The Rescue Inhaler Dilemma
Asthma Attack / Etgar Keret (Translated from Hebrew by Miriam Shlesinger)
When you have an asthma attack, you can’t breathe. When you can’t breathe, you can hardly talk. To make a sentence all you get is the air in your lungs. Which isn’t much. Three to six words, if that. You learn the value of words. You rummage through the jumble in your head. Choose the crucial ones–those cost you, too. Let healthy people toss out whatever comes to mind, the way you throw out the garbage. When an asthmatic says “I love you,” and when an asthmatic says “I love you madly,” there’s a difference. The difference of a word. A word’s a lot. It could be “stop,” or “inhaler.” It could be “ambulance.”
GeckoCap is an up and coming startup that has set out to revolutionize the way people manage their asthma. The (Gecko) cap itself is a small glowing smart button that can be easily added to any asthma inhaler. The fun, colorful, and durable design is made for kids. There are no batteries to replace, cables, or hassle. What’s really awesome is that the cap starts glowing when the next dose is due.
I recently learned that people with asthma have, not one, but two distinct inhalers – one called maintenance and the other rescue. This came as a surprise because my understanding of asthma was mostly shaped by characters like Mikey from the movie The Goonies who puffed on his inhaler whenever something scary or exciting was about to happen. For years, I was under the impression that this was how asthma patients dealt with their condition – by puffing on an inhaler whenever asthma flared up. But like so many other Hollywood-induced misconceptions , that’s not how it works and Mikey was displaying a blatant non adherence to the prescribed medical regimen. In other words, Mickey wasn’t using his maintenance inhaler like he should have.
Patient adherence to medical regimens is a major problem in chronic disease management. Adherence to asthma medication regimens tends to be very poor, with the reported rates of non adherence ranging from 30 to 70 percent. That’s an insanely high number.
What is the medication regimen for asthma?
Long-term asthma control medications: Taken regularly to control chronic symptoms and prevent asthma attacks — the most important type of treatment for most people with asthma. This is the maintenance inhaler which contains corticosteroids (to relieve symptoms).
Quick-relief: Taken as needed for rapid, short-term relief of symptoms — used to prevent or treat an asthma attack. This is the rescue inhaler which contains short-acting beta agonists (to open airways).
Doctors instruct their asthma patients to use the maintenance inhaler once (sometimes twice) a day on a daily basis and only use the rescue inhaler in case of an attack. But most patients don’t use the maintenance inhaler and only carry the rescue inhaler to “treat” attacks.
Why?
The Behavioral Psychology explanation
Dan Ariely, professor of behavioral economics at Dukes University, says that it’s hard for us to act based on future reward. We’re just not programmed to endure a long wait time in anticipation of a reward. Ariely says there’s no use fighting our human inclination to procrastinate. Instead, he proposes to associate an unpleasant task with an immediate reward. For asthma patients, the relief brought on by the rescue inhaler is physical, emotional, it’s the immediate reward of your airways opening up and allowing you to breath. It’s an intense experience, that I can only imagine. What is the reward of using the maintenance inhaler? Well, it’s decreasing the chance of an attack in the long term. But remember, we’re not programmed to act based on long term rewards. We’re impatient. We want it now. The rescue inhaler provides that causal relationship between our asthma and its relief.
The Brain & Cognitive Science explanation
A team of researchers at MIT, led by Institute Professor Ann Graybiel — who is also an investigator at MIT’s McGovern Institute for Brain Research — decided to study how dopamine changes during a maze task approximating work for delayed gratification. The researchers trained rats to navigate a maze to reach a reward. During each trial a rat would hear a tone instructing it to turn either right or left at an intersection to find a chocolate milk reward. Previous studies have linked dopamine to rewards, and have shown that dopamine neurons show brief bursts of activity when animals receive an unexpected reward. These dopamine signals are believed to be important for reinforcement learning, the process by which an animal learns to perform actions that lead to reward. From previous work, the researchers expected that they might see pulses of dopamine released at different times in the trial, “but in fact we found something much more surprising,” Graybiel says: The level of dopamine increased steadily throughout each trial, peaking as the animal approached its goal — as if in anticipation of a reward. I’d be shocked if something similar were not happening in our own brains.” It’s known that Parkinson’s patients, in whom dopamine signaling is impaired, often appear to be apathetic, and have difficulty in sustaining motivation to complete a long task. “Maybe that’s because they can’t produce this slow ramping dopamine signal,” Graybiel says.
If we accept Graybiel’s hypothesis that the same dopamine ramping effect happens in humans, we have to ask ourselves: For how long? How much dopamine is our brain able to produce in order to sustain our engagement toward an anticipated reward? An hour? A day? Maybe a month? Trying to answer this question might start to explain the typical procrastination behavior Ariely describes when people are faced with long-term goals. Is it really likely that the brain can sustain an increasing (!) level of dopamine over the span of a week or a month? I’d bet our hypothalamus would burn out long before it was able to produce that much dopamine. What’s more likely is that when we set out to conquer a goal our brain produces dopamine to get us fired up but as time passes dopamine levels drop and we procrastinate.
Takeaway message:
- Associate an unpleasant tasks with an immediate reward or replace a negative reward with a positive one (for example, it’s been shown that dieting with friends / others is more effective because it replaces a negative reward, i.e., unhealthy eating, with a positive reward, i.e., social connection and relatedness).
- Break a long-term goal into smaller short-term goals (or milestones) allowing for more opportunities to reward (or correct a behavior in case of failure).
References:
http://www.uptodate.com/contents/enhancing-patient-adherence-to-asthma-therapy
http://www.ncbi.nlm.nih.gov/pubmed/8298770
http://web.mit.edu/newsoffice/2013/how-brain-remains-focused-on-long-term-goals-0804.html