was titled “COVID-19 and climate change - Where do we go from here?” and consisted of a panel of speakers, including physicians and other board members of the organization. I was interested because I had heard something about carbon emissions dropping ever since people have been staying home and the economy had been slowing down. I wouldn’t say I have a passion for the environment, but I care about climate change and what inaction could mean for the Earth we are inheriting from our parents and the Earth we are leaving behind for our children. There are also many health implications. I heard this phrase once, “there are no healthy people on a dying planet”.

I wanted to share some of my takeaways from the event. The thing that I think is most effective at conveying the impact of climate change is data, and elegant associations made from that data. But maybe that’s just me.

Exhibit A - COVID-19 and energy use

An environmental consulting organization from Guelph called eMERGE put together some interesting data. They plotted Ontario’s hourly electricity demand for the last week of March, and compared it with the usage data during the same week during the years 2005-2016. It’s fascinating to see how the usage is fairly consistent at the start of the week, but then drops in anticipation and following the closure of all non-essential workplaces in Ontario by Wednesday March 25.

Source: https://emergeguelph.ca/how-our-hydro-footprint-is-changing-in-a-covid-19-world/

Another thing you’ve probably noticed are the unbelievablely low gas prices. Oil hasn’t been this cheap since the early 2000s! Besides the small fact that people aren’t driving to work anymore, this is also superimposed on top of a price war between Saudi Arabia and Russia, who are both increasing their crude oil production since an OPEC (Organization of Petroleum Exporting Countries) deal to lower output had expired at the end of March. This has crippled the oil markets, with the price of oil plummeting more than 50% since Jan 2020.

Source: https://tradingeconomics.com/commodity/crude-oil as of April 6, 2020 09:53AM

Exhibit B: The Research – who would’ve thought, nature is good for you!

Dr. Melissa Lem, a family doctor in Vancouver as well as a CAPE board member, highlighted four scientific papers that looked at the intersection of nature and health. She is also the Director of Parks Prescriptions for the BC Parks Foundation, which could explain the articles that she chose to share.

The first one was published by Kardan et al. in 2015 in the Nature’s Scientific Reports journal. It’s called “Neighborhood greenspace and health in a large urban center”, and basically they used satellite imagery and questionnaire-based self reports to see if there was any correlation between the density of trees of where someone lived in the city of Toronto with their general health. They found that “having 10 more trees in a city block, on average, improves health perception in ways comparable to an increase in annual personal income of $10,000 and moving to a neighborhood with $10,000 higher median income or being 7 years younger”. They also found that “having 11 more trees in a city block, on average, decreases cardio-metabolic conditions in ways comparable to an increase in annual personal income of $20,000 and moving to a neighborhood with $20,000 higher median income or being 1.4 years younger.” Wow. And cardio-metabolic conditions by the way includes hypertension, high blood glucose, obesity (both overweight and obese), high cholesterol, myocardiac infarction, heart disease, stroke and diabetes. Interestingly, there was no significant difference found with mental health problems including depression, anxiety, and addiction.

Side note: I was wondering why they chose to look at the perception of health as an outcome, and here’s what they say: “Subjective self-rated health perception was chosen as one of the health outcomes because self-perception of health has been found to be related to morbidity and mortality rates and is a strong predictor of health status and outcomes in both clinical and community settings”. Interesting! I can’t say I understand the math behind how they got those exact numbers for income and age, but they are powerful, objective measures!

Data was constructed from Geographical Information System (GIS) polygon data set ‘Forest and Land Cover’, which from a Google search is simply available here. Cool!

The second study Dr. Lem mentioned was done by Taylor & Kuo in 2008, published in the Journal of Attention Disorders. The study was called “Children With Attention Deficits Concentrate Better After Walk in the Park”, and the result is right there in the title. They enrolled 17 children aged 7 to 12 years old who are clinically diagnosed with ADHD and had them go through 3 guided 20-minute walks through a city park, downtown, or residential area. The walks were 1 week apart, and children were randomized to the order of walks. After each walk, concentration was measured using the Digit Span Backwards test (repeating lists of numbers backwards). The result? They found that the children with ADHD had the highest concentration after the walk in the park, and the effect size was comparable to those reported for the ADHD medication methylphenidate, otherwise known as Ritalin!

DSB = Digit Span Backwards test

Ok big deal, outcomes like perception of health and concentration are prone to confounding factors and subjectivity. I want cold, hard indisputable evidence. Well, the next study proved just that.

In their 2019 paper, “Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers”, Hunter et al. looked at two physiological biomarkers of stress—salivary cortisol and alpha-amylase, before and after spending at least 10 minutes outdoors in nature (“a nature experience”). This can be done any time throughout the day, at the participants’ discretion. As they write in their introduction, the researchers’ ultimate goal was to come up with a “nature prescription” as a preventative, self-administered, low-cost treatment for mental well-being. As with any medication, the effectiveness of “nature pills” need to be validated for their clinical pharmacology and dose-response. Sometimes this can be nuanced, for example, cortisol release follows a diurnal (daily) pattern. Due to a phenomenon called the cortisol awakening response, salivary cortisol levels are highest in the morning around half an hour after awakening, and then drop off during the day. Cortisol is produced by the adrenal cortex and regulated by the hypothalamus-pituitary-adrenal axis (brain feedback pathway), however the cortisol awakening response is controlled by the hippocampus, which takes over the HPA axis. The theory behind this increase in cortisol is thought to have to do with the hippocampus “preparing” the body for the stresses of the day. Interestingly, this response is reversed in people who work night shifts. It does not seem to occur with naps and seems to be elevated in people of lower socioeconomic status. A similar phenomenon occurs with alpha amylase, the other stress marker the study looked at, which is a digestive enzyme secreted by the pancreas and salivary gland, to pre-digest starches into sugars in your mouth. However, alpha amylase undergoes a diurnal rise rather than a drop.

Anyway, because of these phenomena, which is different for each individual, the researchers needed to separate the effect of the nature pill from the diurnal cycles in cortisol and amylase (which are relatively stable for each individual). Instead of taking multiple saliva samples throughout the day to establish individual patient baselines, they were able to extrapolate the diurnal trajectory based on pre-nature pill samples and accommodating for time of day (I have to admit, I don’t fully understand this part). And the results? They found that a single “nature experience” (of 10 minutes or more) reduced salivary cortisol by 21%/h and reduced salivary amylase by 28%/h. The optimal “dose”? 20-30 minutes. That’s all it takes, half an hour of being outside! A quick walk around the block, or even as part of your commute.

NE = nature experience

And finally, the last paper was another Nature Scientific Reports article written by White et al. in 2019, entitled “Spending at least 120 minutes a week in nature is associated with good health and wellbeing”. Couldn’t get clearer than that. They took the survey responses of just under 20000 people in the UK and looked at relationships between weekly recreational nature contact (defined as contact with parks, woodlands, and beaches) and self-reported health and well-being. They controlled for confounders such as residential greenspace (which we know has a positive effect, from paper #1!). The results? Compared to no nature contact in the past week, people who had at least 120 minutes (2 hours) of nature contact were 1.6 times as likely to report better health, and 1.2 times as likely to report higher well-being. And as we know from study #1, self-perception of health has a strong correlation to actual morbidity and mortality, as well as health status. Positive associations peaked between 200-300 minutes per week, with (interestingly) no further gain. The pattern was consistent across people of older age and with chronic health conditions. Another key finding was that it didn’t matter how the 120 minutes was achieved, whether in one sitting (ironic phrase), or spread out across the week.

TL;DR. So what does this all mean?

More greenspace in your neighbourhood = more health, wealth, and youth.
A 20min walk in a city park had the same effect as Ritalin for children with ADHD.
A 20-30min “nature experience” optimally drops the biomarkers in your saliva associated with stress.
2-5 hours of nature contact per week = better health. Doesn’t matter how you do it.

Humans evolved and adapted to living in nature, not the concrete jungle. Nature is better for your health.

Exhibit C — The idea of “Planetary Health”

Dr. Courtney Hayward is an ER doctor in Yellowknife, NWT, as well as the CAPE board president. She talked about the concept of “Planetary Health”, how our health care system can only function when it is built on a foundation of natural systems (oxygen, water, food, climate) and socioeconomic factors (job security, shelter, education), which are determinants of health. The quote from above still rings true: there are no healthy people on a dying planet.

In 2015 the Rockefeller Foundation and the Lancet medical journal formed a commission and wrote a report. I’m just going to copy and paste the executive summary because I think it is just fantastically written:

By almost any measure, human health is better now than at any time in history. Life expectancy has soared from 47 years in 1950–1955, to 69 years in 2005–2010, and death rates in children younger than 5 years of age have decreased substantially, from 214 per thousand live births in 1950–1955, to 59 in 2005–2010. But these gains in human health have come at a high price: the degradation of nature’s ecological systems on a scale never seen in human history. A growing body of evidence shows that the health of humanity is intrinsically linked to the health of the environment, but by its actions humanity now threatens to destabilise the Earth’s key life-support systems.

As a Commission, we conclude that the continuing degradation of natural systems threatens to reverse the health gains seen over the last century. In short, we have mortgaged the health of future generations to realise economic and development gains in the present.

“We have mortgaged the health of future generations to realise economic and development gains in the present.” Wow.

Full infographic: https://www.thelancet.com/infographics/planetary-health

Conclusions

The current pandemic is greatly affecting the way we use energy.
Research clearly shows positive health effects of nature.
Human health is very much integrated and dependent on environmental health. If we care about human health, then we must care about the health of the environment as well.

One of the stated goals of the webinar was “How can we talk about climate change during a global pandemic without seeming tone deaf or opportunistic?”. I don’t know the answer to that. I can say I care about the environment as much as I want without doing anything. Hopefully, this summary and the links help to increase awareness—I know writing it has taught me a lot. But I’ll end with a quote from Dr. Hayward near the end of the Q and A session, regarding the zoonotic transmission of the novel coronavirus:

COVID-19 is exactly an example of why we need to care about the interface between human society and nature.

Addendum (April 14). Some of my classmates sent me some additional articles related to COVID and climate change. I didn’t go through them in detail, but here they are with a one-liner:

Exposure to air pollution and COVID-19 mortality in the United States.. This is a neat study from Harvard that looked at pollution data (measured in average PM2.5 levels, which is basically a measure of fine particulate matter with a diameter of less than 2.5 microns) and the COVID-19 death rate across the country. They fonud that an increase of 1 ug/m^3 in PM2.5 level is associated with a 15% increase in the COVID-19 death rate. You can’t get a more direct connection than that.
Positive Effects of Nature on Cognitive Performance. Another use of the backwards digit span task, this time as a measure of cognition in general, and in adults. Results showed significant beneficial effects of nature compared to urban environments. Awesome.