Thursday, October 1, 2009

Pain-Blog Carnival, September 2009 | How To Cope With Pain Blog

A new blog to join us, Wellscent, joins us this month with information about Trigeminal Neuralgia.

Living Your Best Life Possible When You Have a Chronic Illness, another new blog to our pain-blog carnival, shares that being mindful and accepting pain are usually a lot easier said than done, but why he finds it helpful.

Chronic Babe gives her views on health care reform and invites us to join the conversation.  Timely!

CRPS/RSD A Better Life reviews how to prevent CRPS.  Very important info to know.

Psychology of Pain posts a NY Times article about formulating opioid medication so it can't be abused so easily.  Hot topic!

Nickie's Nook writes about when touch becomes difficult for people with pain.

I encourage you to take another look at all the goodies from Invisible Illness Awareness Week- perhaps Lisa Copen will have to change it to "II Month" because of all the wonderful material!

In Sickness and In Health explores how to tell a potential partner about your health issue.

Health Skills offers some ways to have strength to cope with pain.

Andrea's Buzzing About reviews "universal design," incorporating accessibility right from the start of building projects.  This post includes some funny pictures about what's considered accessible.

I hope you enjoy the selections.  Next month's carnival will be on October 28.

Grand Rounds, a medical-blog carnival, is published this week at Laika's MedLibLog.

Wednesday, September 30, 2009

N.Y. Health Care Workers Revolt Over H1N1 Vaccine -

They're upset over an ultimatum from the health department.

Workers are being told to either get the swine flu vaccine or lose their jobs.

New York is the first state in the country to mandate flu vaccinations for its health care workers. The first doses of swine flu vaccine will be available beginning next week. Much of it is reserved for state health care workers, but there is growing opposition to required innoculations. 

Health care workers in Hauppauge screamed "No forced shots!" as they rallied Tuesday against the state regulation requiring them to roll up their sleeves.

"I don't even tend to the sick. I am in the nutrition field. They are telling me I must get the shot because I work in a health clinic setting," said Paula Small, a Women, Infants and Children health care worker.

Small said she will refuse, worried the vaccine is untested and unproven, leaving her vulnerable. In 1976, there were some deaths associated with a swine flu vaccination.

Registered nurse Frank Mannino, 50, was also angry. He said the state regulation violates his personal freedom and civil rights.

"And now I will lose my job if I don't take the regular flu shot or the swine flu shot." 

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The American Way of Dentistry: The story of my teeth. - By June Thomas - Slate Magazine

If you were to run into me at one of the New York gatherings to which I am occasionally invited, you might think that I was born into the cocktail class. I'm reasonably well-educated and confident, I have an interesting job, and I know which fork to use.

Until a few years ago, though, you might have spotted a clue that I was a newcomer to the haute bourgeoisie: my snaggle-toothed smile. Many Americans believe they live in a classless society, but this conviction is tested by the sight of a mouth packed with mangled or missing teeth. It's visual code for hillbilly. In my case, that happens to be wrong. I was raised not in an Appalachian holler but in the industrial north of England. Many Americans are intimidated by a British accent, which connotes status and smarts, but if there's one area where they have a superiority complex, it's teeth.

I feel guilty about bringing up The Big Book of British Smiles. British dentistry's aesthetics may not be up to American standards, but when I was a kid, anyone could get an appointment to see a National Health Service dentist, and there was no out-of-pocket cost for treatment. Still, in my working-class community in Manchester, perfect teeth were seen as a bit of an affectation. Until my mid-30s I had a gap between my front teeth. When American acquaintances asked whether either of my parents sported a similar diastema, I would answer truthfully that I had no idea. My interlocutors would often leap to the sad conclusion that I was an orphan or an adoptee, which I'm not. It's just that everyone in my family, and every other adult that I grew up around, had false teeth by the time they were 30.

Whenever I asked my maternal grandmother how old she was, she would reply, "As old as my eyes and a little bit older than my teeth." And on my first day at a fancy secondary school, I had a hard time concentrating on the long list of rules the senior mistress was attempting to impart because I couldn't take my eyes off her gold tooth—I was boggled by the sight of someone over 50 who still had at least some of the teeth she was born with.

As a child, I visited the dentist somewhat sporadically. Unfortunately, the dentists embraced the local attitude that dentures were inevitable and nothing to be feared or fought against. Within a few years of my permanent teeth coming in, about a quarter had been pulled or crowned with little effort made to save them. I was destined for dentures, so why waste time or effort preserving my gap-toothed, maloccluded, decay-ridden choppers?

Of course, it was my fault that the dentists saw the need for these procedures in the first place. I didn't even own a toothbrush—my parents had never brushed their teeth, and as adults their oral hygiene was achieved by soaking rather than brushing. I'd never even heard of dental floss, and I ate far too much candy. I prefer not to think about the excruciating pain that decay and resulting abscesses caused—pain that you can hear, that stops the world, that makes listening to the teacher or concentrating on homework impossible.

There would be little point in showing you photos from that era, because like most people who feel uncomfortable about their teeth, I always kept my mouth closed in front of a camera. If I couldn't resist a laugh, I made sure to put my hand in front of my face. Picture Shane McGowan from the Pogues, and you won't be far off base.

During my years at university in England, I finally started to brush my teeth regularly, and I got more crowns, but the dentist never suggested that I do anything about the movement caused by missing teeth or address my overbite so that I could chew better. That was how things stayed for the next decade, even after I moved to the United States. I lived in the land of Hollywood smiles, but I didn't have dental insurance, and I couldn't afford to see a dentist except in the direst of circumstances, such as an infected root canal.

About 17 years ago, I coughed and shattered a front tooth, and a referral from my boss led me to the dentist who would change my life. At first I couldn't afford to do much more than tackle the most aesthetically offensive problems. My dentist (I'll call her Dr. Lifesaver) wrote me a very sweet note recommending that the University of Washington take me as a patient in its dental clinic. Unfortunately, the clinic turned me down because my case was too complicated for the students. A couple of years later, I went to work at Microsoft, and for the first time in my American experience, I had dental insurance. Soon I also had access to a flexible spending account. Since I didn't have kids or a car or any other huge expenses, I finally had the money to tackle my teeth.

I embraced American dentistry unreservedly: braces, new crowns, gum grafts, implants. The June Thomas Wing of Dr. Lifesaver's office housed a file as thick as a phone book, and I had so many specialists with offices on the 15th floor of Seattle's Medical-Dental Building—orthodontist, endodontist, periodontist—that some people thought I worked there.

Because my dental coverage, like most, had an annual reimbursement cap and because the procedures were complicated, the reclamation project took more than a decade and about $45,000 of my own money to bring to a state of near-completion. I moved to New York before finishing the treatment, but I finally felt good about my teeth. I opened my mouth when I smiled, and even though I didn't have a glittering grin (the gradual nature of the process prevented a dramatic change of shade), my teeth were healthy. I could chew and—most important—I had no dental pain.

A few weeks after I started researching this story, I developed a sore throat. My glands were swollen, and I felt tired and lightheaded. I'd been traveling a lot—by planes, trains, and subway—and I had spent time on college campuses and in clinics. Since swine flu had just hit the United States, I wondered whether I'd picked up the virus somewhere along the way. Then one morning, I bit into a piece of toast and felt a sharp pain. It was as if I had driven a pin deep into the gum under that same tooth that a cough had smashed all those years earlier. Every subsequent bite seemed to drive the sharp point a little deeper. I still didn't know whether it was a medical or a dental problem—the flu can sometimes bring on a toothache—but I knew which one I was pulling for. If the sickness was located anywhere other than in my mouth, a visit to the doctor would be covered by my medical insurance. A trip to the dentist's office, on the other hand, could cost me serious money.

The problem turned out to be "internal resorption"—a suicidal tooth, as it seemed to me. The area had become infected, and Tooth No. 26 had to come out. I'd lost a lot of bone, so we couldn't just slap in an implant. Instead, an oral surgeon pulled the tooth and inserted some artificial bone in the hope that it would fuse with my own and provide a stable home for a new titanium anchor. For the four or five months it would take to see if the bone "took," I would have to wear a "flipper," which turned out to be a euphemism for a partial denture.

At first, the flipper didn't fit—it was painful, and it would become detached at the slightest provocation, especially when I was eating or speaking. My diction was a little less crisp, and suddenly I remembered those years of social awkwardness—the worry that people were looking at my mouth in dismay, the fear that the device would fly out as I bit into my lunch or launched into a presentation. But I also knew that it was temporary. I had a job that allowed me both the time to return to the dentist's office for adjustments until the device fit comfortably and the means to attempt this complicated treatment. My missing tooth is artfully disguised, and within a year, the flipper should be out of my life. The final out-of-pocket cost will be somewhere between $4,000 and $5,000.

What if I didn't have that kind of money?

Everybody knows about the crisis in American medical care. Nobody knows about the crisis in American dentistry, which shares some symptoms with the larger health care mess and differs from it in other, more intriguing, ways. Dentistry is the shirttail cousin of the health care system. It is the branch of medicine the affluent use most, but in many ways it is the least familiar, its shortcomings and inequities hiding in plain sight. Few people take dentistry seriously enough to contemplate the possibility that it might be in a dire state. But it is. In the coming days I'll try to explain why.

Tuesday, September 29, 2009

After a Death, an Extreme Form of Grieving -

Each of the 2.5 million annual deaths in the United States directly affects four other people, on average. For most of these people, the suffering is finite — painful and lasting, of course, but not so disabling that 2 or 20 years later the person can barely get out of bed in the morning.

For some people, however — an estimated 15 percent of the bereaved population, or more than a million people a year — grieving becomes what Dr. M. Katherine Shear, a professor of psychiatry at Columbia, calls "a loop of suffering." And these people, Dr. Shear added, can barely function. "It takes a person away from humanity," she said of their suffering, "and has no redemptive value."

This extreme form of grieving, called complicated grief or prolonged grief disorder, has attracted so much attention in recent years that it is one of only a handful of disorders under consideration for being added to the DSM-V, the American Psychiatric Association's handbook for diagnosing mental disorders, due out in 2012.

Some experts argue that complicated grief should not be considered a separate condition, merely an aspect of existing disorders, like depression or post-traumatic stress. But others say the evidence is convincing.

"Of all the disorders I've heard proposed, they have better data for this than almost any of the other possible topics," said Dr. Michael B. First, a professor of clinical psychiatry at Columbia and an editor of the current manual, DSM-IV. "It would be crazy of them not to take it seriously."

There is no formal definition of complicated grief, but researchers describe it as an acute form persisting more than six months, at least six months after a death. Its chief symptom is a yearning for the loved one so intense that it strips a person of other desires. Life has no meaning; joy is out of bounds. Other symptoms include intrusive thoughts about death; uncontrollable bouts of sadness, guilt and other negative emotions; and a preoccupation with, or avoidance of, anything associated with the loss. Complicated grief has been linked to higher incidences of drinking, cancer and suicide attempts.

"Simply put," Dr. Shear said, "complicated grief can wreck a person's life."

More ...

Awash in Information, Patients Face a Lonely, Uncertain Road - New York Times (reposting)

Nothing Meg Gaines endured had prepared her for this moment. Not the six rounds of chemotherapy for ovarian cancer that had metastasized to her liver. Not the doctor who told her, after Ms. Gaines was prepped for surgery, that he could not operate: a last-minute scan revealed too many tumors. "Go home and think about the quality, not the quantity, of your days," he said.

Not the innumerable specialists whom Ms. Gaines, then 39 and the mother of two toddlers, had already mowed through in her terrified but unswerving effort to save her own life. Not the Internet research and clinical trial reports, all citing the grimmest of statistics. Not the fierce, frantic journey she made, leaving home in Wisconsin to visit cancer centers in Texas and California.

Now, just about out of options, Ms. Gaines faced an excruciating decision. Her last-ditch chemotherapy regimen did seem to be working. Three medical oncologists thought she should stick with it. But two surgical oncologists thought she should first try cryosurgery, injecting liquid nitrogen into the tumors to shrink as many as possible, and then following up with chemotherapy, allowing it to be more effective.

The catch? Ms. Gaines's chances of even surviving the procedure were uncertain.

"Who will decide?" she asked a surgeon from Los Angeles.

The doctor then recited what has become the maddening litany of medical correctness: "We're in the outer regions of medical knowledge," he said, "and none of us knows what you should do. So you have to make the decision, based on your values."

Ms. Gaines, bald, tumor-ridden and exhausted from chemotherapy, was reeling. "I'm not a doctor!" she shouted. "I'm a criminal defense lawyer! How am I supposed to know?"

This is the blessing and the burden of being a modern patient. A generation ago, patients argued for more information, more choice and more say about treatment. To a great extent, that is exactly what they have received: a superabundance of information, often several treatment options and the right to choose among them.

As this new responsibility dawns on patients, some embrace it with a sense of pride and furious determination. But many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming.

Many prostate cancer patients can choose a passive treatment, like watchful waiting, or a more aggressive therapy, like radiation or surgery; each has differing risks and different patterns of side effects. Women with breast cancer often hear conflicting advice from the experts: lumpectomy or mastectomy? Some patients with heart disease can be told by one doctor that they need a bypass, by another that they need angioplasty and by a third that drugs would be just fine. Infertility patients face a blizzard of options.

Such quandaries do not apply only to life-rattling illnesses. Last summer, with the second joint of his left big toe painfully throbbing from gout, Carl Schneider, a law professor at the University of Michigan who had already consulted his internist and a rheumatologist, leaned wearily against a hospital wall as three other doctors argued over which regimen he should follow. One doctor handed him a 20-page Internet printout that cited gout treatment studies, none of them definitive.

"At 57, it's a little late to be starting medical school," Mr. Schneider remarked acidly. "But the burden still falls on me, having to pick among opinions."

The job of being a modern patient includes not only decision making, of course, but often coordinating doctors, medical records and procedures, as well as negotiating with insurance companies, who are often the ultimate arbiters over which treatment options will be covered.

As Ms. Gaines was being treated for cancer she had to wage such a battle. Before she had her diagnosis, her H.M.O. gynecologist laparoscopically removed what appeared to be a cyst on her ovary. But during the procedure, the cyst, which turned out to be a malignant tumor, burst, sending cancer cells into her abdomen. She then wanted to be treated by a specialist, but her insurance plan did not have a gynecological oncologist on its roster. So Ms. Gaines spent months fighting to transfer her care to an out-of-network doctor. Finally the insurers relented, but only after the specialist agreed to perform her surgery at the H.M.O.'s regional hospital, not his own.

Like many patients, Ms. Gaines did not turn to a primary care doctor to help coordinate her care or aid with decisions. Increasingly, that soul-healing doctor-patient relationship has become harder to sustain. Whipsawed by insurance plans, patients frequently switch physicians. Pressed by diminishing reimbursements, those doctors are building ever larger, more unwieldy practices, with less time for each patient.

The strain has left doctors themselves feeling exhausted, angry and heartbroken.

"My visits are almost ludicrous," said Dr. John Russo, an internist in West Orange, N.J., who sees 5,000 patients a year. "But economically you have to see so many more patients than you should, just to keep the lights on. You can't sit and talk and really get an entire history. So you do what you were taught as a resident: do more tests, don't spend more time with patients, getting to know them."

Ms. Gaines was out of time. She had to make a decision. She felt the chill of mortality and the full weight of nearly a year of drastic operations, blood clots, a punctured lung, chemotherapy, research, traveling, countless specialists and unanswerable questions bearing down on her.

"Who's in charge here?" she thought that night, wishing someone would just issue her marching orders. "Oh. I am."

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Monday, September 28, 2009

Digital Patient Records Get a Big Endorsement -

The nation's drive toward computerized medical records is getting a push from big hospitals, which hope not only to improve patient care but to gain an edge on competitors.

And an effort to be announced on Monday by a big New York regional hospital group may be the most ambitious effort of this type yet — a sizable investment intended as a linchpin in the group's $400 million commitment to digitize patient records throughout its system, including 13 hospitals.

North Shore-Long Island Jewish Health System plans to offer its 7,000 affiliated doctors subsidies of up to $40,000 each over five years to adopt digital patient records. That would be in addition to federal support for computerizing patient records, which can total $44,000 per doctor over five years.

The federal program includes $19 billion in incentive payments to computerize patient records, as a way to improve care and curb costs. And the government initiative has been getting reinforcement from hospitals. Many are reaching out to their affiliated physicians — doctors with admitting privileges, though not employed by the hospital — offering technical help and some financial assistance to move from paper to electronic health records.

Efforts by hospital groups to assist affiliated doctors include projects at Memorial Hermann Healthcare System in Houston and Tufts Medical Center in Boston. But the size of the North Shore program appears to be in a class by itself, according to industry analysts and executives.

Big hospitals operators like North Shore, analysts say, want to use electronic health records that share data among doctors' offices, labs and hospitals to coordinate patient care, reduce unnecessary tests and cut down on medical mistakes.

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Don't look at us, America - National Post, Canada

The United States is looking for a new health-care model. Should Canada, as a country with a relatively simple single-payer system -- featuring GP shortages and wait lists, but gloriously little paperwork for patients -- put ourselves forward as an example that the Americans should emulate?

In the September issue of The Atlantic magazine, business executive David Goldhill writes about "how American health care killed [his] father" and shares his conclusions, after a year of research and thought, about what's wrong with the U.S. system. After reading the piece, one of my smug colleagues sent around an email saying, if I may paraphrase slightly, "Look how awful their system is. This makes me grateful to be living in Canada."

It's true that Goldhill makes a convincing case for U.S. health care needing a massive overhaul -- and quick. But all I could think, as I read the article, was: Their problems sound a lot like ours.

The common terribleness of important aspects of our health systems is not something Americans and Canadians tend to dwell on. We are usually too busy pointing out the differences: Americans have HMOs; Canadians don't. (Good on Canadians.) Americans have a plethora of MRI machines; Canadians don't. (Good on Americans.) While in the throes of a catastrophic illness, a lower-middle-class American will spend more time worrying about going bankrupt than about getting better. While in the throes of a catastrophic illness, a lower middle-class Canadian will spend more time worrying about whether he'd be getting better care in Buffalo, Boston or Seattle than about getting better. You get the idea.

Yet consider this: Goldhill, who says he's a Democrat, thinks that no matter what reforms Obama and his fellow politicians come up with -- whether or not there's a public option, or some kind of insurance mandate -- they won't do any good unless Americans learn to "rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices and sensible trade-offs between health-care spending and spending on all the other good things money can buy."

In other words, the problem lies not with who's insured or what's covered, but with placing all the power in the hands of one or a few bureaucratic entities (insurance companies and/or government) instead of consumers. The theory applies equally to Canada, where we have the same his father, and they're certainly a distressing expression of a troubled system. While I am fortunate enough not to have any first-hand experience with anything as dire, I can attest to having witnessed in both Canada and the U.S.: lengthy emergency room waits with no pain killers for the broken-limbed, delayed lab results and botched lab results, week-long stays in the ER because of no beds in real rooms available, nurse call buttons unanswered, nurse call buttons answered by surly nurses, misdiagnoses, lost records, broken diagnostic equipment, months-long waits for tests and specialists. And I'm a healthy person under 40.

We put up with the poor treatment because we have no choice.

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Sunday, September 27, 2009

The gospel of men's weight-loss according to Brooker - Toronto Star

"I'm going to talk to you about rice cakes, which are very important to me," says Peter Rosenthal.

On weekdays, Rosenthal is a math professor at the University of Toronto and a noted defence lawyer. On Sunday mornings, he is one of Harvey Brooker's disciples.

Following Brooker's diet precepts means learning to love the little things – like rice cakes. For 10 minutes, Rosenthal does a decent impression of genuine enthusiasm. He tosses out bags of rice cakes to the 100 men gathered around him. They taste like cardboard.

"They have that great crack you get out of other snacks," Rosenthal says. "Like potato chips." Someone in the audience groans erotically.

Rosenthal, who looks like an aging linebacker, lists off toppings to punch up a rice cake – half a wedge of Laughing Cow cheese (11 calories, he says), or a "very, very, very thin" layer of margarine (6 calories).

"Here's a trick," says Rosenthal. "Eat it upside down. Your tongue goes on (the spread) first. That way you taste it more." A dozen heads nod. This is useful stuff.

"I'm Peter and I've lost 37 1/2 pounds," Rosenthal says before he leaves the stage.

All hundred guys clap lustily. Hands reach out to slap Rosenthal on the back as he returns to his seat. And then Harvey Brooker takes the small stage. This is the Sunday morning Power Hour at Brooker's namesake weight-loss clinic for men only.

"This is church for us," says Mike Parsons, a west-end realtor. "This is the Harvey Brooker church."

The program is, in essence, a dietary regimen. Men are allowed so many starches, vegetables, proteins, etc., per day. They must eliminate most sugars, white flour, alcohol and oils.

"It's the Canada Food Guide, is what it is," says retired mailman Randy Ward, who lost 94 pounds and now weighs 188.

So, what makes these men willing to pay $1,875 for information they could patch together themselves on the Internet? Why do seemingly successful guys want to get rice cakes thrown at them?

The clientele tend toward the middle-aged business set – a lot of male-pattern baldness, golf shirts and BlackBerrys. During the hour before the meeting, while the men wait to weigh in, they talk about Phil Kessel, cottages and work stress. They chew on apples (three fruits allowed per day) and drink artificially sweetened coffee.

Many of them are successful entrepreneurs. The doyen of Canadian print journalism, Robert Fulford, is in attendance this morning. CBC host Michael Enright is a member. Brooker claims a "couple of billionaires" on his roster, but won't name them.

The hyper-successful mix cheek by jowl with cab drivers and cops and mechanics.

There are no pills, vitamin B12 injections or specialty foods. Brooker maintains that the secret, if there is one, is himself. "The whole business is personality driven," Brooker says. "I have to take pride in that."

Brooker is a small, solidly built 65-year-old. In his 20s, he shed a bunch of weight and has maintained it for nearly four decades.

After losing his weight, Brooker made dieting his business. Over the next 30 years, he operated a pair of franchises purchased from U.S.-based diet chains. It was a slow-motion business disaster.

In 1985, he began a subset to his faltering unisex business – a Sunday meeting for men only. At first, it was something he did for fun. And for Brooker, this sort of proselytizing is clearly fun. When his second business collapsed in the early '90s, "all I was left with was this hobby on Sunday mornings."

He kept at it. At times, only a dozen men would show up. Brooker's wife, Helen, went back to law school in middle age, anticipating the family's need. But in 1998, shortly after he began advertising, the men-only diet business found its stride. Today, he has roughly 250 active clients, many paying the full-ride – $1,875 for a 12-month course. Personal coaching sessions are extra.

Vanity is only one of the things that drove members here, to the second floor above one of those anonymous two-storey business malls at Dufferin St. and Finch. Ave. W.

Many are beset by serious weight-related health problems. This must be the only roomful of men in Canada who all seem to know that Allopurinol is used to treat gout.

The meeting itself is like a Tony Robbins presentation delivered at the Water Buffalo Lodge. Brooker rereads the 20 rules his dieters must maintain (Rule #1: "Come each Sunday for the fellowship").

Brooker wanders the room, picking out success stories. He knows everyone by name. As he pulls them out of their seats, speakers repeat Rosenthal's 12-step mantra: "My name is X and I've lost Y." Every speaker gets a round of applause.

One man, Brian, tells the group that for the first time in 35 years he walked a golf course and carried his own bag the whole way. He was playing with his grandson that day. The applause has a new, emotional edge.

Brooker asks all the men who've lost 90 pounds or more to stand up. Nine men rise. One of them has shed 180 pounds. How many men over 70 years old do we have here, Brooker asks. Another eight stand up. The applause keeps rolling.

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Across New York Region, Alarming Wave of Young and Suburban Heroin Addicts -

THE kids weren't all right. They lived in the same comfortable Long Island town and were barely in their teens when they took their first hit of marijuana or sip of alcohol, propelling them on dark journeys they couldn't seem to escape. Within a couple of years, they were in heroin's grip.

"My parents had no idea," said one of them, a 17-year-old girl who, like other formerly addicted youths interviewed, spoke on the condition of anonymity because of her past drug use. "My mom thought I was smoking a lot of weed and taking diet pills, because who would've thought that such a bad drug could be so easily accessible to me?"

The girl grew up in western Suffolk County, in a town where, she said, "everything is perfect," with white picket fences and two cars in each driveway; for her birthday last October, she received a black Jeep, and she went to a wealthy, high-performing public school. "Growing up, everything is pushed on you," she said. "You're trying to be the smartest, trying to compete with everyone."

Heroin, she said, was an escape. The girl said that she had not used drugs since entering rehabilitation in January, but that many of her former friends were still hooked on heroin, and at least two had fatally overdosed.

They are part of a new wave of heroin abuse that officials across the New York region are grappling to understand. During the first six months of 2009, 25 people in Nassau County died of heroin overdoses — more than from homicide and drunken driving combined; in 2008, 46 people fatally overdosed on heroin, up from 27 in 2007, according to Nassau officials.

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Economic View - Making It Easier to Register as an Organ Donor -

WHEN Steven P. Jobs, Apple's chief executive, appeared in public recently for the first time in months, he revealed that he had received a liver transplant from the victim of a car crash. "I wouldn't be here without such generosity," Mr. Jobs said, adding that he hoped that many people would become organ donors.

With the help of a little behavioral economics, it is possible to make that hope a reality.

More than 20,000 organ transplants take place every year in the United States, with a vast majority coming from deceased donors. Demand greatly exceeds supply: in 2006, for example, 3,916 patients died while waiting for kidneys, according to the National Kidney Foundation.

Some economists have come up with a simple solution: a market allowing the buying and selling of organs. Because people have two kidneys and need only one to live, a robust market could greatly increase supply.

The idea may have some merit, but it is spectacularly unpopular. As the Harvard economist Alvin Roth has noted, many people consider it "repugnant," mainly for two reasons. First, they object to the possibility of rich people buying their way to the front of the line. (The hospital where Mr. Jobs's procedure took place said he received the liver transplant because he was the sickest person on its waiting list who matched the donor's blood type.) Second, they object to incentives that would induce the poor to sell their kidneys.

These objections can lead to some logical quandaries. Why, for example, is it O.K. for a parent to donate a kidney to save a child's life but not for her to sell her kidney, thereby also saving a life? And why is it acceptable to risk your life for money, say, by becoming a coal miner, but not by selling a kidney?

Still, whether you think a legal market for organs is a brilliant or a dreadful idea, it's a political nonstarter, so it is important to obtain donors from another possible source: patients who have been declared "brain dead" but are being kept alive temporarily.

Nationwide, roughly 12,000 to 15,000 people fall into this category each year, but only half end up as donors. Because each such donor could supply an average of three organs, having another thousand donors could save 3,000 lives. We need more people to agree to be donors in advance.

One strategy is to alter the default rules for signup. Most states, as well as many other countries, use an "opt in" or "explicit consent" rule, meaning that people must take a concrete action, like going to a public library or requesting and mailing in a form, to declare they want to be donors. But many who are willing to donate organs never get around to such steps.

An alternative approach, used in several European countries, is an "opt out" rule, often called "presumed consent," in which citizens are presumed to be consenting donors unless they act to register their unwillingness.

In the world of traditional economics, it shouldn't matter whether you use an opt-in or opt-out system. So long as the costs of registering as a donor or a nondonor are low, the results should be similar. But many findings of behavioral economics show that tiny disparities in such rules can make a big difference.

By comparing the consent rates in European countries, the psychologists Eric Johnson and Dan Goldstein have shown that the choice of opting in or opting out is a major factor.

Consider the difference in consent rates between two similar countries, Austria and Germany. In Germany, which uses an opt-in system, only 12 percent give their consent; in Austria, which uses opt-out, nearly everyone (99 percent) does.

Although presumed consent is generally accepted in countries that have adopted it, the idea can bring strong opposition. Many people object to anyone presuming anything about their organs, even if the costs of opting out are low. In Britain, a proposal by the Labour government to adopt an opt-out system was opposed by Muslims who objected to organ removal on religious grounds.

Fortunately, there is another possibility, called "mandated choice," under which people must indicate their preference. In Illinois, where I live, this system has been in use since 2006 and doesn't seem to have ruffled many feathers.

Here is how it works: When you go to renew your driver's license and update your photograph, you are required to answer this question: "Do you wish to be an organ donor?" The state now has a 60 percent donor signup rate, according to Donate Life Illinois, a coalition of agencies. That is much higher than the national rate of 38 percent reported by Donate Life America

The Illinois system has another advantage. There can be legal conflicts over whether registering intent is enough to qualify you as an organ donor or whether a doctor must still ask your family's permission. In France, for example, although there is technically a presumed-consent law, in practice doctors still seek relatives' approval. In Illinois, the First-Person Consent Law, which created this system, makes one's wishes to be a donor legally binding. Thus, mandated choice may achieve a higher rate of donations than presumed consent, and avoid upsetting those who object to presumed consent for whatever reasons. This is a winning combination.

THE key, however, is to make signup easy, and requiring people to make a choice is just one way to accomplish it. The private sector could help create other simple methods. Here is a challenge to Mr. Jobs: Why not create a Web site — and a free app for the iPhone — that lets people sign up as organ donors in their home states?

At the same time, he'd need to work with the states to create the technology for a secure, simple signup procedure. Social networking sites like Facebook could also help, by encouraging signup campaigns.

Many Americans say they want to be organ donors, but they just don't get around to acting on their intentions. Helping these potential good Samaritans overcome their inertia could prolong thousands of lives a year. Signing up to be an organ donor should be at least as easy as downloading a song to your iPhone.

Richard H. Thaler is a professor of economics and behavioral science at the Booth School of Business at the University of Chicago.