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Everyone knows this old saw and the implication is that keeping away from a doctor implies that you are healthy. I like the message that healthy eating and living translates to better health, and in fact one of my favorite cartoons depicts a man sitting on his doorstep happily eating an apple with three men in white coats lurking off in the distance with the caption “An apple every 8 hours keeps three doctors away”. It slays me every time. But as you might intuit, not seeing a doctor (or other health care provider) may not be so good for your health.

Just last month JAMA Internal Medicine published a study by Basu et al, which looked at the impact of having doctors available to see patients and the results were eye opening. They studied outcomes in 3124 counties across the US from 2005 to 20015 and without getting into the details of their methodology, here is what they found:

  • In those 10 years the number of physicians in those counties increased from 196,014 to 204,419, but the population at large grew faster.
    Primary care physicians (e.g. family doctors, internists and pediatricians) decreased from 46.6/100,000 people to 41.4, with greater losses in more rural areas.
  • For every 10 additional primary care physicians/100,000 people life expectancy in that population increased by 51.5 days, but only by 19.2 days for every specialist 10 specialists/100,000 people.
  • Increasing the number of primary care physicians had the most positive impact on mortality (death) from cardiovascular disease, cancer and lung diseases.

It makes sense that cardiovascular disease, cancer, and respiratory illness are most sensitive to the presence or absence of primary care. Those illnesses are especially responsive to careful management with nimble responses to flare ups, and cancers can be impacted by reliable, evidence based screening, all of which is most impactfully provided through primary care.

This kind of data should compel our policy makers to work to enhance primary care and its availability in our rural states like Maine, which has experienced an overall drop in life expectancy in the last 15 years. CMS has comprehensive primary care initiative aimed at this, robust loan repayment programs and financial and tax incentives to attract health professionals to rural areas would help, states could invest much more in supporting primary care and our health care delivery system must change to value primary care at a level commensurate with its importance. A recent issue of the Journal of Ambulatory Care Management includes an important article on sustaining access to healthcare in rural areas, and PCHC’s CEO, Lori Dwyer and I have a companion opinion piece. I’ll be discussing both in a future Noah’s Notes.

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Since the advent of the Affordable Care Act in 2009 over 20 million previously uninsured people have gained health insurance coverage. This has had a number of positive impacts on access to care and health outcomes which I’ve covered in previous blogs. But as we all know, there have also been challenges. The Supreme Court ruling, which made expansion of Medicaid optional for states, the compromises on benefits coverage that were required to get the plan passed in the first place, and the elimination of a public option (e.g. Medicare buy in for people 55 and older) by the US Senate diminished the impact of the law. Congress’ removal of the individual mandate last year and the current administration’s dramatic reductions in outreach funding and time access to enrollment have further undermined the ACA.

And now a Commonwealth Fund survey reveals some disturbing trends. While the uninsured rate has declined from 20% in 2010 to 12% for the past 3 years (and it is unfortunate we could not make more progress on that) the rate of underinsured has risen from 16% to 23% during the same time period). And more surprisingly, the most rapid rate of increase in the underinsured is among those with employer based insurance, not those who purchase their insurance as individuals. This is a reflection of ever increasing deductibles and co-pays as health care cost increases outpace wages, driven largely by pharmaceutical costs and the ongoing waste in healthcare spending ($1 trillion of the $3 trillion spent on healthcare each year).

Most of us have experienced this phenomenon on a very personal level as year after year our personal costs for health insurance coverage increase while there is simultaneous pressure on benefit design to try to create cost reductions. The authors of the survey suggest several strategies to reverse this trend and they include:
• Improve the basic required coverage under the ACA to require coverage of more of the costs of care and of medications.
• Increase Medicaid expansion.
• Support growth of reinsurance markets.
• Restore outreach and enrollment funding.
• Reinstate funding to reduce cost sharing (which ahs been cancelled by the Trump administration).
• Eliminate “junk plans”, the short term plans with very limited benefits that were expanded by congress last year.
• Make health insurance premiums tax deductible.

There are other strategies that ought to be considered as well. Medicare buy in for people aged 55 and over was seriously considered in 2009 and ought to be re-evaluated. States may also undertake innovations like allowing buy in to Medicaid. We ought to be able to do better and we can if we put people first in public policy.

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While the scope the opioid crisis has become apparent to most people in this country, most of our broad understanding of the challenges we face are a result of its impact on adults.  Relatively little is known about how children are affected and what we have known is often based either on extrapolation from data related to adults or indirect measurement.  Childhood opioid poisonings are one such example.

Up until this point we knew how many children each year presented to hospital emergency departments with opioid poisoning and how many of those children died.  However, for the first time researchers carefully examined trends in pediatric deaths from opioid poisonings and published their findings in JAMA Open Network last month.  What they revealed is startling and should serve as a call to action.

  • Between 1999 and 2016 just under 9000 children died from opioid poisonings and 38% of those deaths occurred at home.
  • During that time period the mortality rate for children from opioid poisonings increased by 300%, poisonings by prescription opioids increased by 95% and heroin overdoses in adolescents increased by 400%.
  • 73% of those who died were males.
  • 73% of those poisonings were from prescription opioids.
  • 7% of the deaths were children under the age of 5.
  • 25% of the deaths in children under the age of 5 were actually homicides.
  • Adolescents make up 80% of the deaths and heroin was the primary cause of death in 1900 of the deaths in children between the ages of 15 and 19.

We all must work to identify effective prevention strategies, including education, safer packaging and storage of prescription opioids and of the medications we use to treat opioid use disorder (methadone and buprenorphine), and promotion of responsible prescribing practices.  Naloxone, the antidote for opioid overdose, should be in every home in which there is a prescription for opioid medications, and should be easily accessed by people who use drugs and by those who care for them.  We must develop reliable screening for substance use among pre-adolescents and adolescents so that early interventions can be offered.  We must strengthen community and public health support for struggling families.  And we must be be certain that appropriate treatment is available if they have developed a substance use disorder.

What could be more important?

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Many of us who are committed to universal access to healthcare have celebrated some of the successes of the Affordable Care Act, like 20 million more Americans having health insurance, but a recent UPI report reminds us that our healthcare system is far from perfect.  In a December 17 article they reported the results of a Gallup survey which showed the following:

  • 29% of adults in the US postponed treatment due to costs.
  • More than half of them reported a serious or somewhat serious medical condition (representing 19% of all US adults).
  • The extent to which people delay treatment depends on the nature of their health insurance coverage – those with no insurance are the most likely to forego treatment, those with Medicare and Medicaid are the least likely to delay, and those with insurance but higher deductibles and/or co-pays are somewhere in between.

It is likely that no one would find this data surprising, but it should be alarming to everyone.  Delayed treatment leads to escalated costs and unnecessary suffering and death, and this is compounded when public policy results in increased costs to individuals.  No matter where you stand on the ACA, the decisions last year to reduce support for the insurance exchanges and to remove the penalty for the individual who chooses not to get health insurance means that fewer people have insurance than otherwise would be the case, and that the pool of insured people have a higher disease burden and therefore higher costs, which unarguably leads to higher costs for all manifested in their deductibles, co-pays and premiums.

In addition, 30% to 50% of all health care costs are unnecessary and wasteful, the administrative burden on the system is unsustainable, and industries like Big PhRMA are profiteering from a broken model.  In the US we spend $3.5 trillion a year on healthcare – 19% of GDP.  There is a great deal of interest in congress in addressing this and the bills that result will represent either the interests of insurers and pharmaceutical companies or the interests of people living in our communities.  It compels all of us to learn and to engage on this issue and to work toward an outcome which moves us toward broader access to more affordable care.

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During the debates about healthcare in the last 2 years one argument that was made by Senator Ron Johnson of Wisconsin against Medicaid expansion was that more people with access to health care resulted in more opioid prescriptions and made the crisis of addiction worse.

Most people working in healthcare argued that the origins of the opioid crisis were far earlier than Medicaid expansion (which only began in 2010), but with expansion of MaineCare now imminent it would be helpful to have information which would help us to anticipate its impact.

In August of this year Saloner et. al. published an article in the Journal of the American Medical Association Open Network outlining the results of a study they conducted on prescribing patterns in 3 Medicaid expansion states (California, Maryland and Washington) and two non-expansion states (Florida and Georgia). This study included 11.9 million people who filled 2 or more prescriptions for opioids over the course of a year and analyzed on a county by county basis. Here is what they found:

  • Prior to expansion nearly 70 people per 100,000 filled prescriptions for Suboxone across all counties, meaning that they were being treated for opioid addiction, or Opioid Use Disorder (the medical term).
  • After expansion, the counties where Medicaid was expanded showed and increase in Suboxone prescribing by nearly 13% compared to non-expansion counties.
  • Conversely, the rate of prescribing for opioid pain relievers did not increase after expansion, relative to non-expansion counties. In fact across all sectors, opioid pain reliever prescribing decreased steadily.

These data suggest that when Medicaid is expanded access to treatment for Opioid Use Disorder improved and expansion did not increase the prescribing rates of opioid pain relievers, in fact there is a trend of steadily decreasing rates of those prescriptions. Given that we know from very strong clinical evidence that treatment of people with Opioid Use Disorder with medication like Suboxone decreases deaths from overdose, decreases transmission of diseases like Hepatitis C and improves retention in treatment programs this is good news for Maine as we move toward MaineCare expansion and allowing more people to access healthcare.

 

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The term ‘burnout’ has become prevalent in both discussion of the healthcare delivery environment and in medical literature.

It is vitally important and threatens the stability of our healthcare system, and most importantly our primary care practices across the country.  Burnout most generally refers to providers (especially physicians, nurse practitioners and physician assistants) but can impact anyone, and is described as a loss of empathy as a consequence of an environment in which resources are not matched to the tasks expected of providers, new tasks are added on a regular basis, there is a shifting role for providers and there is little control over the amount and pace of work we face on a day to day basis.  The loss of empathy then results in cynicism, fatigue and a failure of engagement with each patient and with the full embrace of the management of a panel of patients, and the consequences for quality of care can be profound.  Most alarmingly, burnout rates for family doctors are estimated to be over 50%.  As you might imagine, healthcare organizations must attend to this challenge and that attention should be urgent.  Here at PCHC we have had a Joy in Medicine workgroup tackling this for the past 18 months and our scribe pilots, the standard primary care schedules, and efforts at increased staffing and reducing desktop documents have resulted from that endeavor (which is ongoing).

But a recent article raises the possibility that the situation may be more nuanced than burnout alone.  The authors, Dr. Simon Talbot and Dr. Wendy Dean, writing in STAT magazine argue that there is an unrecognized threat to provider wellbeing and they label it as “Moral Injury”.  They assert that moral injury is mistaken for burnout and that risks misapplied and ineffective solutions.  They go on to make these points:

  • The complexity of the work that we undertake and the myriad of interests (patient, employer, payers, self, etc.) involved create highly conflicted allegiances on the part of providers and it is this conflict that robs us of our resilience.
  • The ongoing moral injury in healthcare is being unable to provide high quality care and healing in a consistently reliable fashion due to financial concerns, limited or no insurance coverage, and the overwhelming impact of electronic health records.
  • Most providers feel called to their work, and have sacrificed a great deal of time, energy and money in order to train to do that work. Leaving training and entering a work environment that is as rapidly changing and challenging as healthcare creates an ongoing tension that is difficult to manage and “Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting”.  I would argue this is most dramatic in primary care.

So in addition to providing support and resources, leaders of healthcare organizations must consider these “competing allegiances”, strive to mitigate their impact, and advocate for public policy and organizational innovations aimed at creating an environment in which the best interests of the patient are paramount.  I’m all in.

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That was one of my Dad’s favorite aphorisms, and a recent article brought that particular quote to mind. “Adverse events associated with opioid-containing cough and cold medication in children” was published in April’s online version of Clinical Toxicology.

Opioid containing cough syrups (Robitussin AC, Tussionex and others) have been around for a long time and are widely used, despite the fact that other studies show that they are ineffective in reducing cough. The risks of these drugs are elevated in children but their use has persisted. In this current study they looked at US cases of adverse events in children related to these cough medications between 2008 and 2015. The results were:

  • 114 of 7035 cases reviewed involved an opioid containing product.
  • In 98 cases the adverse event could reasonably be linked to the opioid.
  • There were 3 deaths and all involved a cough medicine combination of an antihistamine and hydrocodone (the opioid in Tussionex).
  • Other adverse events included somnolence, lethargy, lethargy (all also more common with hydrocodone than with codeine).

In January of this year the FDA required warning labels on these cough medicines to attempt to limit their use in children under the age of 18 and included their highest level of warning (“black box warning”) about the risks of misuse, abuse, addiction, overdose and death, and slowed or difficult breathing that can result from exposure to codeine or hydrocodone.

Another article published in Pediatrics in June of 2017 looked at the risks of over the counter cold and cough remedies for children and found that between 2009 and 2014 there were 3251 reports of adverse events, 60% of which were in children under the age of 4, and which included racing heart, somnolence, hallucinations, gait disturbances and agitation. There were 20 cases of death, most in children under the age of 2 and involving an unsupervised ingestion of diphenhydramine or dextromethorphan.

One of the authors of the first study stated, “Health care providers should never prescribe opioid-containing cough and cold products to children. Ever”. Given the fact that none of these medicines, with or without opioids, works to reduce cough or other cold symptoms I would expand that to say don’t prescribe or recommend them at all, to anyone, ever. Another of my favorites of Dad’s sayings, which he always used when people asked what they should use for a cold: “a handkerchief”.

 

Ian M. Paul, Kate M. Reynolds & Jody L. Green (2018) Adverse events associated with opioid-containing cough and cold medications in children, Clinical Toxicology, DOI: 10.1080/15563650.2018.1459665

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Much of my work and much of the public’s attention in the last several years has been focused on the opioid crisis, and properly so.  But addiction (or substance use disorders) are the result of a complex mix of genetics, environment and exposure to the substance.

The environment includes the stability of the household and exposure to emotional traumas (like the loss of a parent, witnessing domestic violence, suffering emotional, physical or sexual abuse, etc.) but also the larger environment, or what has been termed the social determinants of health.  These include issues like poverty, education, housing, and a sense of community and belonging.  To the extent that we fail to meet our ideals in all of these areas we place people at risk for the “diseases of despair”, like addiction.  Another disease of despair is suicide, and the news on that front is not good.  The CDC reported recently that 45,000 Americans age 10 and older took their own lives in 2016.  More alarmingly, across the nation suicide rates have risen by nearly 30% in the last 18 years.  Some additional findings:

  • Between 1999 and 2016 suicide rates increases significantly in 44 states.
  • 25 states experienced an increase of over 30% (Maine’s increase is 27%).
  • The range of increases were 5.9% (Delaware) to 57.6% (North Dakota).
  • 54% of people who took their own life did not have a known mental health condition, like depression.
  • Circumstances more likely among those who did not have a known mental health condition included relationship problems, life stressors, and recent or impending crisis.
  • Suicide rates increased among all age groups under age 75, and people age 45 to 64 had the steepest increase in suicide rates.
  • Men still are more likely than women to take their own life, but the increase in suicide rates in women is twice that in men.
  • Firearms are the most common method for suicide.

So what can be done?  We need to work to raise awareness, and to work to improve human connection (belonging) in all of our communities.  In primary care we need to reliably screen for depression and offer appropriate treatment when it is identified.  Working to expand people’s access to healthcare is fundamental to this work, and we must study gun violence and its role in suicide so that effective interventions can be developed.  There are important resources available including:

  • BeTheOneTo.com where you can learn about the warning signs for suicide.
  • 1-800-273-TALK (8255) – the National Suicide Prevention Hotline
  • 741741 – the Crisis Text Line

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For the past 49 years the American Academy of Family Physicians (AAFP) has taken a formal policy stance that has championed clean air, clean water and clean land as vital to public health.

The mission of the Environmental Protection Agency (EPA) is to “protect human health and the environment” by “working to ensure that Americans have clean air, land and water, and by ensuring that national efforts to reduce environmental risks are based on the best available scientific information”. Toward that end, in 2014 the EPA proposed the Clean Power Plan in order to reduce carbon dioxide emissions. At the time of the adoption of Clean Power Plan in 2015 coal powered electrical plants emitted 71% of the carbon dioxide (CO2) from the electric power sector (1.3 billion metric tons of CO2). The best available scientific information informs us that greenhouse gases like CO2 are a major cause of climate change and its impact on public health, including drought, famine, flooding and other human caused catastrophes.

On February 1 of this year the EPA, under the leadership of Administrator Scott Pruitt, proposed repealing the Clean Power Plan and invited public comment. The AAFP released a letter to Administrator Pruitt urging that the Clean Power Plan not be repealed. The letter pointed out that repeal of the plan would lead to increased air pollution, and that there are vulnerable populations who would be placed at increased risk as a result, including children, the elderly, the poor, people with asthma and chronic lung disease, and minorities in the US. In addition the resulting increase in pollution will increases risks of heart attack, stroke, and heart failure as well as increased risk of death in the elderly. In short, clean air is a very important determinant of health. For example, 68% of African Americans live within 30 miles of a coal powered plant and they are hospitalized for asthma at 3 times the rate of white Americans. In addition, climate change leads to:

  • Deteriorations in mental health
  • Increase in vector borne illnesses (like Lyme disease)
  • Food shortages
  • Water shortages

Over 7 million deaths worldwide can be attributed to air pollution. In Maine, we are known as the tailpipe of the nation as the pollution from states to our south and west produce pollution which is then swept to us by the prevailing winds. You have experienced this with ozone and particulate matter warnings which, when bad enough, urge people with lung disease (including children with asthma) or chronic diseases to limit physical activity and stay inside. I’m proud that the AAFP has taken a strong public stand on this fundamental health issue and I full agree with their recommendation.

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I was alarmed in February when I read reports of a study performed by the Governors Highway Safety Association (a national group) which showed that while pedestrian fatalities decreased by 6% in the first 6 months of 2017 compared to the first 6 months of 2016, in the 7 states with legalized recreational marijuana pedestrian fatalities were up more than 16% in the same time period.

Of course, association does not mean causality, but with the inevitability of legalized recreational marijuana and its growing use for a wide range of health issues. I thought it important to understand more about how marijuana can impact driver performance. Fortunately the April 17 edition of JAMA included a piece entitled “Driving Under the Influence of Marijuana: An Increasing Public Health Concern” by Johannes Ramaekers, PhD, who is a at Maastricht University in the Netherlands where they have longer experience with legalized marijuana. In that piece Dr. Ramaekers summarizes what we know about the impact of marijuana on driving:

  • Cannabis is the most frequently detected illicit drug among drivers involved in car crashes and it is often in combination with alcohol.
  • Studies have shown that cannabis impairs driving performance and increases crash risk.
  • Impairment is most significant in the first hour after smoking or consumption and then declines over the next 2 to 4 hours.
  • The impact is equivalent to a blood alcohol level of 0.05 g/dl (legal limits in Maine are 0.08 for adults over 21).
  • Cannabis produces dose related impairments of distance keeping and reaction time (similar to alcohol) and the affect is additive when it is combined with alcohol.
  • Driving impairment occurs in regular users of cannabis as well as those who use infrequently.
  • Cannabis use is associated with a 1.2 to 2 fold increase in crash risk and combining it with alcohol creates a greater risk than the use of either substance alone.
  • Driving under the influence of cannabis was estimated to be responsible for 8700 traffic deaths worldwide in 2013. As a comparison, alcohol accounted for 188,000 such deaths.
  • Regular users of cannabis often admit to driving under its influence and believe that cannabis does not affect their driving, or that they can compensate for it (studies have shown that they cannot).

None of this is to say that we ought to fight legalization (which seems inevitable). Many people, including me, have concerns about the broad application of cannabis for myriad unrelated medical conditions with scant evidence to support its use, but that cat is out of the baggie and it may take decades to gather the real science needed to guide rational decision making. However, the public health impact of the broader availability of marijuana in our state ought to be considered as we develop education programs for users of marijuana and for the public at large. Think of the impact that Mothers Against Drunk Driving has had on our perceptions of that practice. The risks of driving under the influence of marijuana are not as severe, but they are real and they can be reduced by thoughtful consideration of evidence, education and public awareness.