Dude, Where’s My Cure? (a pharma mystery solved at last)

6 October »

Fourteen years ago, a drug called J695 cured (more or less) my Crohn’s Disease. Then it disappeared.

Ever since, I have wondered what happened to it. At times — in bad flares — I  searched desperately.

I recently learned why J695 disappeared, and the story is even uglier than I imagined. It is a cautionary tale about the pharma industry, clinical research, and the prospect for a cure for any chronic illness.

Hope made me hotter then. (me with the research team at NIH, in 2003)

Clinical Trials

My experience with J695 began in early 2001. I was living in the Washington, DC metro area and looking for work. My health insurance situation was a bit tenuous, but I happened to see an ad recruiting Crohn’s patients for a clinical trial at the National Institutes of Health. The trial meant I would get free, cutting-edge care for my Crohn’s — or a placebo.

Even if I got the placebo, I saw the trial as something like community service: helping to advance the science for all patients. Just a couple years earlier, my friend Chuck had died from a genetic immune disorder. He had been treated extensively at NIH, and always spoke of it in glowing terms. To some extent, I volunteered because it reminded me of Chuck.

Still the best hospital I've ever been to.

I signed up for the trial, driving almost an hour across town to the NIH campus. I was told only the basics of the medicine: that is was called J695, and it was an IL-12 antibody made by Abbott. Interleukin-12 is a chemical signal the body uses to regulate the immune system; it plays a role in the inflammatory response typical of Crohn’s and certain other autoimmune disorders. (It turns out that J695 is an antibody to IL-23, a similar immune signal.)

I received weekly injections for six weeks, but neither I nor the doctors knew whether I was getting J695 or the placebo. I also volunteered for sigmoidoscopies — basically, quick colonoscopies — so the doctors could check my insides and take cell samples to track histologic change. I did bowel prep four times in eight weeks. The flex-sigs were done with only light sedation. I still cringe when I remember what it felt like when the doctors plucked tissue samples from my insides.

For the first few weeks, the drug did nothing — which was a huge downer. Then, all of a sudden, it started working. I felt great — the best I had felt in seven years of living with Crohn’s. I felt so good, in fact, that I’m too embarrassed to go into specifics. My health changed so quickly that it felt like a switch had flipped somewhere.

I remember the research nurse telling me, “We think you might be on the placebo.” Since the placebo was saline injections, I replied, “If that’s true, I’ll be stealing stuff to finance my saline habit.”

It turned out I was in the placebo group — except that I accidentally received a dose of the medicine towards the end of the study. I didn’t find out until 2004, when the  New England Journal of Medicine published an article about the clinical trial:

One patient in the subgroup (Patient 2) (data not shown) was randomly assigned to receive placebo but inadvertently received a single dose of antibody as the fifth scheduled dose. This patient’s baseline secretion of interleukin-12 (310 pg per milliliter), interferon-γ (18,515 pg per milliliter), and TNF-α (6468 pg per milliliter) fell to 0, 1471, and 4342 pg per milliliter, respectively, two weeks later, coinciding with the induction of remission (reflected by a decrease in the CDAI score from 279 to 143).

What this means is that one dose of the medicine was enough to induce remission in me: my disease activity dropped from 279 to 143 — just about halved, in two weeks. The effect was very durable. I felt awesome for a couple of months.

Let me admit: this might not qualify as a cure. But it sure seemed like it at the time. Granted, I don’t know what the long term effects of J695 are, or whether my body would become resistant to it, or whether it still even works for me. But compared to every other drug for Crohn’s I have taken before or since — including other clinical trials — J695 felt pretty damn close to a miracle.

When the J695 started to wear off, I asked for more. The doctors told me they couldn’t — and at that point, even they didn’t know whether I had received J695 or the placebo. We looked into compassionate use, an FDA policy that allows patients to use unapproved drugs, but got nowhere. Instead, they gave me a dose of Remicade and started me on Imuran — part of an open-label protocol they were running. That combination put me back into remission.

Even though I was in remission, I developed a stricture. The team at NIH diagnosed it, but I had to get the surgery done somewhere else. In the meantime, I was getting my blood tested regularly at the NIH. Then, in 2003, the doctor informed me that I had to stop the Imuran: it was causing neutropenia, lowering my white blood cell count too far.

Within weeks, I began to flare. I tried Remicade again — through a private gastro practice — but it turned out I had developed an infusion reaction. The GI refused to try it again. I contacted the NIH and asked if I could try J695 again. I was told, again, that I could not — and, in fact, that the drug had been shelved by Abbott, its manufacturer.


Back to 2001: when I started the J695 trial, Remicade was a brand new drug for Crohn’s. Nobody knew that it would be a runaway success for its parent company, Johnson & Johnson. The drug — an antibody to the TNF molecule — was expensive to make and expensive to take. But within a few years, Remicade became a blockbuster drug, even despite fairly significant risks of infusion reactions like mine, among other adverse effects.

Based on the success of Remicade, several other companies turned their attention to anti-TNF drugs in development. For Abbott, that was Humira, which was developed as a rheumatoid arthritis treatment. Meanwhile, Abbott had begun to see the results of the J695 trials, and they were not outstanding. Because J695 and Humira were aimed at the same market, and Humira was farther along in the approval process, they shelved J695.

At this point, I should explain that ‘biologic’ drugs are produced by genetically engineered cells. Most biologics are antibodies: that is, molecules that attach to bad molecules (or even other cells, like bacteria) in the body to flag them for removal by the immune system. Your immune system wouldn’t normally produce antibodies to IL-12/23 or TNF, simply because those molecules are supposed to be good.

The antibody molecules are simply too complex to produce with normal chemistry, but cells have all the necessary equipment.  To develop the drugs, scientists take a cell, insert DNA to produce the appropriate antibody, and then clone that cell a jillion times so that the cloned cells produce enough of the antibody to sell.

The use of these cells makes the drugs ‘biologic’ — as opposed to most drugs, which are relatively simple chemicals. Any drug name that ends in ‘mab’ is a biologic ‘monoclonal antibody’ — infliximab (Remicade), adulimumab (Humira), certolizumab (Cimzia), etc. — made more or less the same way.

Remicade was developed from murine cells — that is mouse cells, genetically engineered to produce the TNF-alpha antibody. The problem with this approach is that antibodies produced by mouse cells look foreign to human immune systems. So the scientists had to further engineer the mouse cells to produce a human-like antibody that would be less likely to be rejected. These human-like antibodies are called ‘chimeric’ — from the ancient Greek myth of the Chimera. In my case, the chimeric antibodies didn’t fool anyone: my immune system had fully rejected them by my third dose of Remicade.

The other way to make TNF antibodies is to engineer them directly from human cells. This is a little trickier, but makes the immune system much less likely to reject the drug product. That is what Abbott did for its anti-TNF drug, Humira — which is why Humira is considered safe enough to be self-administered by patients in their homes.

As a result, Humira quickly took market share from Remicade. The year it was launched for Crohn’s — 2007 — Humira did $3 billion in sales. Last year, Humira posted $12.5 billion in sales, making it the best-selling drug in the world.  (In fact, 3 of the top 5 drugs were anti-TNF biologics; Remicade was third, Enbrel was fifth.)

Remicade and Humira are both protected by patents, of course. Threatened with encroaching sales from Humira, Johnson & Johnson filed suit against Abbott — in 2007, the same year Humira was approved for Crohn’s. J&J’s argument was that their patent on Remicade (mouse cells) covered any similar drug derived from human cells (like Humira), and therefore Abbott owed them money for patent infringement.

In 2009 a jury decided in favor of J&J, awarding them the largest patent-related damages award in U.S. history: $1.67 billion. The verdict seems like a big pile of money, until you see the huge-er pile of money it was supposed to come from. Abbott, not wanting to see any of their piles of money get smaller, appealed the case.

In 2011, Abbott won a reversal of the verdict. The judgment combines the mind-boggling complexity of immunology biotech with the lead-plate opacity of patent law, and — in all honesty — I am barely treading water reading it, but basically it says that J&J (rather, its subordinate Centocor) failed to produced a written description for its Remicade patents that covered fully-human versions of the molecule (like Humira).

You might reasonably think: good for Abbott. They had a better drug, it was different in significant ways from Remicade, and this ruling is good for patients because it creates more options for us.

Back to J695

But but but…. while the above case was pending in Federal court, Abbott filed a lawsuit against J&J subsidiary Janssen for exactly the same thing.

Apparently Abbott started looking at J695 again — which it now called ABT-874 or briakinumab — several years after my clinical trial ended. After letting it sit on the shelf, they pulled it down and started testing it again for Crohn’s disease, under the new name. They also started testing it on plaque psoriasis, because Janssen had developed an anti-IL-12/23 drug called Stelara that was on the verge of winning approval for that disease.

Abbott sued Janssen in 2009, claiming that Stelara (ustekinumab) violated the patent protection Abbott held for J695. The major difference between the two is that J695 is a human antibody, where Stelara is a chimeric antibody originally from mouse cells. And, of course, Abbott’s patent on human antibodies was not written to include antibodies derived from mouse cells. Abbott even used the same expert witness for both trials — first to claim J&J’s patent was invalid, then to claim Abbott’s patent was valid.

The jury returned a verdict against Abbott — now called AbbVie — which was subsequently upheld on appeal by the same appellate court that overturned the J&J victory on Remicade. The court even cited their decision in that earlier case, to explain why AbbVie’s patent claims held no water. In fact, as a result of the case, AbbVie’s patent on J695 was invalidated: they no longer have a patent on an IL-12/IL-23 antibody.

Now you might reasonably think: it’s good to see that justice is blind. This was a decision that is bad for Abbott — but good for patients, because it encourages competition with J695 and rewards Jannsen for bringing Stelara to market first.

But: even before this case went to appeal, AbbVie stopped development of J695. They terminated a clinical trial for Crohn’s — forcing test patients to stop taking it, even if the drug was working for them.

They reported the reason was that regulators had asked for more information from Phase III clinical trials, but it would also be a bad financial decision for AbbVie to pursue a drug that they had no patent for and wasn’t even the first of its kind. The previous link says projected revenues from J695 were $800 million — barely a rounding error on the insanely piles of money they are already making from Humira.

I am f—–d

Remember that I burned out on Remicade: I had an infusion reaction because my immune system recognized the mouse-human chimera antibodies as foreign. That means I probably won’t be able to take Stelara, either, since it’s also a chimeraic antibody. Stelara is currently FDA-approved for plaque psoriasis, and it seems to work really well. But if you have psoriasis and your system can’t tolerate chimeric antibodies, it’s not going to do you any good.

With J695/ABT-874/briakinumab gone — and extremely unlikely to come back, even if Stelara proves a knockout bestseller — there is probably zero chance of me getting J695 again. My only hope — oh so very slim — is that some other company will produce a human antibody to IL-12/23. Until then, that one accidental dose of J695 will live in memory — probably idealized, sure — as the closest I ever came to a cure.

Anyway, it’s too late for me. After I was taken off Remicade, I flared for three years straight — during which time I tested two other drugs at the NIH, and then tried Humira off-label in 2005, two years before it was approved for Crohn’s. Humira didn’t do jack for me. There weren’t even guidelines for its use in Crohn’s yet, so my gastro doubled my dose for a while, until he found out that was probably what was sending me to the hospital once a month.

When we gave up on Humira, he decided the only thing left was to cut out most of my colon. So we did that, and it worked, albeit with some significant lasting consequences. Even if J695 is approved some day, it won’t regrow my colon. But I might still flare again — godforbid — and the one drug I am absolutely certain will work, I can’t have.

In our various patient communities, we have the idea that research is all that’s standing between us and a cure — whether it’s Crohn’s, UC, or even some non-IBD disease. I thought that in 2001, when I volunteered for the J695 clinical trial — and, wouldn’t you know, it looked like I was right. For a while, at least. Until I realized I couldn’t get J695.

The truth is the research we pray for, the research we raise money for, and the research we volunteer for doesn’t matter at all, if the pharma company that holds the intellectual property decides not to bring a given drug to market. The job of these companies is to produce value for shareholders: in that light, it would be criminally negligent of Abbott to market a patentless biologic that competes directly with its flagship product.

I am not against hope, and I am not against research. Both are good and necessary. But we square our hope against the economic realities of our pharma system, in which the decision to produce a cure depends not on the good it does for sick people, but on the good it does for shareholders.

If that forces us to moderate our hope, to live a little more in the present, to confront our disease more directly — well, that’s okay. Maybe even good. For me, I don’t spend any time these days hoping for a cure.

I found a cure. I just can’t have it.

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I Shared My Netflix Password With Death

2 October »

I love when people say, ‘I was at Death’s door.’ Oh, were you? Really? So what. I moved in with the guy.

To be fair, I didn’t know it was Death’s door, not at first. I thought it was just a cheap sublet: utilities included, pool privileges, no security deposit, no references. Sure, that should have been a red flag, but I was really sick and only could afford month-to-month.

So I moved in. I quickly found out why Death was cool about the references: every time I made too much noise or came in too late, he would say in that weird creaky whisper, “Your time is nigh.”

Hot Pockets are nigh?

Death is way into hoodies.

Since he didn’t really eat or use the toilet, I had to do most of the housework. When I left a plate out or a tissue missed the trash can, he’d bring it to my room and just stand at the door moaning, “Your time is nigh….” I’m like — I got it, bro; enough already.

I was surprised Death mostly works from home. With life expectancy steadily increasing and everything done by computers these days, why not? But that meant Death was always there. Death was always present, looming… a little too nigh, if you know what I mean.

He seemed lonely. I asked him, “Did you used to hang with Conquest, War, and Famine?” He just said, “Racists.” And that was the end of that conversation. Later he even asked me to be his emergency contact. I tactfully declined. I mean, we were roomies, but I was never that close to Death.

The downside to being a self-employed eternal malevolent force is that you can’t get a social security number or a credit card or Netflix or Amazon or anything like that. So I reluctantly — after “Your time is nigh” about a thousand times — gave him my passwords.

Guess who loves free two-day shipping? He would sit with his laptop muttering: “Harry Potter is nigh…. Batteries are nigh…. Socks are nigh….” The only way it could have been better for him is if they sold cigarettes and firearms.

Death also couldn’t get an ID, and this was just when alcohol sales were getting really strict and even scything your way through checkout at Harris Teeter wouldn’t get you a six-pack. He’d hand me a blood-stained twenty and I’d get him a case of Pabst Blue Ribbon and keep the change. That was a good night for Death: sitting on the couch drinking beer, watching Christopher Reeve movies from my Netflix, groaning, “Your time is nigh…” over and over at the screen.

Death kept to himself, mostly, but sometimes his job was hard to ignore. When he did Ronald Reagan, I tried to high-five him, but he wasn’t having it. He just said, “His time was nigh….” Then a few days later: Ray Charles — man, was I was pissed! Death looks at me with those huge vacant holes for eyes, and — no lie — sings, “The nigh time… is the right time….”

So when people say, ‘I laugh at Death’, I’m like… why? That’s like admitting you laugh at Rob Schneider. The dude just isn’t funny.

He wasn’t my best roommate ever, but — honestly — not my worst. Things only got awkward when Death decided we should get a puppy. I’m like, dude — you threaten to kill me every time I leave a bottle cap on the counter; who is going to clean up after this dog? Him: “Your time is nigh….” I knew I had to find somewhere else to live.

As I was boxing up my stuff, Death moped around and wouldn’t help. Finally, he asked me why I was moving out, so I say: “The thing is, bro: the rent is too damn nigh….” We both laughed, and then he really did try to kill me.

Seriously: I’m lucky to be alive. Death is a jerk.

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The Guide To The Future of Medicine: a review

28 September »

41nvAZZh4YL._SX331_BO1,204,203,200_Medical futurist Bertalan Meskó, MD, PhD, was kind enough to send me a copy of his book, The Guide To The Future Of Medicine. This review goes on a bit, so let me tl;dr: it’s a good book, but it avoids more questions than it answers.

The Future of Medicine is a thorough and interesting survey of many trends in medical technology. I enjoyed the book and found it provocative — so much so, in fact, that a lot of what comes next is going to sound like criticism. I intend it to be constructive criticism, insofar as my main complaint is that Dr. Meskó did not do more with the material: he skimps on much-needed analysis.

After brief introductions, the book is organized by ‘trend’: there are 22 of them, total, each presented in a few pages, one after the other. Let me say: it is super, super awesome and of extreme importance to me that the first trend is ‘Empowered Patients’. For that alone, I can forgive Dr. Meskó any sins he commits elsewhere in the book.

Later chapters cover topics like “Eating in the Future” (Trend #3), “Surgical and Humanoid Robots” (#7), “Growing Organs in a Dish”(#11); “Hospitals of the Future”(#18), and so on. In each trend, Dr. Meskó documents cutting-edge innovators with interviews and photos. He has certainly done a lot of research for this book: he describes a great many people and products in these chapters.

Alas, the trends can be too product heavy, so that The Future of Medicine sometimes reads like a catalog — namely, the Sharper Image catalog circa 1990: I would go through and point out all the cool futuristic things we needed, which my parents would then refuse to buy.

This is not a trivial comparison. Dr. Meskó describes “the world’s first soft wireless organic sensor system”, which detects liquid and can be “mounted to diapers”. My initial thought – familiar from all those Sharper Image catalogs — was, ‘wow, very cool!’ But then I thought, ‘who is this for?’ — which is probably what my parents remember about those catalogs.

As a new father, I can tell you that I already have a very reliable ‘soft wireless organic sensor system’ that tells me when diapers are wet. She also has her dad’s eyes and malicious sense of humor (so one assumes, at this point). Anyway,  the diapers we buy already have a built-in wireless sensor system for detecting liquids: they have a yellow stripe that turns blue.

The Future of Medicine is at its worst when printing uncritically claims made by people selling things — again, like a catalog. For example, Conor Russomanno, who helped raised $200,000 for a brain-computer interface on Kickstarter: “Miracles take place when technology makes it possible to get the information that we actually need.” This in a book with no index.

Even in some of the better chapters, Dr. Meskó’s map of the landscape avoids important questions about the technologies he describes. In the chapter about robotics, he does not address the problems with robotic surgery: namely that it is more expensive, no more effective, and probably less safe than conventional or laproscopic surgical techniques.

As someone who has had both conventional and laproscopic surgeries, I can say that the latter is a quantum leap over the former. But I’m deeply suspicious of robotic surgery. In fact, when video went around of someone using a DaVinci robot to fold a paper airplane, I found that I could do the same trick faster with tweezers, and almost as fast with chopsticks.

The problem recurs with ethical questions. Dr. Meskó acknowledges them — kudos for that — but does not address them, which is almost as bad as ignoring them. Discussing the use of fetal blood in the maternal bloodstream as a way of detecting chromosomal abnormalities, Dr. Meskó writes: “Would it lead to genetic discrimination before birth?” But this is already happening. It’s not an abstract question, and it’s not somewhere off in the future. This is a very real ethical problem that physicians and patients and parents are wrestling with right now.

I don’t expect Dr. Meskó to have all the answers, but I also can’t help feeling that a ‘Guide to the Future’ ought to do more in the way of, well… guidance. The book devotes two pages to asking, “What will a brand-new society look like?” (Trend #22), which is followed — I swear — by two pages about a guy named DaveCat who has a sex doll wife and a sex doll mistress.

There is room for guidance in the book — it’s a quick read, with lots of pictures (including a half-page picture each for the sex doll wife and sex doll mistress, who presumably couldn’t be in the same photo because they aren’t speaking to one another). But Future of Medicine has been put together without an organizing principle or a sense of the (figurative) bigger picture. I believe in techspeak this is called ‘siloing’.

One of the liabilities of the trend-by-trend siloing is that it encourages the reader to consider trends apart from each other, even when the trends are working at cross purposes. For example, if I am the patient of the future – empowered with a bioinformatic AI system(#9, #16) and my own  laboratory-on-chip diagnostic smartphone add-on (#10), with programmable nano-bots in my blood (#17) that can fight infections, heal wounds, and all sorts of stuff — why do I need a hospital (#18)? In which case hospitals will exist mostly to serve people too poor to afford their own home care, in which case the hospital of the future will look like a shabbier, grimier version of the hospital of the present.

Dr. Meskó’s main goal in the book is to prepare physicians for the change that is coming, but I think he soft-pedals the disruption that could happen. Consider this: my primary need for physicians right now — and for the last several years — has been to write prescriptions for medicines. It is telling that pharmaceuticals — actual, literal medicines — are mostly absent from The Future of Medicine. Based on the trends that are in the book, it seems highly possible that in ten years or so, I will be able buy a home diagnostic kit that connects via smartphone to an FDA-certified medical AI system, which confirms my need for and compliance on those meds — and probably could do so more regularly and reliably than any of my physicians does now. The system could then automatically link to my pharmacy to renew or update the prescription.

In that future, a medical degree would be roughly equivalent to a taxi medallion in today’s Uber markets. I expect the American Medical Association and the hospital lobby would fight just as hard as the taxi drivers — but who is winning that fight?

The lack of integrated thinking — of building the trends into possible futures — plagues this book. Maybe it is because I read it as a patient, looking for things I will do for my health in the future, where Dr. Meskó wrote it with a mind for what he as a physician could do. The difference is also that between social and clinical thinking — a distinction I think is incredibly important to understanding healthcare, even if I can’t convince anyone else. Physicians are trained to think clinically by focusing on how patients are different; social thinking requires us to think about how patients are connected. Dr. Meskó is surely very smart, but his clinical training becomes an obstacle when he approaches what are — ultimately — social questions.

I said something about ‘constructive criticism’ earlier, so let me pay up: one way Dr. Meskó could have incorporated more social thinking into the book is by including patient models — say five or six different fictitious people with various medical histories — and show how their lives and care change with the innovations. Another useful signpost would have been to try to forecast how medical practice might change in 5, 20, and 50 years, focusing on the ordinary sort of medical care that most of us get.

Of course, the flip side of social thinking is that these trends might not make any real difference at all 5, 20, 50 years from now. Technologies do not transform societies simply by being created. Think about the Segway, and the parade of hype before that invention — which is so far “disruptive” only if we are talking about the market for mall-cop golf carts. Society has not changed, because the existing ways of doing things are too deeply entrenched. So might the very deeply entrenched players in medicine prevent many of these inventions from changing how they do business.

Physicians, in particular, have been very slow to adopt to computers — an innovation that other professionals used routinely more than twenty years ago. Consider the extreme hostility many physicians have towards ‘Dr. Google’ — that is, patients looking things up online. To his great credit, Dr. Meskó is working to change that mindset. He writes that the Internet “might be the biggest invention in the history of medicine” – which is a great thing to hear from a physician, although anesthesia and clean drinking water have to be up there, too. But the fact that someone has to convince physicians of the value of the Internet — in 2014! — shows how much the medical profession is guided by inertia.

It is also possible that the inventions just might not work as advertised. If you have been a patient long enough, you know that the past of medicine is littered with broken promises about The Future Of Medicine. Twenty years ago, gene therapy was The Future Of Medicine — TFOM — but it turned out to be more dangerous than any pharma company was willing to tolerate, and almost everyone gave up on it. Only recently has gene therapy returned to favor. Fifteen years ago phakic IOLs were the TFOM, but the surgery is more expensive than LASIK and insurance doesn’t cover it for most people, so it languishes in obscurity. Ten years ago helminths were TFOM for Crohn’s Disease, but the only US company to pursue it was destroyed by poor clinical trial results.

And, in fact, when I look through my history with illness for ‘life-saving’ innovations — things that literally kept me from dying in — I see only three: most obviously,  the laproscopic colectomy surgery I had nearly a decade ago, although the basic operation has been around for much longer. Granted, the appliance system I wear benefits from high-tech innovations in plastics and adhesives, but the high-end biotech drugs that were TFOM for my disease did nothing or made me sicker.

The other two life-savers are the Family and Medical Leave Act of 1993, and a Florida law that allowed me to stay on my parents’ health insurance until I graduated from college. I have no idea how I would have survived without these laws, because they helped guarantee that I had access to the care that I needed. If I were not married to excellent insurance, my fourth life-saver would probably be the Affordable Care Act. My best guess is that I could be kept alive on whatever was state-of-the-art technology in 1980 — but not without some way to maintain health insurance.

Meanwhile, the fact that most of the globe does not enjoy the standard of care I did in 1980 is a huge blind spot for the book. Here is a partial list of things not covered in the book, which will remain medical challenges for most of the world for the foreseeable future: diarrhoeal disease, fetal and maternal health, malaria, tobacco, car-related injuries, tuberculosis, malnutrition. What good does it do to talk about the ‘Future of Medicine’ exclusively in terms of the problems rich Westerners face?

Medicine, as a discipline, has an ethical obligation to address that sort of question — even if it doesn’t have a ready answer. For a physician, Dr. Meskó is remarkably reluctant to offer anything that looks like a prescription for what the future of medicine should look like. This, too, is another way that social thinking would have improved the book: by asking, ‘what is the goal of all this’? By avoiding these questions, Dr. Meskó ties his profession to a strain of socially-unconscious techno-optimism which will be familiar to anyone who has observed Silicon Valley for any length of time. Indeed The Future of Medicine owes more to Hewlett-Packard than it does to Hippocrates.

Let me say: I don’t make a habit of reviewing books I find this problematic. But I am writing now because Dr. Meskó is a very smart person and very influential in discussions about the future of medicine. As an empowered patient, I am working for a future that meets the needs of my fellow patients. That requires me to be prescriptive, to ask and answer ‘should’ questions. Dr. Meskó may believe he is being objective or impartial in not addressing those questions, but that just passes the buck. When smart, caring people avoid ‘should’ questions, they end up allowing the mean and the stupid to answer them instead. Dr. Meskó is neither, and I believe is fully capable of — and in a superb position — to help answer these questions.

My answer is that the future of medicine should help sick and injured people live meaningful lives, on their own terms. Some of the innovations in The Future of Medicine speak to that answer clearly. Many, less than clearly.

I am not saying you should avoid The Future of Medicine. It is an interesting book, and probably excellent if you are reading it with your clinical thinking cap on. But I am saying that you should read it with your social thinking cap, and pay attention to the important questions it raises. Those questions — most of all — will decide the future of medicine.

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Important Developmental Milestones For The Working Child

14 August »

While every parent celebrates their childʼs first words, first steps, and first days of school, in these lean times more and more people are rediscovering the traditional economic benefits that come with parenthood.

By tracking these important milestones, you can teach your child the value of a hard-earned dollar, while helping prepare for a financially secure retirement.

The American Academy of Pediatrics recommends no screen time till 2 years - but are they going to finish mommy's spreadsheets? I don't think so.

0 – 18 Months

Your child at this point is revenue negative, but thatʼs okay. Think of this time as an investment in your future.

Let your child see you working hard on a regular basis. When your baby cries and wonʼt sleep, softly say, “Daddy and Mommy need to go to work now,” and leave the room. This will help the child learn that hard work is more more valuable than personal comfort.

Breast feeding should be limited, as it teaches kids to expect their ʻfree lunchʼ. If you must breast feed, sing corporate jingles while you do: this helps baby associate food with the free market.

It is not too soon to begin reading to your to child the works of great economists like F.M. Hayek and Milton Friedman in kid-friendly versions. You can also let your child watch the educational programming on CNBC and Fox Business.

18 months to 3 years   We're not paying you by the hour, kid!

As your child learns to walk and gains motor skills, youʼll be glad for all that extra energy if it is properly directed towards honest work.

As the saying goes: ʻOld enough to lean, old enough to clean!”At this stage you can make work fun for your kid. Cut out a pony head from construction paper and tape it to your mop or Swiffer(tm): let the child ride it around to clean the floors in your house.

Small children often enjoy banging objects together. A small hammer and a pile of rocks soon produces valuable gravel in the hands of an energetic toddler. Safety goggles are important to protect your child from overzealous OSHA inspectors.

3 – 5 years

shovelboyAs your child gets older, it is time to learn that work is its own reward.

Now is a good time to start semi-annual performance reviews. Discuss your childʼs successes and failings in the previous six months, and set concrete goals for the coming six months. You may be tempted to neglect this, but it preempts most arguments over allowances.

If you buy a toy for your child, make sure that he or she understands that it is your toy, and signs a lease agreement paying you for the right to play with it. Children do not understand compound interest, so these arrangements can be very lucrative in the long run.

5 – 8 years

lemonadeNow that your child is capable of truly useful work, the government expropriates that labor for school. Incentivize achievement by linking grades to work time, but make clear that a long night scrubbing floors is no excuse for a shabby report card.

Lemonade stands should be at least a summer-long commitment, but encourage your child to diversify into a product line with year-round appeal. Make sure your childʼs profits are accounted properly against the overhead of supplies, real estate, and marketing.

8+ years

Congrats! Your child should be ready for his or her first real job. Remember: itʼs not ʻchild laborʼ until the kid brings home a paycheck. Although legally that money belongs to your child, the savvy parent will have saved invoices for eight years of rent, food, and other expenses. Through careful accounting, parents can ensure that their investment in their child’s economic well-being will pay dividends for years to come.


Photo “Enni asentaa äidin konetta” by Flickr User Ville Oksanen modified under CC license.

Photo “Working on The Deck” by Flickr user Lars Ploughman used under CC license.

Photo “Lemonade Stand” by Flickr User Ken Grady modified under CC license.

Photo “Between The Storms” by Flickr User Sharon Mollerus modified under CC license.

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So That Happened: Chelsea Clinton Hit On Me

28 July »

I could have shared their joy.

Photo: Reuters, at Stanford’s convocation in 1997. I was also there.

I ran out of things to complain about — at least for now — so I decided  to write about interesting things I have done despite my illness. This is a true story.

The short version is that Chelsea Clinton hit on me, and — had I played my cards better — I might have been the son-in-law to one, possibly two U.S. presidents. But, as it turns out, I’m kind of a jerk. Before we get there, you’ll need context.

So: when I was in high school, the only colleges I wanted to apply to were the Air Force Academy and the Naval Academy. Finding out I had an incurable chronic illness ended that dream,  and left me with zero ambition.

I spent most of my senior year dragging my heels, telling my parents I didn’t want to go to college. They told me I had to leave the house in any case. I applied to and enrolled in one of the state universities — which I hated.

Actually, that’s not fair: I loved most of the classes. I just hated my classmates, the student health system, my off-campus doctors, the housing, and nearly everything else about the school. Because I really enjoyed my classes, I was getting killer grades.

By my sophomore year of college, I was ready to transfer — as in, get the hell out of there. If not transfer, then drop out. I decide to apply to Stanford and another school, because they both had strong programs in my major.

But, also my sophomore year, I had a serious abscess that ended up requiring surgery. Dealing with that delayed my application process. In fact, I had surgery a few days before Christmas, and the applications were due in early January.

So while recuperating — and, incidentally, high out of my mind on Darvocet — I decided to start my applications. This was before computers did everything, so I borrowed my grandmother’s typewriter and began hammering away. While recuperating from surgery. While high on pain meds.

You can imagine how my applications turned out. It wasn’t until a week or two later, when I went to finish them, that I realized what a horrible mess I had made. And it was too late to send away for new applications. With no hope whatsoever, I patched them up and sent them away.

To my extreme astonishment, I was accepted to both schools. I chose Stanford, and started telling my friends. I was fantastically happy, and also probably the proudest I have ever been.

This was June of 1997 — a few months after Chelsea Clinton, only child of the sitting President of the United States, had decided to attend Stanford. I did not know she was applying when I sent in my application, and didn’t care either way.

But everybody I told had the same reaction: “Oh, that’s where Chelsea Clinton is going.” Some of my friends had reactions that were more graphic: “Oh, man, you could f— Chelsea Clinton.” My mom — my mother — said, “Think of what great hair your children would have.” It was ridiculous.

So when I left for Stanford, I was determined to have nothing to do with Chelsea Clinton at all. I saw her around every now and then, but I spoke to her maybe once the entire year.

The trick to avoiding her was that you could usually spot her Secret Service from a distance: they looked like they had been given a Wal-Mart allowance and told to buy J. Crew clothes. Lots of cargo shorts and polyester polos, and also the only people on campus wearing fanny packs or safari vests (which hid guns).

Skip to a year or so later: I still mostly avoided Chelsea Clinton. But a friend of mine, named Molly, was house manager for one of the dorms on campus, and she asked me to serve at their ‘special dinner’. For one night’s work, I could earn $50 and a couple bottles of wine.

It also meant I was serving dinner to Chelsea Clinton; she lived in the house, where her room had been retrofitted with bulletproof glass. There were 50 other people in the house, so she was just one of the diners — not a big deal. She had the vegetarian plate with no cheese; I think I asked her whether she was allergic, and she told me she just didn’t like cheese.

Also that year, I got a job teaching a public speaking class on campus. One of the requirements for the job was that I had to dress professionally. I bought a suit.

One evening I was in my suit and a bit early for class, and decided to stop by the campus store for a new coffee mug. Somehow I missed the cargo shorts and fanny packs near the entrance. I entered the store oblivious, and went about looking for a mug.

When I took my chosen mug to the cash register at the back of the store, I realized that Chelsea Clinton was standing next to me. The girl working the cash register was a friend of hers, and they were having a conversation when I rolled in. The three of us were the only people in the store.

As I handed my mug over to get scanned, Chelsea Clinton eyeballed me. “You look nice,” she said. One thing I should mention is that Chelsea Clinton is super intense in person, like she’s reading your soul just making small talk. I had heard similar things about her dad.

“Thanks,” I said. “I teach a class, and they make me wear this monkey suit for it.”

“Oh,” she said. “You know, you look really familiar.”

“Sure,” I said. “I’m friends with Molly; I served you at the special dinner.” I think I blushed at this point. I looked away, I’m pretty sure.

Her friend was taking forever to ring up my purchase. There was this long moment of dead air. Then Chelsea Clinton says, “I didn’t mean to be rude — about you looking familiar.”

“Oh, no, of course not,” I said. I did not want to talk her, but I didn’t want to make her think it was her fault. “Actually, I get that a lot.”

And then I said: “People say I look like Brad Pitt. Only, you know, thinner. And handsomer.”

I thought it was funny, but… crickets. Suddenly, her friend had rung up my purchase and had her hands outstretched with my mug and my change, without making eye contact. Chelsea Clinton was looking the other direction — at nothing. It was dead silent. It was still just the three of us, and neither of them was looking at me.

I took my mug and left — and honestly, I felt pretty good about the whole thing. I had come face to face with the most powerful daughter in the world, and kept my wits. I wasn’t sure why my joke had bombed, but I shrugged it off.

Then I told a friend about the encounter, and asked whether Chelsea Clinton had hit on me. “Yes,” she said, “but if I didn’t know you, and you said that to me, I would think you were the most arrogant jerk ever.”

Which is when Chelsea Clinton’s reaction suddenly made sense. I did not feel so good about myself then.

And every time I saw Chelsea after that, she would give me this awful look — not angry, not quite pity, but just like, “oh… you”. Did I mention she’s intense? It was massively embarrassing.

Somehow, I started seeing her two or three times a week. We started going to the same gym at the same time the next quarter, and I would run into her every time I was visiting my friend at her dorm. So crushing embarrassment just became a thing in my life, like flossing or study group. This went on for the rest of the year.

The following summer we were both in DC — her at home, me at an internship — and ended up waiting outside the Air & Space Museum for a group of Stanford people who were going to see the IMAX. She recognized me and gave me that look, from like twenty yards away, and I couldn’t get any closer. I paced alone until my friends showed up — just me, her, and her Secret Service, for maybe ten minutes, separated by twenty yards of humiliation.

I took an extra year at Stanford, because some of my credits didn’t transfer. I hardly ever saw her that year. I honestly couldn’t think of how to explain myself at that point. It would have been brutally awkward, and I was fine sticking to plan A: avoid Chelsea Clinton.

But I sometimes wonder if I had been a little more suave, a little less prickly, and maybe opened up a little, then maybe things could have gone differently for us.

Well… for me, anyway. She was always going to be famous: she’s Chelsea Clinton. Point is, she hit on me.

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“Tig” Part II: The Revenge of Julia Sweeney

21 July »

tigTig is a film about Tig Notaro, a comedian whose standup set about breast cancer shot her to fame. In part one of my review, I wrote that the film implies her fame is due to unique talent and vulnerability — but once you get past the idea that Notaro is exceptional, the film avoids asking how her cancer set became the phenomenon it is.

So I want to use part two, right here, to try to explain the popularity of the cancer set.

For starters, I think Notaro had the best audience possible. The film tells us the show was a regular gig, called “Tig Has Friends”, and the cancer set was her last show. For many people in the audience, Tig Notaro was the draw that night, someone to whom they probably felt connected. Her set were personal for them, in a degree unlikely if she were in some random club.  And when it was over, that audience and the other comedians — especially Louis CK — blew it up on social media. This led to articles, news interviews, and lots more publicity. After months of hype, Louis CK released the set through his website, and it became a smash hit.*

So part of the explanation is that Notaro owes her fame to her audience’s enthusiasm on social media. But even without the technology, there is something to the particular social moment in which Notaro performed the set, and it concerns our narrative of cancer.

That narrative is the story that we tell about cancer, namely that cancer is an awful disease that leaves people either heroic survivors or tragic memories. It is the story that sells run-walk miles and pink blenders and yellow bracelets; it is how our society understands the disease.

Notaro’s cancer set is possible — and funny — because she plays with that narrative. Her jokes work because everyone knows the narrative. But while we usually think of that narrative as a thing that has happened, Notaro presents it to her audience as a thing that has only started to happen. She turns the narrative into oncoming traffic.

Without that narrative, her set would not have the impact it did. Also relevant is that the vast majority of women now survive breast cancer; while Notaro may yet die from cancer, she can joke about it knowing she probably won’t. One might imagine the set being much thornier twenty years ago, when the narrative was less advanced and mortality higher.

Actually, you don’t have to imagine. Almost twenty years earlier, comedian Julia Sweeney did a set — a series of sets, really — about getting cancer. The parallels are uncanny: Like Notaro, Sweeney had lady cancer (cervical vs. breast) that affected her ability to have kids, joked about it in an LA comedy club right after her diagnosis, and got on This American Life. One difference is that when Sweeney did her sets in early 1995, she was more famous than Notaro was in 2012.**

Another crucial difference is that Sweeney had to spend a ton of time explaining her illness. She couldn’t assume the audience knew the narrative, and there’s a discomfort — even a despair — in Sweeney’s set that doesn’t happen in Notaro’s. And in fact, that lack of despair is the ironic detachment that makes Notaro’s style work. But that wasn’t where comedy was in 1995, and it wasn’t where cancer was, either.

Sweeney was, if anything, more vulnerable and more brave than Notaro. So it’s almost criminal that Tig ignores Julia Sweeney’s work, not to mention any deeper questions about society and cancer. For a film about a woman whose subversion of the cancer narrative made her famous, it’s baffling why the filmmakers take that narrative as given.

Would you like a lollipop?Along those lines, my favorite scene in Tig by far had Notaro in an exam room learning that her cancer means she probably can’t have children. It’s just a shot of the room door with audio and captions, as a woman docsplains in a voice normal people would save for sulking tweens: “You know, sometimes in life we don’t always get what we want.”

But the filmmakers — and Notaro herself — seem to miss how hilariously offensive this is. They just let it slide by. There is stuff like that throughout the film, that nobody wants to look at too closely — and that’s the basic problem with the film.

Tig Notaro’s cancer set raised important and interesting questions — about cancer, comedy, and our popular understanding of illness. Unfortunately, Tig doesn’t look at those questions, focusing instead of her romantic and family life — which is a  perfectly reasonable decision on the part of the filmmakers.

But because I went into the film hoping for those questions, I was disappointed.

Tig. 2015, Beachside Films.

* You can hear free chunks in an episode of This American Life called — grrrr — “What Doesn’t Kill You”, or stream the whole thing through Amazon Prime.

**Sweeney later turned her sets into a stage monologue called God Said ‘Ha’! — produced by Quentin Tarantino, which you could almost explain by the fact that Sweeney’s former husband played The Gimp in Pulp Fiction, but still… Anyway, I recommend skipping the film version and listening instead to the original recordings in the TAL episode, which are much rawer and more graphic.

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“Tig” Part I: It’s Not Cancer

20 July »

tigTig Notaro is a lesbian who had breast cancer. If you think her sexuality should be irrelevant, well… so do I, honestly. But with that attitude, you may find Tig — the new documentary from Netflix — disappointing.

This review spun out of control, so I broke it into two parts. This is part one. I also wrote about Tig Notaro in 2012, when she was newly famous for a standup set she performed right after being diagnosed with breast cancer. She covered other ground — pnuemonia, C. Diff., her mom dying, etc. — but the show launched Notaro to national fame as ‘the cancer set’. My point then was that cancer got all the attention because it has the stronger narrative.

Tig, alas, offers little insight into that narrative, because that is not what the film is about. Instead, it is mostly about the fact that Tig Notaro is a lesbian in love. Netflix even puts the film in “Gay/Lesbian” — not, you know, ‘Comedy’.

... and a horse named Trope. Seriously: like a third of the movie is Notaro wooing a straight woman. It explains how they met, shows them on dates, et cetera. There’s a shot of them snuggling in a horse-drawn carriage, to prove lesbians can be cornballs, too. By the end of the film, the happy couple is looking to start a family.

Another third of the movie is Notaro’s attempts to have a child. You meet her sperm donor. You meet her fertility doctor, who seems to be in the film for the free advertising. You meet her surrogate, a nice lady who named her own kid Harpo (only a nickname, God willing).

But — sigh — I don’t care about Notaro’s sexuality or fertility, and not in the bigotry-feigning-ignorance sense, but in the sincere ‘it matters not’ sense.  Sex is not what made Notaro funny or famous. In a movie built on that fame, the lesbian scenes seem like filler. And there is an independent clause I might never write again.

What I wanted was more cancer — more of the cancer set, and the phenomenon it became. For starters, they could have just run the whole set, instead of peppering the film with excerpts. But more to the point, they could have unpacked the set and talked about its meaning for the audience and pop culture.

The movie never questions the audience’s reaction, never asks, ‘why this response?’ The film instead suggests Notaro is a exceptional comedian who was singularly vulnerable. For my money, Notaro is funny, but not exceptionally so. Her style of ironic detachment hits center mass of highbrow comedy these days, but her jokes aren’t that great.

To wit: in the film, she spends months working on a joke blaming her cancer on vengeful breasts. The first time she does the bit, she calls them ‘her chest’, and says it decided to ‘get out of here’. It dies. The film has some process scenes of her working on it, until by the end of the film the joke is that her ‘boobs’ were ‘trying to kill’ her. It gets laughs, yes, but it wasn’t that tricky in the first place.

Once you get past the idea that Notaro is an exceptional standup, the film leaves you with no account of the Tig Notaro phenomenon. Granted, that’s not the filmmakers’ goal, but why not? Incidentally, there was another Tig Notaro documentary released this year, Showtime’s Knock, Knock – It’s Tig Notaro. Notaro is funnier there, but both films trade on the Tig Notaro Phenomenon without really asking any questions.

In Tig, cancer is simply a character quirk of an otherwise hard-working girl looking for love. That’s a decent rom-com maybe, but also drably conventional and trope-y. For 2015, it’s not even ground-breaking insight into the lives of lesbians. Ten years from now, this film will seem flimsy and frustrating for anyone trying to understand Tig Notaro’s place in pop culture.

And that’s really too bad, because there is something important and interesting going on there. I will explore that more in part two.

Tig. 2015, Beachside Films.

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I Am Not The Only Person Whose Disease Made Him Worse

9 July »

It's crazy how hard I worked for this compared to how little it means to me.

Yes: I earned it. Before I got sick.

I fell into this Buzzfeed listicle – 21 Things Only People Living With A Health Problem Know – which is pretty much the clickbait it says it is, so don’t bother.

I was pleasantly surprised that the author used quotes and pics of actual patients with a wide variety of diseases, so… yay. But then this, at the end of the listicle:

But, despite all of the challenges, you still manage to come out a stronger, better person.

…complete with a quote from a 23-year-old. So, clearly: softcore inspiration porn.

I don’t blame a 23-year-old who is probably still on her parents’ insurance for parroting that nonsense. I mean, maybe she really believes it, or maybe it’s something she tells herself, but she didn’t invent the idea. It’s a giant lie healthy people tell sick people.

The lie goes like this: you have this awful problem, but… you are going to come out of it better, so the problem is its own reward. Which means we don’t owe you — not respect, not compassion, not a functioning healthcare system. In fact, we’re maybe even a little jealous!

Let me puncture that balloon. Let me give it to you raw. Let me be the only person to say this: my illness makes me worse. It makes me weak. It makes me a bad person.

Click here: “Idealistic Kid Gets Chronic Illness… But Nothing Prepared Him For What Happens Next!”

I was a good kid. I was smart and athletic and eager to live my life helping others. The year I was diagnosed, I was student body president, earned my Eagle Scout, and was my school’s leading gay rights activist. I wanted to serve in the military, or maybe work in government.

And for a while, I pretended that nothing had changed — even though I could no longer join the military. Even though my rudderless drift through my senior year landed me in a shit-hole state school that made me miserable. Even though I nearly killed myself from prednisone and malpractice.

I kept telling myself I would get better, I would be better, stronger, transcendent. I kept trying to take charge of my illness. I kept trying to work in public service. When that didn’t happen — because of my disease — I decided I wanted to teach. When that didn’t happen — because disease — it nearly killed me. I nearly killed myself. Again.

Click here: “Man Plans Elaborate Suicide… You Won’t Believe What Happens!”

To get through that period in my life, I had to come to terms with the fact that I am not transcendent. I am not better. I am not stronger.

I am weak. I am afraid. I am selfish. I am bitter. I am mean. I am so incredibly, thoroughly angry.

I didn’t choose to be those things. My illness made me so.

I was a deacon in my church for a while — because I keep trying, and failing, to be better than what I am — and was sent to check on a developmentally-disabled member who had health troubles. I had known this guy for ten years, saw him at church, hugged him and shook his hand many Sundays. And as we sat in his apartment, with him going on and on about the two whole nights he spent in the hospital, I realized: I don’t care. I can’t make myself care. I barely have the energy to pretend to care. I quit being a deacon.

In fact, not caring is one of my few luxuries. When the checkout clerk at my grocery asks if I want to donate money to children’s cancer research, I take pleasure in telling her, “I do not care about children with cancer.” Because screw kids with cancer; everybody cares about kids with cancer. Do kids with cancer care about thirty-something burnouts with a ton of student debt? No. So it’s mutual. I care about me, because I have to.

Click here: “Guy Looks In Mirror… You Won’t Believe What He Sees!”

And I’m okay with the fact that I don’t care. Not proud, sure, but okay with it. I have come to terms with who I am. I’d be someone else if I could, but until science invents the personality transplant, I have to stop torturing myself. I don’t have the energy or the money or the friends I need to make myself a better person — all thanks to my illness.

And meanwhile, I don’t owe anyone a mote of pretense that I am better than I am. To the extent I do good — you’d need a powerful microscope to measure it, most days — it certainly isn’t because of my disease. What minimal good I have accomplished in this world absolutely cannot serve as inspiration porn.

I expect I’ll  do a lot more bad before those health problems finally kill me. Then what will I be? Maybe that is the better, stronger me: dead. I suppose if I honestly thought I was the only person illness made worse and weaker, I would go ahead and kill myself.

But I’m not. So for fuck’s sake: let’s stop pretending like I am.

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Yet Another Glowing Review for League of Mortals

7 July »

Carly at ChroniCarly has her review of my novel, League of Mortals. I know we (authors) are only supposed to excerpt the most flattering parts of reviews, so there’s this…

Wesley is not a saint, he is not redeemed through his illness, he does not die in the end so his organs can save his girlfriend, nor does his life serve as the inspiration for national health care policy reform. He’s an average guy who has a pretty crappy year and then learns to get on with his life as best as he can. He uses dark humor to cope and does not have much sympathy for people who try to mold him into inspiration porn. In this way, the book offers the most realistic depiction of the first year of chronic illness that I can remember reading.

But I will admit that my favorite part of the review was this:

That is to say, reading during my daily Metro commute was difficult because of the many graphically realistic scenes of main character Wesley having stomach cramps and diarrhea.

Not sure why; it is what it is. My thanks to Carly for reading the book and writing the review. If you follow the link to her page, Carly has a coupon code for $2 off a download from Smashwords.

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Important Drug Facts: Marijuana

30 June »

Medical-Marijuana(Note: this is not real medical information)



COMMON BRAND NAME(S): 1 Eyed Jamaican, Acapulco Gold, Accidental Tourist, Afghan Kush, Afgooey, Agent Orange, AK47, Alaskan Thunder Bolt, Alien Blues, Arizonan Western Light Purp, Australian Blue, Big Buddha Cheese, Black Rhino OG Kush, Blue Dynamite, Blue Satellite #2, Blueberry Haze, Brainstorm Haze, Buddahs Love, Cali Big Bud, California Dream, Cat Piss, Charlie Sheen, Dankey Doodle, Dr. Grinspoon, Dream Queen, Dutch Treat Haze, Fraggle Rock, Fruity Pebbles, Girl Scout Cookies, Golden Goat, Grand Daddy Purple, Green -O- Matic, Harvard Haze, Hawaiian Snow, Holy Ghost, Hong Kong Star, Ice Queen, Incrediberry, Island Sweet Skunk, Jack Flash, Jack The Ripper, Jorees Diamond, Jurassic Haze, Kandy Kush, Killa Crip Kush, Knock Out, Lamb’s Breath, Lemon Diesel, Lil Afghani, Louisiana Swamp Moss, Mandala #1, Maui Wowie, MK Ultra, Moonlight OG Kush, New Willies, Northern Lights, Orange Widow, Pakistan Chitral Kush, Perma Frost, Pineapple Express, Pink Lady, Plane Crash, Purple Bubba Kush, Purple Monkey Balls, Purple Urkle, Queen Green, Razzle Dazzle, Romulan Cotton Candy, Sticky Icky OG Kush, Sweet Cheese, The Palin, Tsunami Crush, Twilight Indica, White Widow, Yuckleberry Wow. No lie, this is like maybe .0001% of the brand names we found researching for the important drug facts.

USES: Marijuana is used to treat

  • anorexia in patients with AIDS,
  • nausea and vomiting associated with cancer chemotherapy,
  • glaucoma (pressure in your eyeballs),
  • multiple sclerosis (MS),
  • or like whatever the doctor on the Internet says is wrong with me, bro, ’cause, like I got it real, real bad you know. I’ve got like AIDS in my glaucoma, swear to God,
  • For real, marijuana is good for everything. Everything. Like maybe if you were a firefighter and ran into a burning building to rescue orphans and got real bad smoke inhalation and your lungs were filling with fluid. Okay, so maybe marijuana is not good for that. But everything else. It’s the wonderweed that works wonders.

HOW TO USE: When taking marijuana, closely follow your physician’s instructions. You may take marijuana with or without food, before bedtime, when you wake up in the morning, on break at work washing dishes at Shoney’s, or like whenever, ’cause that job is hella boring and the only way you are getting through a shift without totally killing Tiffani is with some prescription strength, for real.

Do not take marijuana before or while driving. Marijuana may cause drowsiness or confusion like this one time we were baking in Andy’s sister’s VW Golf and got crazy lost before he asks this guy trying to change a tire which way is Krispy Kreme, and then we fell asleep and Andy left us in the Golf in like a thousand degree sunshine in the middle of summer with the windows rolled up and we woke up because we thought our shit was for real on fire. And like, he didn’t even save us a donut. Ha ha funny Andy you douchebag.

Contact your doctor if your condition persists or worsens, so he can write you a prescription for totally more marijuana. Marijuana is good for that.

Tell your physician or pharmacist if you have ever had an allergic reaction to marijuana, because oh hey — we forgot to say that marijuana is totally good for allergies, too. Here cut this part out and paste it up there with the AIDS and the glaucoma: also allergies.

Do not use marijuana if:

  • You are pregnant or breast-feeding.
  • You have heart problems or hypertension (high blood pressure).
  • You have lung problems from being a hero firefighter.
  • You have seizures (epilepsy).
  • You are bogarting that joint.
  • You have immune system problems, except AIDS, because we already said marijuana is good for AIDS.

SIDE EFFECTS: Some for real side effects that can happen when you take marijuana include asthenia. Get it? Ass. Thenia. Ass. Thenia. It’s like when you get weak or lazy or couchlock or whatever.

Another side effects you can get are palpitations, tachycardia, vasodilation and facial flush. Palpitations is totally the name of the Emperor in Star Wars. It is. Yes it is. It is. Bro, it totally is. It totally is. Totally is. Yes, it is. Totally is. That’s totally the dude’s name. For real. Look it up. Look it up. Look it up. Look it up. Look it up. Look it up. Look it up.

What was I saying just now? Oh, yeah. You can get abdominal pain, nausea, and vomiting, too, while taking marijuana — but mostly that only happens to people who are on chemo already so maybe, it’s, you know, maybe the CHEMO. Just sayin’.

Marijuana may also cause slacking, slack-lining, slacktivism, hackey-slack, and sixth-year senioritis. Marijuana may also definitely cause the guitar solo in Creedence’s cover of “Heard It Through the Grapevine” where they just play the same thing over and over for like an hour. Great tune.

Some other side effects include amnesia, anxiety, ataxia, confusion, depersonalization, dizziness, euphoria IS FOR REAL THE WHOLE POINT, hallucination, paranoid reaction, somnolence, and thinking abnormal but what is normal, right? Like what was normal for dinosaurs was just walking around naked and then the comet hits and it gets really cold and maybe this one dinosaur is like ‘yo, there’s totally all these warm little fuzzy creatures running around – we should make shirts and hats’ but the other dinosaurs were like ‘whoa, Nerdceratops, that’s abnormal thinking’ and so the one dinosaur was all alone wearing his shirt made out of tiny mammals and he felt super smart but then the other dinosaurs all died and he was like OH MY GOD I’M THE ONLY ONE LEFT OH NO OH NO OH NO and then at his funeral it’s just this one angry lemur whose mom the dinosaur wore as a poncho and the lemur pees all over the dinosaur’s grave and then later evolves into a caveman and that’s why humans rule the Earth, right? What I’m saying is ‘abnormal thinking’ is just what BIG BROTHER calls your imagination, for real. Abnormal thinking is what keeps you from being just another froze-ass dinosaur wondering why there’s so many furry animals running around throwing snowballs. Don’t be a frozen dinosaur. Minds only work like parachutes. Think about it.

Oh, hey — look what’s not on this list of side effects: death. Like nobody ever OD’d from too much marijuana. It’s like impossible to kill yourself with marijuana. Like the only way you could die from marijuana is if you smoked so much weed that your mom and her boyfriend staged an intervention and got you signed up in the Army and you got sent to Afghanistan but guess what THERE’S TONS OF WEED IN AFGHANISTAN HA HA so you go Operation Enduring Freebase on your buddy’s Talibong and you’re so high you have no idea what the sirens mean anymore when the for real Talibong starts RPGing your camp and then MAYBE you could die from marijuana. But maybe maybe maybe also you survive and get diagnosed with PTSD and guess what’s good for PTSD? Marijuana. Hells yeah. Totally happened to my friend’s cousin. So death is NOT a side effect, bro.

Other possible side effects that occur in less than 1% of burners including conjunctivitis, fecal incontinence (HA HA ANDY HOW YOU LIKE THEM DONUTS NOW!), myalgia, depression, nightmares, speeth diccifulties, tinnitus, vision difficulties.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome, because you know what’s good for side effects….? That’s right, bro: marijuana.

(Note: this is not real medical information. Drug information adapted from RXList. Graphic adapted from The Daily Chronic. Consult your doctor, for real.)