This week, Dr. Sydney Spiesel discusses a potential link between smaller elementary school class sizes and better health, a safer way to give painkillers, and treatments for ADHD.
Smaller classes, better health?
Question: An extraordinarily provocative article in this month's American Journal of Public Health ties together two seemingly unrelated phenomena: the size of school classes and the health of students. Could smaller class sizes be a good investment not only for educational reasons but for medical ones?
New study: Peter Muennigof the Columbia University School of Public Health and Stephen Woolf of Virginia Commonwealth University in Richmond drew their data from Project STAR, which began in 1985 and randomly assigned almost 12,000 Tennessee kids to classes of different sizes in kindergarten through third grade. Some of the kids were in classes of 22 to 25 students, and others were in classes of 13 to 17 students. Teachers were also randomly assigned. The children were then tracked to determine the effect of class size on educational attainment.
Model: The educational effects were considerable. Now Muennig and Woolf are making use of the findings in a whole new way. They used Project STAR's statistics about educational attainment to build a computer model of a hypothetical group of 5-year-olds exposed for four years to small classes (of 13 to 17) and then followed until the age of 65. The researchers calculated projected earnings, welfare payments, and crime costs based on what we know about the relationship between these outcomes and educational attainment. They also drew on statistics relating degree of education to quality-of-life scores and age-specific mortality. And they accounted for the cost of maintaining smaller class sizes.
Findings: Based on their model, the authors project that reductions in class size would generate a lifetime net cash return of almost $200,000 (presumably in the form of taxes collected) for each additional low-income student who graduates from high school as a result of early placement in a small class. In addition, they project that four years of small classroom size will lead to improvement in health and longevity. These benefits, they calculated, would on average add up to the equivalent of an additional 1¾ years of life in perfect health.
Conclusion: It's important to point out that these numbers are based heavily on assumptions that might not hold true for the future or for places outside Tennessee (kudos, by the way, to that state for supporting this bold experiment). But these are plausible assumptions, at least. And the numbers they generate are astonishing, because they suggest that investment in reducing elementary school classes is better, in cost-benefit terms, than money spent on antibiotics, or hospital buildings, or even vaccines (long thought to be one of the most cost-effective interventions for health care). Perhaps I would do better for my patients if I gave up pediatrics and became a member of my local school board.
How to give more morphine for pain relief
Question: Do the risks of using narcotics to help chronically ill people with pain outweigh the benefits? Morphine, a natural opioid made from the unusually beautiful opium poppy, is a tremendously powerful painkiller. It's much better for almost every medical use than, say, Demerol. But when given in a high dose to a patient who has not been previously exposed, morphine is likely to cause respiratory depression. A patient's drive to breathe dwindles, which can easily be lethal. Fears that this may happen can discourage doctors from prescribing adequate amounts of opioids to fully control a patient's pain.
Treatment: While initial treatment with an opioid carries a real risk of respiratory depression, repeated dosing creates tolerance. Patients become far less sensitive to respiratory depression, yet are still able to get the pain relief, as the medication dose is raised. However, many doctors are unaware of this transformation, and so don't give the larger doses needed to fully control pain in their chronically ill patients.