Health Discovered

WebMD Chief Physician Editor Neha Pathak, MD, and Chief Medical Officer, John Whyte, MD, MPH, explore fascinating stories to find the unexpected things that help us understand our health.

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Navigating Opioid Risks: Questions to Ask Before Accepting a Prescription 08/22/2024

Navigating Opioid Risks: Questions to Ask Before Accepting a Prescription In 2023, the opioid crisis claimed over 81,000 lives -- a staggering number, yet many of these deaths could have been prevented. While prescription can be essential for managing pain, they come with significant risks that are often overlooked. In this episode, we dive deep into the hidden dangers of opioid prescriptions and explore the crucial questions you should ask before accepting these medications. a leading expert in opioid treatment from the University of Alabama Birmingham, joins us to discuss the real risks of misuse, the warning signs to watch for, and the steps you can take to protect yourself and your loved ones. From , to navigating the road to recovery, this conversation sheds light on the opioid epidemic and the urgent need for prevention and education. Transcript Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's, Chief Physician Editor for Health and Lifestyle Medicine. Many of us have talked to our children and loved ones about how to respond if they're offered an opioid or some other unknown substance, even if it's candy at a party, fearing the dangers of opioids and overdose. But how many of us think about the risks in these situations? Our child is injured playing sports and we're given a 14-day prescription for an opioid containing medication. We're at the dentist's office and we're given a prescription for an opioid for a short course after a procedure. New data shows that there were over 81,000 opioid deaths in 2023. So, what can we do to keep our loved ones safe? Today we'll talk about the best strategies to prevent opioid misuse and abuse in the first place. Even if it starts with a prescription from our doctor's office. The journey to addiction and to recovery and what we need to know about preventing opioid deaths. But first, let me introduce my guest, Dr Ellen Eaton. Dr Eaton is an associate professor at the Department of Medicine at the University of Alabama at Birmingham. She's the director of the office based opioid treatment clinic at the UAB 1917 clinic, and a member of the leadership team of the UAB Center for Addiction and Pain Prevention and Intervention. Welcome to the WebMD Health Discovered podcast, Dr Eaton. Ellen Eaton, MD: Thank you so much for having me. Pathak: I'd love to just start by asking you about your own personal health discovery. So, what was your aha moment that led you to the work that you're doing with opioid treatment, management, and addiction and pain prevention interventions? Eaton: Yeah, I have an interesting story as an infectious diseases physician who is primarily working on substance use treatment and prevention. I had the honor of being a fellow with the National Academy of Medicine, really a health policy fellowship. And as an infectious disease physician, I was invited to a working group around infectious consequences of the opioid epidemic. And that was in 2017. It was a tremendous opportunity to go to D.C. and work with thought leaders in the field, other physician scientists, infectious diseases doctors, and those experiences and treatment models that I was hearing about in D.C. were not happening in my home institution at UAB. There were addiction medicine physicians, but we hadn't integrated care. We were not doing syndemic care where you're treating the infection, preventing Hep C, and you're treating their substance use disorder. So that opportunity in 2017 inspired me to come home to UAB, create a clinic here that is for our patients living with HIV who have opioid use disorder, and from there, we've really expanded services broadly for substance use and infectious diseases. So really grateful for the National Academy and that opportunity. That really was a launch pad for my career. Pathak: I would love to talk about what you've seen as the entry point for a lot of people when it comes to opioids and that progression to addiction, potentially overdose. What does that look like for many of the people that you see? Eaton: Because of the care I provide, I am seeing patients who are living with substance use disorder, but I always start when I meet them with really open-ended questions like tell me about your first exposure to opioids. Tell me when you began using them for medical reasons or recreationally. And what I hear over and over again is that many of our patients are starting to experiment or use from a prescriber for a medical condition in their teens or early twenties. And that is often a trusted medical provider. It may be an urgent care physician for a musculoskeletal injury, for a teenager on the athletic field who was injured. It may be a woman who just delivered a baby, a very healthy, common touch point, where there may have been a tear or maybe some residual pain. Another common touch point is a dentist treating you for a dental infection. And so, I hear these types of anecdotes over and over from my patients, and often it is a trusted physician, so they don't feel like this is a scary medication. They may be given a 14-day supply of opioids, not realizing that can lead to physical dependency and opioid misuse in the future. And often don't ask questions about what to look for, warning signs, and certainly as young people, I haven't ever heard that their caregiver expressed concerns. I think more often the patient has a prolonged course seeking opioids for various conditions, becomes dependent, is seeking them more and more, and often caregivers or family members don't get involved until they are pretty far down the continuum of opioid use disorder. So, those are the stories I hear when I meet patients and ask about their journey. Pathak: What are some of the questions we should ask before we even accept that prescription? Eaton: This is a really important question at that prevention touch point, that we often miss. I think asking your provider do you really need oxycodone. Could you start with something like an NSAID or a Tylenol. Asking your provider to be very explicit. When my pain hits a seven out of 10, when my pain hits an eight or nine out of 10, when do I need to take this opioid as opposed to some other opioids sparing pain modulators? And then number of days. So not just at what point today, but also tomorrow, the next day, what pain should I expect, and I think setting the expectation you will have some pain. This is a challenge that many of us that see patients in a primary care setting have to remind patients, you will have some pain. That is normal. That is healthy. That means your nerves are telling you they're giving you feedback on what's going on after your leg fracture. And I think unfortunately opioids have been normalized as safe, in many cases they can be, but in many cases they are not. I also see amongst families where an individual will tell me, “Oh, well, I got a Tramadol from grandma, or I had some opioids leftover from that time that I had a surgery and so I took that for some other condition,” comparing them to medications like chemotherapy, which also have risks. You would never hear a patient self-medicating, sharing with friends and loved ones. But I think because opioids became so ubiquitous, in past decades, entire families, kind of normalize them. They feel comfortable sharing them, taking others. And that type of culture leads to a culture where young people feel comfortable experimenting. They take pills at parties, they take pills from friends and, they purchase them off social media, like TikTok for example, because they do not appreciate the adverse outcomes that can be associated with these types of medications. Pathak: So, tell us about this slippery slope. What is it that happens to us when we take these medications unnecessarily? Eaton: Often one of the biggest teaching points that I make with trainees in my clinic, when is someone experimenting and when does it become a use disorder? And in my clinic, it's usually pretty clear and that includes negative consequences. So, taking opioids and falling asleep, nodding out, overdosing, right? Those patients have gone from opioid misuse to use disorder. So having negative consequences, becoming physically dependent. We do see that needing to take more and more to prevent withdrawals, which with opioids, unlike some other substances, you can pretty quickly become physically dependent. And then you need to continue to opioids just to not feel sick, to not have the flu-like symptoms. So, becoming physically dependent, having to take more and more, increasing your dose to get the same desired effect. Those are the things that I see most commonly in clinic. With opioids and certainly the very potent non-medical opioids we're seeing now, heroin, fentanyl, we don't see people who just dabble here and there at a party, at a wedding. Now the other substances that I see pretty routinely used in my clinic with or without opioid use disorder, stimulant use disorder, marijuana use disorder. Alcohol use. I do have to ask more questions and certainly there are validated screening tools out there that physicians and clinicians can use to determine very objectively. Did they just drink too much at that wedding two months ago and it was a problem because they got in a fight or had a DUI? Or is this a pattern of use that meets criteria for alcohol use disorder? So, it is important to ask those questions and know, but I would say really the negative consequences, the physical dependency, escalating use, those are things to look for in your patients. As a caregiver or a parent, those are things to look for as well because we are really in a position to identify these before our loved ones have escalated their use. Pathak: And then what do you do? So, you notice some of these types of red flags. What is the intervention that you should make as a parent or a loved one or a caregiver? Eaton: I think starting with a primary care provider is always the best step. And most of us do use these objective screening tools. There are several you can find. My clinic uses an assist. These are validated tools that have been tested on many patients, not physicians, not PhD scientists, that have been tested on patients to make sure that they are asking the right questions to get to the true use behaviors and patterns. And I would go from there with your primary care provider. I think if you as a parent or loved one are even asking yourself, is it time to go? It's time to go. I think too many of us wait until there are very obvious motor vehicle accidents, overdoses. And I think most parents that I encounter in a clinical setting knew there were issues much longer before they sought help. And this gets to your question around stigma, shame that a lot of families do not want associated with their loved one or their family. And so, they wait until there are really negative consequences. Ideally, we'd be intervening much sooner. Pathak: I'd love to talk a little bit and dig into what you just said about stigma and shame and some of the words we use when we talk about having a problem, quote unquote, with opioids, or becoming addicted or physically dependent. In that recovery phase, oftentimes we'll talk about someone becoming sober or sobriety from some of these medications. Can you talk a little bit about the terms that you use and what best helps uplift your patients? Eaton: This is a really nuanced area, and it does take some retraining of us as clinicians who have been in practice for a while. When I went through medical school, you were either 100 percent abstinent or not. We weren't taught that there was this whole middle ground of harm reduction, and I think as physicians, once we get some additional education on this, we realize that our words really matter. We can be much more supportive of our patients because this is a journey and much like diabetes or hypertension, your patient may have chapters where they aren't in care. Their chronic disease, substance use to chronic disease, is unmanaged. But unlike diabetes or hypertension, where we just counsel them and support them and bring them in maybe more frequently to check in, have them bring their spouse to help with the pill bottles and set their phone alarms so they don't forget. Unlike those medical conditions, this chronic brain disease of substance use, we treat patients unintentionally as if they have failed. They have failed our clinics. They have failed the treatment. We treat them with judgment and shame. And there are a lot of complex routes for that that I am not an expert in. But what I tell my colleagues and my trainees is that we need to know and our patients need to know that they have not failed us. They are not a failure. They are living with a chronic disease, just like diabetes or hypertension. And just like diabetes or hypertension, if they fall out of care, if they stop taking their medications, we allow them to come back when they're ready to reengage. Just like my patients with HIV, right? So, using words are often the first interaction that we have with our patients. I even say when I get to meet them, “tell me about your journey. Have you ever been in recovery before?” rather than tell me about your addiction. “Have you ever been abstinent?” Have you ever been sober? Did you fall off the wagon? These are all terms that have very negative connotations and really reinforce a lot of the stigma that our patients already feel. My patients come with a lot of stigma to clinic. I have to remind them not to use stigmatizing words to describe themselves. They'll say things like, “I've really been an addict for 20 years.” And I have to say, “you've been a survivor for 20 years. You’ve been a survivor.” Or, you know, I'm the black sheep of my family. And I remind them. Actually, you have a chronic disease, and didn't you tell me your uncle has the same brain disease it runs in your family? Just reminding them much like the diabetes example again, this is a chronic disease. Those are some of the strategies I use to be really person centered and inclusive. And I do use the survivor language a lot. If they're using opioids in 2024, they are a survivor because we know the substance is out there. I do try to use a lot of empowering language as well. Pathak: I come at a lot of this from the primary care lens. I’m a primary care physician and prevention is the key for what we're always trying to do before we get to treatment and management. If we're talking about red flags or the types of questions we should be asking before we even prescribe these the first time, is it asking about family history? Should our patients be thinking about that? Like, oh, you know, Uncle Jim has had a problem with opioids in the past. That's probably not a medication we want to start in our child. What are some of the other types of questions we can be asking before we even think about that very first prescription or letting your child know that this is something that you need to be thinking about if you're at a party and someone offers you something because this is our family history. What are some of the other things you ask about? Eaton: Family history is really important. Past experience with opioids. And if you have a patient who is in recovery, many of them will say, I know I have to have my hip replaced. Please do everything you can. Give me blocks. They want to avoid opioids. So, asking about any experience with opioids, how that went. I would also ask about social support. You know, remind me where you're living these days. Oh, you're in an apartment with your niece. Do you have a safe place to store your medications? Tell me about that. Where do you store your medications? This comes up a lot with our unhoused population, that they are frequently having to move. Their medications are often stolen. That doesn't mean that they don't meet criteria for opioids. It may just mean you need to be more thoughtful. Do you need to go to a boarding care or shelter while we get through this period where you're recovering from your injury and you need opioids to be kept in a locked box? I think those are most of them. And then just appreciating that things like a history of trauma and social determinants of health are really going to put our patients at risk. And a lot of the young people that I see are 30 and 40 year olds who started experimenting with substances in their teens and 20s were in these multi-generational households where mom had substance use. Grandma had substance use. There were always pills around. So, if you are seeing a patient who has a lack of social structure, living with other people with substance use, without a lot of accountability boundaries, without close follow up with a physician, that may be someone you want to consider alternatives or, you know, give them a three-day supply post op and bring them back. Right? Clinics are so full. We may not have that structure or care model in place, but that's ideal. Giving a short course. Reassess. Maybe it's time to transition something else. Pathak: Great. Can you help us understand what exactly an overdose is? What does it look like? And what are some of the strategies like naloxone that we should be aware of? Eaton: Yeah. So right now, we're seeing the vast majority of overdoses have opioids as a contributing substance. So many of our decedents who pass away and have toxicology results have multiple substances, including stimulants. But currently, fentanyl is contaminating so many types of street drugs, whether they're a counterfeit, benzodiazepine, or a counterfeit Vicodin, or cocaine. So, the vast majority of overdoses we're seeing right now, are opioid related, and that usually involves people looking sedated, stuporous, failure to respond to verbal stimuli, tactile stimuli. And in the current setting where we're seeing so many overdoses, I think you should always think opioids first when you're seeing someone like that. It is important to approach them, call their name, shake them if they don't respond. That's when you're going to call 9-1-1 and be looking for naloxone. I have some in my backpack. I travel on airplanes with naloxone. And my kids who are elementary age know about naloxone. I haven't gotten to the point of educating them. But because these events are more common than cardiac arrest in many, many communities, we're training our Boy Scouts how to do CPR, but we're not necessarily training our Boy Scouts how to do naloxone for overdose reversal. But we should. These are happening in schools. If you have a young person in your home, if you have a teenager in your home, you should have naloxone, and your teenager should as well and be trained to use. It doesn't mean your teenager is using or experimenting. It just means the people in places that young person is around have a higher likelihood of overdose than a cardiac arrest in many settings. Right? I know a lot of schools. My community schools are getting naloxone because they do appreciate that children are experiencing at school. They've had some adverse outcomes in my state on school property. I would encourage anyone who is living with young people or older people who have access to opioids, even prescription opioids, to have naloxone. And then obviously if you know your loved one has opioid use disorder, you and they and anyone who is a caregiver for them should have naloxone on their person. Truly. So that's pretty much all of us, right? And whenever I talk to the rotary, I've talked to schools, I talked to clinicians. There are very few people who don't need to know about naloxone in the current day and age. And think of compared to something like an AED or CPR. You know, we're really good about these less stigmatized acute medical events, right? We feel very comfortable training our Boy... /episode/index/show/healthnow/id/32607807

Your Guide to Safe and Effective Sunscreen: Advice from an EWG Scientist 08/15/2024

Your Guide to Safe and Effective Sunscreen: Advice from an EWG Scientist As we spend more time outside, it’s important to remember to protect our skin from the sun’s rays. While we know is needed, it’s also important to know how to select the right sunscreen. Which chemicals in sunscreens should we avoid? How are manufacturers ensuring their products are safe and effective? And what ingredients provide the best protection against overexposure to the sun? We spoke to , deputy director of investigations and a senior scientist at Environmental Working Group (EWG), about what to look for when buying a protective sunscreen, how to minimize our risk to harmful exposures, a step-by-step approach to protecting our skin, and . Transcript Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Even though we usually associate summertime with sunscreen, the truth is we need sun protection all year long. In today's episode, we're going to focus on all things sunscreen and sun protection. What are the safest steps to protecting ourselves and our skin? How do we make sense of all the labels, SPF, broad spectrum, UVA, UVB, chemical, mineral, and how can we be sure that we're using the safest and most effective products? To guide us through this topic is our guest, Dr David Andrews. Dr Andrews is Deputy Director of Investigations and a Senior Scientist at Environmental Working Group. His work focuses on finding ways to protect public health by educating consumers and driving change to government policies and regulations. Dr Andrews has been researching sunscreens for more than 15 years and has published a peer reviewed study on sunscreens with EWG colleagues and a book chapter with researchers in Australia. Welcome to the WebMD Health Discovered podcast, Dr Andrews. David Andrews, PhD: It’s a pleasure to speak with you today. Pathak: Before we jump into our conversation, I'd love to ask about your own personal health discovery, your aha moment around the work that you do specifically around sunscreens. Andrews: I've actually been at EWG for just over 15 years now. My oldest just turned 16. So, I also have a few kids and know their response to sunscreen, some positive and some negative. What stood out to me was when I started researching the efficacy of sunscreens. In particular, I'm coming at sunscreen and sunscreen use from the perspective of really long term skin damage and increased skin cancer risk. What really stood out is kind of the lack of scientific knowledge still on what exactly causes in particular increased melanoma risk, and that linkage to sunscreens and some of the uncertainty that has enabled what is somewhat subpar sunscreens in terms of providing UVA protection. So providing protection from a portion of the spectrum. Part of that is really a reflection of how sunscreen use has changed incredibly over the decades and the initial products were really just to prevent sunburn. In my family growing up we referred to them as sunburn creams. But it was really that change in use and kind of the lack of really strong protection in the UVA region that stood out to me. One piece that really stood out is when the FDA published what was more or less their more recent change to sunscreen regulations in 2011. They discussed how sunscreen use was associated with reduced risk of skin damage and skin harm when you use the products because it reduced the amount of UV rays that hit your skin. But the FDA also noted that the few studies that had looked at sunscreen users found that they actually changed their behavior and spent more time in the sun and were actually getting slightly increased sun damage. There's this juxtaposition of we know UV rays and sun rays can cause skin harm and sunscreens reduce the amount of those UV rays. But if we're using sunscreen and changing our behavior, then we may actually be negating some of the benefits of sunscreen. Those complex science issues have really drawn me into this issue and have kept me kind of focused on trying to understand this and provide guidance to the public for the last 15 years. Pathak: That's so interesting. Let's start with some definitions of some common terms. We all think of sunscreen as helping to protect us from damaging rays from the sun. Help us break down those components of solar radiation that we're talking about UVA, UVB, visible light, and infrared. Help us think about those different types of solar radiation that we're trying to protect ourselves from. Andrews: It does get very complicated with the terms. The UV radiation or ultraviolet radiation is sun radiation we cannot see. The radiation is broken into two parts, typically, UVB and UVA, at least in the context of sunscreens. Those UVB rays are the rays most associated with acute damage that's turning your skin red and sunburns. UVB rays are also associated with increased skin cancer risk. But UVA rays are also associated with increased cancer risk as well as skin aging, long term skin damage and impacts on the skin immune system. So the ability to heal from sun damage. But the original sunscreens primarily just block the rays that cause sunburn and actually led to increased UVA radiation. So it's those two portions of the spectrum that I often refer to. UVB is the portion that causes direct skin damage. You see the impact right away or within 24 hours. The UVA rays penetrate deeper into the skin and are associated with long term skin harm. Pathak: Tell us about SPF and broad spectrum and some of these terms that we see on the sunscreens that we're buying. What are these different components? What are we supposed to be looking for when we're looking for a good protective sunscreen? Andrews: I think of a good sunscreen or the ideal sunscreen as something similar to a shirt. A shirt actually provides perfect uniform protection against UVA, UVB rays, and even blocks visible light. People can't see you through your shirt typically, and so that is kind of the ideal. The SPF value in sunscreens is representative of the sun protection value. It comes from a measure of skin redness. The way sunscreens are tested, they apply small amounts on people's back, expose them to high intensity radiation for a short period of time, equivalent to, solar exposure, much stronger than the sun, and then look a day later and see how read the skin turned. That SPF number is the direct reflection on primarily UVB protection. The UVA protection or the broad spectrum protection is not incorporated into that SPF or UVB value, although there are some standards in the United States for how much UVA protection is required. The issue is those standards in the United States are very low. They actually lag the rest of the world. In part, that is due to the ingredients available to sunscreen manufacturers in the United States. The underlying concern here is that people are being overexposed to UVA radiation, which is leading to long term skin damage and skin harm. Pathak: Can we have it all? Do we have products available to us in the United States that provide strong protection and also minimize the risk from certain chemical exposure. Is that a unicorn or can we find that on our shelves in the US? Andrews: There are good options available. That is an important takeaway. Primarily these are products that are using zinc oxide. These are mineral based sunscreens. Sometimes they can be a little bit whitening, although formulations have improved significantly over the last decade. These zinc oxide mineral based sunscreens do a very good job of providing UVA and UVB protection, They do so without the use of concerning ingredients. There is a space there, and there's definitely options available to consumers, and we have typically directed people to first try those products and potentially you need to try a few different products to find one that works for you. But these zinc oxide based products are the best available option on the market currently Pathak: What are some of the things we're looking out for if you have skin of color? Andrews: That's a really interesting question. I think it reflects a deficiency in both that SPF value and the current structure in the regulations from the FDA on how sunscreens are tested, and how the effectiveness is communicated. Primarily, these are products tested on very light skin types, that are looking for that skin redness. I don't have a direct answer to that question of if there is no skin redness, how can you be sure that you're protecting the skin because of that lack of direct feedback other than the advice of if you're going out in the sun, especially for prolonged periods, consider covering up using a sunscreen or seeking shade. I think it's important to come back to that, though, that in the context of sun damage, and sunscreens, the sunscreens alone are not the complete solution here. It is a mixture of wearing a shirt, covering up, seeking shade, and using sunscreens to reduce that overall exposure. Pathak: I definitely want to talk a little bit more in depth around your step by step approach to thinking about all of the different tools we have in our arsenal to protect us from solar radiation. But I wanted to go back to an earlier point you made around some safer ingredients that you're looking for such as looking for zinc oxide. What is the converse of that? What are some of the ingredients that you would really recommend people stay away from? Andrews: I should note that the FDA proposed changes to sunscreen regulations four or five years ago now that have not been finalized. They highlighted that all of the non mineral ingredients, these are oxybenzone, avobenzone, a large portion of the sunscreen market in the US. The active ingredients were absorbing into the skin at levels where they were being systemically distributed throughout the body and the FDA was looking for more safety data on all of those ingredients for them to stay on the market because people use sunscreens daily. They apply them to a large part of their body and FDA said we don't have adequate data for any of these ingredients for long term use to ensure that they're not causing harm. There are a few ingredients that raise higher concerns. One in particular that stood out is oxybenzone, which a number of studies have associated with both allergic type skin reactions as well as some impact on endocrine disruption and changing hormone levels. There's still some uncertainty there, but we thought there was enough evidence and available alternatives that consumers should look elsewhere. That is one ingredient in particular that raises concerns. It's also the ingredient that's absorbed at much, much higher levels than any other sunscreen ingredient. Pathak: If I'm understanding you correctly, it's a chemical of concern, an ingredient of concern. The FDA is still looking at long term data to see if the amount which is absorbed into our bloodstream from the skin is going to cause long term harm. But there is enough evidence to suggest that there's some risk as it relates to endocrine disruption and some allergic type reactions. Andrews: Correct. From a providing guidance perspective, we think consumers should seek out alternatives. The FDA has actually requested that companies and the manufacturers do additional safety testing to validate some of those studies. But as far as I know, that testing is not moving forward. Pathak: You mentioned that there are certain ingredients that are available to people in other parts of the world that may not be available to us. Can you tell me what those are? Are they safer? Is there a different standard in other parts of the world than we have? How do we make sense of some of our protections compared to the rest of the world? Andrews: This is a really interesting issue and sunscreens in the United States and the formulations available to consumers have been largely unchanged for the last decade. One of our big concerns is the lack of strong UVA protection. I mentioned earlier UVA rays are associated with increased skin cancer risk, as well as long term skin damage. It is worth noting that using a tanning bed, which has actually been classified as a known human carcinogen due to increased melanoma risk in young women, exposes you primarily to UVA rays, similar to using an unbalanced sunscreen. The importance of sunscreens that reduce UVA radiation is critical and the options available to formulators in other countries or sunscreen manufacturers, there are a half dozen ingredients at least that are formulated to significantly reduce UVA radiation. Those ingredients have been in use for over a decade around the world. In part, that's because sunscreens are considered cosmetics in the rest of the world, so the ingredients don't have to go through any specific safety testing before they're used. Whereas in the United States, they're considered over the counter drugs, and the FDA has said people are going to be applying these to their body for long periods of time, we want a comprehensive evaluation of the toxicity of these ingredients before widespread use. The problem is we're really stuck a little bit in a Catch 22 because FDA doesn't actually have that information, that safety testing data for most of the ingredients on the US. market. Nor do they have it for the ones available internationally. But the internationally available ingredients seem to be better from an efficacy perspective, and have less known, health concerns or toxicity concerns. So the marketplace is really stuck here where the FDA says we don't have enough data to keep most of the ingredients on the market in the United States, but we also don't have enough data to let new ingredients into the United States in sunscreens. We've been stuck in this status quo for what is going on over a decade now. Pathak: The status quo at this point is we don't potentially have the most effective ingredients for UVA, and the logic that is sort of preventing that from being used in the US market is not being used to protect us from some of the chemicals that currently are available to us in the US. Andrews: Right. More or less. That's where we are. We don't have adequate safety data for most of the ingredients in the US outside of zinc oxide and titanium dioxide. And so those mineral ingredients, the FDA says there is actually adequate data. and they are effective from a UVA perspective. They are the best option, but there's a significant portion of the population that still will not use those mineral based ingredients for aesthetic reasons. And so recognizing that we think there's an important need to look towards some of those international ingredients and look for a way that the safety of those can be fully substantiated to FDA standards so that there is market access. We think there's really a public health need for more performance based sunscreens, especially in the UVA portion of the spectrum. Pathak: So what is the full arsenal of tools that we have to protect our skin? And how do you sort of think about it? Andrews: Rash guards, shirts, hats, and sunglasses are a fantastic place to start, especially when swimming in sensitive marine environments. There have been a lot of concerns raised about the impact of sunscreens on coral and coral damage. Wearing a rash guard eliminates most sunscreen use, especially in those environments. But even day to day, going to the pool and going outside or to the beach, starting with a shirt or rash guard is a fantastic way to go and incredibly effective at reducing UV radiation. Sunscreen is another tool, though, and available to be used. As long as it's not being used to significantly change your behavior, so where you're applying the sunscreen and then spending three times as long in the sun, you may be negating the benefits of it. But everything from clothing, seeking shade, bringing an umbrella and potentially limiting time during the sunniest part of the day, those are all effective strategies at reducing sun exposure. Pathak: And how does your group fit in? How do you see yourself fitting in the work that you do with how we can think about the behavioral components and dressing appropriately for the weather. How should we think about it along with what's FDA approved and accessible to us? Andrews: We're both trying to educate consumers in the public about sunscreens, the importance of protecting yourself from damaging UV rays, as well as providing guidance on what we think are the best available sunscreens on the US market based on the ingredients and the known hazards of those ingredients as well as the efficacy of the active ingredients in reducing UV rays. A large part of our message is to the public, but we also do interact with FDA. We provide comments on all of their regulations and try to reach out to them and shift the market entirely in the direction of safer and more effective sunscreens. Pathak: I wanted to come back to SPF as well. I have a lot of patients ask me, so what exactly does that number mean? Is there a number beyond which there's no benefit? Can you help us think through SPF and broad spectrum what we're seeing on the label. Andrews: The SPF number on that label is where companies are supposed to have their product tested on individual skin and they look at skin redness a day later. The problem is, there's a lot of ways to optimize or game the system in terms of the SPF value, and that's particularly concerning. We have actually recommended that consumers stick with an SPF 50 or lower. Some of this depends on your skin type and your skin pigmentation, but we don't really see any benefit to going above SPF 50. In particular, we're concerned that the higher SPF numbers are less balanced protection. So actually providing a lower ratio of UVA to UVB ray protection. This is actually something that's known in the industry. I was quite shocked reading comments submitted to FDA over a decade ago, where a major manufacturer had purchased a competitors product, an SPF 100, submitted it blindly to five labs, and the results came back with everywhere between an SPF 37 and a 75. No one reproduced the SPF 100. There's a lot of uncertainty in those actual numbers, but we think sticking with an SPF 30 to 50 is in the optimal range for most people. Pathak: Oftentimes, and I will definitely put this under the category of mom guilt, when your kid comes home and they are peeling and you recognize that, wow, we did not do a good job sunscreening or protecting you from the sun. What is the best thing to do in the post, in the follow up? Are there tips that you have in terms of fixing something that you may have messed up to prevent future damage? What are the best tips that you have there, if any? Andrews: It happens to everyone, especially everyone who has kids. And I think, after some exposure, sometimes I'll reuse sunscreen and apply it to them even after the fact, because a lot of products have anti inflammatories in them. But at that point, it is largely both reducing some of the inflammation on the skin, but also using it as a learning opportunity to try to make change in the future. No one's perfect all the time, but ultimately we are trying to take action to reduce the odds of long term skin damage. The difficult part here is that the damage we're most concerned about can occur decades later and so it's just trying to do as well as we can to reduce the odds of that ever occurring. Pathak: I love to close all of my episodes with bite sized action items for anyone who's listening so they can make a sustainable change in the way they're living day to day. Can you give us just a few tips, your takeaways that folks should think about when they're thinking about... /episode/index/show/healthnow/id/32573327