Quitting: Patty's Piano

Quick sensitiveness is inseparable from a ready understanding.

— Joseph Addison

Long after my grandmother lost the label for and concept of piano, my mother could lead her over to the baby grand and place her hands on the keys, an encouragement that would jump-start memories living in solitude somewhere deep in her brain. The connections that joined the act with the memory, linguistics and semantics of it had withered, but when Nanny's hands graced the ivory keys, they were able to range over them and make music; "Amazing Grace," "Autumn Leaves," "Moonlight Sonata."

My own mother's journey into dementia looked different; she began to falter in her music quite early, long before we even knew there was something terribly wrong. It didn't seem so strange in the living room, but her failure to pull off playing for a school or church function was, in retrospect, a harbinger.

That piano, a 1949 mahogany Knabe, has a matrilineal history; it went from my grandmother to my mother to me. It moves again this month, into a new home at the Portsmouth Music and Arts Center. I want to tell you its story.

It came into the family in 1949, as a gift from my grandfather to my grandmother. My first memory of it was in the double living room of my grandmother's North Hampton home, next to her organ, and within reach of the built in bookshelves that housed music, so much music.

I remember plucking out tunes and learning chords, but mostly gathering around and singing as a family group. My mother would play the piano, my grandmother the organ.

After Nanny died, the piano was moved to my mother's house. Shortly after, she and her own piano man, Tommy Gallant, took up together, and the gatherings around the piano became decidedly more professional. Happy Birthday was an occasion to improvise; holidays gave way to harmonies from Tommy's pitch-perfect family, and merely listening to him warm up for a gig was like attending a concert.

When my mother was moved to a nursing facility, despite the fact that my primary instrument is not piano, I took custody of it. It was housed for a time in my small crooked living room in Portsmouth. You didn't quite have to crawl under it to get to the front door, but almost. The playing to room-taking-up ratio became too great, and I lent it to a local family.

They had a perfect room for it, children to learn to play it and cared enough to move and house it.

After my mom's passing, I began to wonder what to do with it. My sister still owns my mother's other piano, a blonde upright that fits neatly into middle class homes.

What to do with this gorgeous behemoth? Should it go to the University of New Hampshire? Tommy would like that. To the Portsmouth School Department? A wonderful thought, but who would be its caretaker over the years? A private sale? No, doesn't feel right.

I remembered, finally, the wonderful blues classes I took a few years ago at PMAC, the professionalism of the faculty, the folks I know on the board, the commitment of local musician Russ Grazier to passing on the love of learning to play. It seems a perfect fit; the piano will stay locally and will exist in service to music education and edification of children. There is no better choice for Patty's piano. It has gotten harder lately to remember her clearly, or summon her support by imagination. I have had the gift three times in the past month of having someone approach me to tell me they knew my mother, followed by the story of how; her advocacy for children, her ability to demystify print for the struggling reader and her quick sensitivities.

Her friend told me I have never seen anyone cry as hard as your mother, with such depth and pain. That is a strange comfort to me, because I need her to tell me that our family will coalesce, that I will survive unexpected threats against the lives of those I love. Her saying, for years, was "Life is a series of adjustments."

It is easy to remember, as a daughter, her strength and fortitude. Of course she would shield me from the grief of her own worries. Where I can't, she would be able to tell me that although I too am sensitive, take too long to get over circumstances and entered the social world much later than the typical adult, that I am going to survive and even thrive.

It's a lot to think about, but perhaps PMAC will let me sit with Patty's piano soon, and pluck out some old tunes and maybe feel her there with me.

Smoking? Is this a column about smoking? Maybe next week. suzanne.danforth@gmail.com.

Quitting: Weeping, Tobacco and Fair Play

Ouch. People are taking sides in the Chantix debate, some who have pointedly penned this week that I am over my head writing about this subject and a failure to boot. Because I am attempting to distill the science in a way that is manageable for the rest of us, there is some small measure of disdain coming my way.

It didn't come during a particularly good week. I have been weepy this week, prone to welling up unexpectedly. Beyond some of the larger issues in my life and the lives of those who are dear to me, I have been sitting day by day in the Brentwood courtroom where the trial of the year is playing out. The macabre information streaming from there has been wiggling its way into my thoughts even after the day is done.

A week ago, I left the courtroom briefly, when the reality of what was being discussed hit me square, both in the tear ducts and the gut. I'd like to be able to compartmentalize, but it seems my lot to tend to the integrated opposite.

Science is uber-compartmentalized, which may be why one Chantix developer seems to be taking what I write personally. This is the same person I wrote of a while back and who has never given me his credentials or agreed to come on record. He e-mailed me that "you are writing about a subject that is way over your head. There certainly are nicotine receptors in the brain and that's where nicotine from tobacco binds and it's the same place that Chantix binds."

In homage to accuracy, I have read more and continue to maintain that there are no more nicotine receptors in the brain than there are Ben & Jerry's receptors. There are acetylcholine receptors, to which nicotine binds. I'm not quite sure where ice cream binds, but it must be somewhere.

This e-mailer pointed out the role of confounding variables, characterized patients as being able to "claim all sorts of things" and pegged the ISMP report as failing to pass scientific muster. All leading to a situation ripe to "inflame a scientifically ignorant public."

Seems I am the ignorant media and you are the ignorant public. It is my long held principle that anecdotal experience is valid. Perhaps the scientifically ignorant public counts on the scientifically gnostic to acknowledge real-world effects?

This person positing a role in the development of Chantix attached a report by Jonathan Foulds, a professor of public health in New Jersey, but not before reminding me that the lack of peer review in the ISMP report made "a big difference."

Dr. Fould's report was also not peer reviewed, since it was published in a blog on May 28. Read it online at www.healthline.com/blogs/smoking_cessation/.

Fould's concerns and conclusions are well stated. However, he calls three out of four methods of adverse drug event reporting voluntary and haphazard. These methods (direct reporting to the FDA by the public, health care professionals and lawyers) are subject to influences like drug novelty, frequency of use and media coverage. The fourth method is above those messy concerns. That method? Drug manufacturer reporting to the FDA of reports brought directly to it.

The primary concern that Fould states is that the ISMP report does not take in to account the massive number of Chantix prescriptions relative to the numbers of adverse events being reported. It does make sense that a drug prescribed in the millions (ka-ching) may logically result in higher numbers of adverse events.

Fould also points to the difficulty of teasing out the effects of Chantix versus the effects of nicotine withdrawal. Nicotine withdrawal is nasty, no doubt, but at least in my case history, quitting before Chantix never made me stay up for days on end, produce volumes of writing and fail to discern between sleep and waking states.

Just as there are people out there scratching their heads and wondering how the anti-Chantix people reach their conclusions, I remain puzzled how Fould can write his way to this statement; "It therefore remains unclear whether any of these serious adverse events were caused by varenicline (Chantix)."

Without information on funding pipelines, stock shares held or seats on boards of directors, it continues to look from this vantage point more like a case of market forces driving the drug harder than old-fashioned axe-less science.

Finally, this comment from the un-named scientist stung the most. "Remember, your activism could cost lives by preventing folks from quitting smoking."

My activism responds thusly: Quit. Quit now. Quit again. Keep trying. Quit any way you can. But if you decide to try Chantix, pay attention to how you feel and stop if it isn't normal for you.

Losing the battle. suzanne.danforth@gmail.com.

Chantix Antics

By Suzanne Danforth
May 29, 2008 6:00 AM
It's been a big week for Chantix, reader. The kind that makes we want to jump on and shape the story, but since one source of my income flows from on demand writing (it's not pretty, but it pays) and the other doesn't come from a benevolent editorial source with health benefits, I have to make do with making the case once, here, on one Thursday morning of many.
Early last week I received a Chantix e-mail. The same day the FAA banned the drug for pilots and air traffic controllers. Each story was triggered by a report of the ISMP, the Institute for Safe Medical Practices, a non-profit in Pennsylvania that stands alone in the country in its mission of safe medication use. The day after, the Wall Street Journal reported that an arm of the Department of Transportation, the Federal Motor Carrier Safety Administration advised medical practitioners not to qualify "anyone currently using this medication for commercial motor vehicle licenses."
The ISMP report demonstrated "a wide spectrum of injuries, including serious accidents and falls, potentially lethal cardiac rhythm disturbances, severe skin reactions, acute myocardial infarction, seizures, diabetes, psychosis, aggression and suicide."
The back story behind this week's move by leaders in the trucking and aviation industries to ban Chantix in their workers is threefold. In the most recent quarter alone, more serious adverse event reports were made regarding Chantix than any other drug on the market. Any drug at all, regardless of market share or numbers of prescriptions sold.
Those reports, which the FDA publishes to the public, were analyzed by the ISMP in a pilot program meant to track drug risks. Their data are strong, because of the high numbers of people taking Chantix (much higher than Pfizer's clinical trials that brought the drug to market), and the real-world circumstances. They are not without limitation, however, including that the numbers cannot point to causality as sufficient to answer all the safety questions.
Even so, the ISMP concluded their report by noting "concern about the use of varenicline (Chantix) by persons in settings where the risk of accident is high."
The third aspect of the story is that the legal community is on it. Kristian Rasmussen is an attorney working the legal angle of the more nefarious effects of the compound in question. From his Alabama practice, Rasmussen said last week that "It is clear that Chantix is dangerous and evidence suggests that Pfizer has known the risk for a long time."
Rasmussen is the co-author of several legal articles showing that the base compound in Chantix, cytosine, has been prescribed for years in Europe for tobacco cessation. As far back as 1972, there are cases linking cytosine to suicide, both attempted and successful.
Rasmussen called the magnitude of the evidence mounting against Chantix alarming and noted that Pfizer, as its manufacturer, has been attempting to "hide this information since the release of the drug on the open market in 2006."
Just how can one drug be responsible for so many systemic reactions, from suicidal impulses to heart attack to diabetes? Some of the theories being advanced are complicated, but sensible. Because of the nature of medical literature, these theories are coming well in advance of peer-reviewed journal articles.
In the meantime, we'll just have to use our common sense. Chantix works on certain receptors in the brain and nervous system that are responsible for pleasure. These are the little brainiacs that move you unconsciously toward a pack of cigarettes, and which release all kinds of warm fuzzy chemicals into your system when you do light up. These are not nicotine receptors, no such thing in the brain world, they are pleasure receptors. Chantix is an inhibitor; it blocks those receptors so you crave the pleasure of nicotine less, and if you do smoke it blocks the resulting warm fuzzy chemicals and sense of satisfaction. Nothing gets downstream to one of my favorite brain systems, the meso-limbic dopamine system. Forget all the fancy talk, just remember that pleasure, reinforcement and reward are the watch words.
As humans, we derive reinforcement and reward from countless acts ranging from organic to physiological to actual interactions out in the world. Chantix may be blocking a system that allows all kinds of pleasure and reward, whether it comes from kissing your kid or smelling a flower or smoking tobacco.
This makes the simple explanation seductive; why wouldn't the world turn gray and dispiriting? But how to account for aggression, psychosis, heart attacks, diabetes? This is more difficult, but perhaps we walk a delicate balance in our inner lives that exerts cascades of influence on a variety of bodily systems, all relating in some way back to pleasure, reward and reinforcement.
It might really be, after all, about pleasure in all its forms; sybaritic delight, Utilitarianism and Epicureanism.
What's your pleasure? Visit www.ismp.org/docs/vareniclinestudy.asp for the ISMP report. suzanne.danforth@gmail.com .