Friday, February 17, 2012
Thursday, February 16, 2012
In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years (Figure 1) has been driven by increased use of a class of prescription drugs called opioid analgesics (1). Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined (Figure 2) (1). In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment (2), 35 visit emergency departments (3), 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics (4). Implementing strategies that target those persons at greatest risk will require strong coordination and collaboration at the federal, state, local, and tribal levels, as well as engagement of parents, youth influencers, health-care professionals, and policy-makers.
Overall, rates of opioid analgesic misuse and overdose death are highest among men, persons aged 20–64 years, non-Hispanic whites, and poor and rural populations. Persons who have mental illness are overrepresented among both those who are prescribed opioids and those who overdose on them. Further defining populations at greater risk is critical for development and implementation of effective interventions. The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids (5), and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month (4). In an attempt to treat patient pain better, practitioners have greatly increased their rate of opioid prescribing over the past decade. Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600% (6). That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin (hydrocodone and acetaminophen) every 4 hours for 3 weeks. Persons who abuse opioids have learned to exploit this new practitioner sensitivity to patient pain, and clinicians struggle to treat patients without overprescribing these drugs.
Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (≥100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus on strategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.
Wednesday, February 15, 2012
Medical associations don't recommend such patient bans, but the practice appears to be growing, according to vaccine researchers.
In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.
By comparison, in 2001 and 2006 about 6% of physicians said they "routinely" stopped working with families due to parents' continued vaccine refusal and 16% "sometimes" dismissed them, according to surveys conducted then by the American Academy of Pediatrics.
"There's more noise among pediatricians, more people willing to argue that it's OK to do this versus 10 years ago," said Douglas Diekema, a professor of pediatrics at the University of Washington in Seattle. Dr. Diekema wrote the AAP's policy on working with vaccine refusers, which recommends providers address the issue at repeated visits, but respect parents' wishes unless it puts a child at risk of significant harm.
Most pediatricians consider preventing disease through vaccines a primary goal of their job. The Centers for Disease Control and Prevention and AAP issue an annual recommended vaccination schedule, but some parents ask if their child's immunizations can be pushed back or skipped altogether, pediatricians say.
Parents often voice concerns about autism or that their child's immune system may be overwhelmed by too many vaccines at once. Worries about a link between vaccines and autism arose because some parents noticed their children regressed, or lost some skills, around the time of their vaccinations at two years of age. Another concern centered on the former use of mercury as a vaccine preservative.
Numerous studies since have dispelled these concerns among scientists. Rather, scientists say, it is more likely that autism symptoms begin showing up around the same age children are vaccinated.
The rise in patient firings reflects another factor. As patients have become savvier and more willing to challenge doctors, physicians have become increasingly reluctant to deal with uncooperative patients, said Arthur Caplan, a bioethics professor at the University of Pennsylvania. In addition, doctors may feel financial pressure to see more patients and so have less time to contend with recalcitrant ones.
For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven't yet been fully vaccinated.
In one case, an unvaccinated child came in with a high fever and Dr. LaReau feared the patient might have meningitis, a contagious, potentially deadly infection of the brain and spinal cord for which a vaccine commonly is given. "I lost a lot more sleep than I usually do" worrying about the situation, he said.
"You feel badly about losing a nice family from the practice," added Dr. LaReau, but families who refused to vaccinate their kids were told that "this is going to be a difficult relationship without this core part of pediatrics." Some families chose to go elsewhere while others agreed to have their kids inoculated.
Pediatricians disagree about what their duty is to these families. "The bottom line is you should try to do whatever you can to maintain the family in the best care," said Michael Brady, chair of the pediatrics department at Nationwide Children's Hospital in Columbus, Ohio, and a member of the AAP's immunization committee. "If they leave your practice, they're probably going to gravitate toward another practice with unhealthy practices."
Other physicians say they rarely have had luck persuading vaccine opponents to change their minds.
David Fenner and his 20-plus colleagues at Children's Medical Group in Rhinebeck, N.Y., discuss vaccine concerns but ask families to leave if they don't comply by a certain point.
Dr. Fenner said he tells new families, "You've been bombarded with information before you came here, some accurate and some not." Iif a family refuses to vaccinate after a discussion of the issue, he tells them "there are so many things we're not going to see eye-to-eye on."
So far, the practice has fired a couple of families per year since it implemented the policy about five years ago.
Pamela Felice, who lives in an Atlanta suburb, had difficulty finding a pediatrician for her two children though they have waivers from a previous pediatrician exempting them from school requirements for immunizations. Her older child had gastrointestinal trouble and regressed development after receiving vaccines, she said, which she believes were related to the shots.
Ms. Felice received a letter from her pediatrician a few years ago stating that because the family chose not to vaccinate, it needed to find another doctor. She called four or five other practices but none would agree to an appointment after she told them she was opposed to vaccines. The family ended up with an elderly family doctor who said he had "seen it all" and was willing to treat the children if they got sick, Ms. Felice said.
"A doctor should feel obligated to discuss [potential vaccine] risks with any parent who wants to discuss them," said Ms. Felice.
Tuesday, February 14, 2012
The very idea of psychotherapy seems to defy the instant-access, video screen chatter of popular digital culture.
Not for long, if some scientists have their way. In the past few years researchers have been testing simple video-game-like programs aimed at relieving common problems like anxiety and depression. These recent results have been encouraging enough that investigators are now delivering the programs on smartphones — therapy apps, in effect, that may soon make psychological help accessible anytime, anywhere, whether in the grocery store line, on the bus or just before a work presentation.
The prospect of a therapy icon next to Angry Birds and Fruit Ninja is stirring as much dread as hope in some quarters. "We are built as human beings to figure out our place in the world, to construct a narrative in the context of a relationship that gives meaning to our lives," said Dr. Andrew J. Gerber, a psychiatrist at Columbia University. "I would be wary of treatments that don't allow for that."
The upside is that well-designed apps could reach millions of people who lack the means or interest to engage in traditional therapy and need more than the pop mysticism, soothing thoughts or confidence boosters now in use.
"That is what makes the idea so promising," said Richard McNally, a psychologist at Harvard whose lab recently completed a study of 338 people using a simple program accessible on their smartphones. "But there are big questions about how it could work, and how robust the effect really is."
The smartphone study is only one of the most recent tests of an approach called cognitive bias modification, or C.B.M., that seeks to break some of the brain's bad habits. The premise, pioneered by Colin MacLeod of the University of Western Australia, is straightforward. Consider people with social anxiety, a kind of extreme shyness that can leave people breathless with dread.. Studies have found that many who struggle with such anxiety fixate subconsciously on hostile faces in a crowd of people with mostly relaxed expressions, as if they see only the bad apples in a bushel of mostly good ones.
Modifying that bias — that is, reducing it — can interrupt the cascade of thoughts and feelings that normally follow, short-circuiting anxiety, lab studies suggest. In one commonly used program, for instance, people see two faces on the screen, one with a neutral expression and one looking hostile. The faces are stacked one atop the other, and a split-second later they disappear, and a single letter flashes on the screen, in either the top half or the bottom.
Users push a button to identify the letter, but this is meaningless; the object is to snap the eyes away from the part of the screen that showed the hostile face, conditioning the brain to ignore those bad apples. That's all there is to it. Repeated practice, the researchers say, may train the eyes to automatically look away, or the frontal areas of the brain to exercise more top-down control.
"It's a little boring, because it's repetitive, but you're only doing it for a few minutes a few times a day," said Stefanie Block, 26, a University of Michigan graduate student who took part in the Harvard study while living in Boston. "I just did it when commuting to work on the subway; it's crowded, there isn't much you can do, it was the perfect time."
In lab experiments, some researchers have gotten very strong results, "with effect sizes like you'd see in regular therapy," said Nader Amir, a psychologist at San Diego State University. In a series of experiments, Dr. Amir has found that about half of people with an anxiety disorder who complete a full course — practicing on a computer for about 30 minutes twice a week, for four to six weeks — improve enough that the diagnosis no longer applies. He has tested programs that target social anxiety and generalized anxiety disorder and is part owner of a company that is marketing the technology.
A study among 40 children with chronic anxiety, published in December, found that a similar attention bias program produced "significant reductions in the number of anxiety symptoms and symptom severity," according to the authors, who included Dr. Daniel Pine of the National Institute of Mental Health and Yair Bar-Haim of Tel Aviv University.
Psychologists in Europe have even tried a bias modification program aimed at heavy drinking — a computer task in which people push away images of alcoholic drinks, using a joystick, and zoom in on nonalcoholic ones — and found that it improved the effectiveness of talk therapy aimed at reducing the habit.
Other researchers have not had quite the same success. "I am far from convinced that this is for real," said Willem Van der Does, a psychologist at Leiden University in the Netherlands, who has several papers under review testing bias modification.
"I did not notice any positive effect," one woman with social anxiety who participated in the Harvard study said in an e-mail. "It seemed similar to when I played Scramble or other games on my phone."
In a review of studies of bias modification, researchers at the University of Pennsylvania concluded last year that the technique had a small effect that "significantly modified anxiety but not depression." The authors noted that there was evidence of what scientists call a "file drawer" problem — in which studies finding no effect are filed away or ignored, while encouraging ones are published. "I think in this field the standards for publishing positive studies are lower than for negative ones," Dr. Van der Does said in an e-mail.
It is perhaps fitting that the largest study to date — by Phil Enock, a graduate student at Harvard; Stefan Hofmann, of Boston University; and Dr. McNally — produced results that were both encouraging and confusing. The team began recruiting participants in the summer of 2010, using Craigslist and online bulletin boards for social anxiety.
In March 2011, they were flooded, after an article in the Economist magazine about cognitive bias modification mentioned the project. Months later, after 338 participants with anxiety symptoms that ranged from mild to severe completed a total of more than 4,000 sessions of the two-face therapy application, the researchers had some results.
Participants who got the treatment improved their scores on a questionnaire measuring anxiety, dropping by an average of 22 points, compared with an 8-point drop among people in a "waiting list" group, who got no computer games to play. However, a placebo group in the study practiced with a two-face video program not intended to shift the eyes from one face or the other, and their anxiety levels as measured on questionnaires also fell by about 22 points, just as they had for those who got the treatment.
Karin Langer, 34, an architectural historian in Chicago who scored high on some measures of social anxiety, was among those who seemed to improve using the app. Ms. Langer works at home, interacts almost entirely by e-mail, and found herself increasingly anxious about phone conversations with colleagues. "I did notice a difference after using the therapy," she said. "But it may have been due to a placebo effect. I felt good about myself, that I was doing something for my issues, and a lot happened in those two months outside the study that could have helped."
Stranger still, the people who reported that they had learned about the study from the Economist article responded very well to the program — whether getting the treatment app or the placebo one — as if the article itself had some power of suggestion.
"We're not exactly excited about that finding; we have no idea what it means," said Mr. Enock, adding that there is still a lot of work to do to determine who best responds to which specific type of bias modification, and how strong the effect really is.
But, he said, "We certainly have shown that you can deliver treatments on smartphones, you can put attention and bias modification tools literally in people's hands, and there's no reason to hold back" from testing them.
Sunday, February 12, 2012
In the space of three years … my mother's ferocious independence gave way to utter reliance on her two adult children. Garden-variety aches and pains became major health problems; halfhearted attention no longer sufficed, and managing her needs from afar became impossible … We were flattened by the enormous demands on our time, energy, and bank accounts; the disruption to our professional and personal lives; the fear that our time in this parallel universe would never end and the guilt for wishing that it would … We knew nothing about Medicaid spend-downs, in-hospital versus out-of-hospital "do not resuscitate" orders, Hoyer lifts, motorized wheelchairs, or assistive devices for people who can neither speak nor type. We knew nothing about "pre-need consultants," who handle advance payment for the funerals of people who aren't dead yet, or "feeders," whose job it is to spoon pureed food into the mouths of men and women who can no longer hold a utensil.