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 The AAFP released a letter to Administrator Pruitt urging that the Clean Power Plan not be repealed.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.
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.
In December the CDC released updated data on trends in deaths from drug overdose between 1999 and 2016 and, as you might imagine, there is nothing good about it.
Anyone paying attention knows it is getting worse, but this data from the National Vital Statistics System also gives us insights into specific groups, geography and types of drugs. All of this is important to understand if we wish to have an appropriate medical response and effective public policy.
Here are the “low-lights”:
- In 2016 there were 63,600 drug overdose deaths in the US, up 21% from 2015.
- Deaths from drugs like fentanyl and tramadol doubled between 2015 and 2016.
- Drug overdose death rates increased by 10% per year between 1999 and 2006, by 3%per year between 2006 and 2014 and by 18% per year between 2014 and 2016 (probably due to the introduction of potent synthetic opioids).
- Overdose rates are rising in all; age groups.
- For people 55 to 64 drug overdose deaths have been rising steeply in the last 2 years (@ 17%).
- The highest rates are in people aged 25-54.
- Males have higher rates of overdose deaths than females.
- 22 states (including Maine) and the District of Columbia have rates higher than the national average, 23 states had rates lower than the national average, and 5 states are at the national average.
- The 5 worse states are West Virginia, Ohio, New Hampshire and Pennsylvania.
- The 5 best states are Iowa, North Dakota, Texas and South Dakota.
To put all of this in perspective, the number of people dying from overdose each year is higher than the number of people who died in the Viet Nam war, higher than number who died from AIDS at the peak of that epidemic, and higher than the number who died in car crashes before safety changes to cars.
It is evident that the health care system is not doing its job, our political leaders are not doing their job and our society is not doing its job. We must address the stigma associated with addiction, spread understanding of substance use disorders as chronic disease, expand access to medication assisted recovery, improve governmental and private payer support for these programs, make naloxone (the overdose antidote) widely available in our communities, and confront the poverty and emotional trauma that are the major causes of these challenges.
Each year United Health Foundation releases “America’s Health Rankings”, which is an overview of the status of our health as a nation and a ranking of states, and there are concerning trends across our country and in Maine’s performance relative to other states.
In the US premature deaths are up 3% just since 2015, drug related deaths are up 7% in the last year and deaths related to heart disease are up 2% since 2015 (and by the way, chronic daily use of opioid pain medication increases the risk of heart disease).
Even more alarming – Maine has dropped from #8 in the health of our citizens in 2010 to # 23 now, and that decline has been steady and persistent during those 7 years. It can largely be chalked up to a series of factors:
- Increases in poverty (20% of Maine’s children live in poverty)
- 20% increase in Maine’s infant mortality since 2012
- Increases in overdose deaths (52% increase in the last 3 years – Maine has one of the highest per capita rates in the country)
- A plateauing of adult smoking rates (Maine has not increased the cigarette tax since 2005, which is the single most impactful way to lower smoking rates)
- An increase in adolescent smoking and other tobacco use
And what is especially distressing is that this was avoidable. All other New England states have maintained a high ranking since 2010, including Massachusetts, which is #1.
All of this did not just happen in a vacuum.
- The contraction of MaineCare in 2012 meant thousands of Maine families lost health insurance coverage.
- The decision to cut payments for mental health providers meant that even people with insurance could not access vital care.
- The slow response to the opioid crisis and completely avoidable delays in making naloxone more widely available have resulted in unnecessary deaths from overdoses.
- The decimation of public health nurse positions means less support for at risk families and especially at risk infants.
- The cut of the Fund for a Health Maine means the loss of programs aimed at preventing substance use and abuse in the first place.
- The elimination of funding for school based health centers results in a loss of access to care for adolescents.
- Withholding bond funds approved by the voters for senior housing places elders at unnecessary risk.
- The significant narrowing of the role of the Maine CDC weakens our public health leadership in the state.
- The failure to expand MaineCare prevented 70,000 to 80,000 people from gaining health insurance.
We can turn this around but it will take a serious effort by people of good faith from across the political spectrum to recognize the consequences of these and other decisions and to commit to improving the health of the people of Maine. Those of us who work in healthcare can help with information and education but all Mainers will have to express this as a shared value to move as rapidly to improvement in the coming years as have toward decline in the past 7 years.
The passage of the Affordable Care Act in 2009 (signed into law in March of 2010) was a watershed moment in US history.
Regardless of your perspective on the politics of that debate and its outcome, it has had a dramatic impact on healthcare in the US. One metric of that impact is the number of uninsured people in our country. Most Americans agree that healthcare coverage is important both to health and to financial stability, and although discussions of universal coverage can be contentious, most agree that it is a laudable goal to insure as many Americans as possible. A PEW poll earlier this year found that 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility.
Earlier this month (November 2017) the CDC released the National Health Interview Survey on health insurance coverage in the US and the results are striking.
- This year there are 28.8 million people (9% of the population) of all ages who are uninsured. This compares to 48.6 million in 2010 (15.7% of the population) in 2010.
- Among people age 18 – 64 5% are uninsured.
- 5% of children are uninsured.
- The poor and the nearly poor are 3 times more likely to be uninsured but the rate of uninsured among the poor is down from over 40% in 2010 to 24% in 2016, likely due to Medicaid expansion in most states.
- Children in poverty are twice as likely to be uninsured but their rate of uninsured is down from 12% in 2010 to 7% in 2016
- In states which expanded Medicaid the uninsured dropped from 18.4% to 8%.
- In states which did not expand Medicaid the uninsured dropped from 22.7% to 19%.
There are other interesting tidbits in the data as well. For instance, the rate of uninsured in New York is 7%, but in Texas it is 25%. 8.8 million people get their insurance on the healthcare exchanges (“marketplace”) and more employers and individuals are choosing high deductible plans (up from 39% to 43% in the last year alone).
This kind of information should inform all of us (including our policy makers) as we consider whether to repeal and replace, adjust or improve the Affordable Care Act. However, it is common sense (and a concept supported by every healthcare organization in the country) that changes that result in loss of insurance or loss of important benefits within an insurance plan is detrimental to the health of individuals, to the public health, and to the healthcare delivery system.
PCHC has been a national leader in the development of what is known as the “integrated model of primary care”. That is, in addition to a primary care provider and their team, our patients also have access to mental health providers (psychotherapists and psychiatric specialists) and their care is coordinated and communicated in a manner that improves safety, improves efficiency and convenience for patients, saves costs and, we think, improves care.
Sometimes this approach is successful and we can often cite specific cases in which patients have uniquely benefitted from this model of care. But often we simply can’t know. It can take years to identify true trends in healthcare and even then it requires sophisticated analytics and consistency in care and documentation, which can be elusive in busy primary care settings. So it is always exciting when others can demonstrate that the integrated model of care that is, in fact, the right model. An article published recently in JAMA Internal Medicine did just that.
Entitled “Integrated primary care models expand access to opioid abuse treatment”, it immediately caught my eye, and my preference for the title-as-most-important-finding approach was satisfied as well. But there was much more to the study than that. In fact they found that patients with substance use disorder had greater access to treatment and were more likely to refrain from using drugs when they received their care in an integrated primary care setting compared to being referred to an addiction specialist. 39% of patients with use disorders in the integrated settings received treatment for their addiction, as opposed to just 17% of those in non-integrated primary care practices. And 32% of those receiving treatment for use disorders in the integrated model reported abstaining from opioids or alcohol after 6 months, compared to 22% in the non-integrated model. These findings are critically important. An article by Steven Ross Johnson in Modern Health Care points out that there are over 20 million Americans with use disorders and over 15 million of them have alcohol use disorder, 2 million people in this country abuse prescription opioids and/or heroin and only a small fraction (about 10%) receive treatment for their problem. 2/3 of those receiving treatment access it through addiction specialty practices.
This is a clarion call to integrated primary care practices like PCHC. We have the resources to treat use disorders and there is now evidence not only that we can be effective, but that we are a better model for the delivery of this care. It makes intuitive sense. Having an interdisciplinary team of primary care and mental health providers, partnered with resources like care management and clinical pharmacists, (and in our case chiropractors and physical therapists) removes important barriers to care, allows for much more powerful communication and coordination of care, strengthens patient safety and engagement, and goes a long way to creating a trauma informed, stigma free environment in which people can receive care.
Our work together here at PCHC includes the treatment of more than 300 people with opioid use disorder this year alone. We have expanded from one site to 4 sites providing this vital service. We now have 24 people with X waivers which allow them to prescribe Suboxone for the treatment of opioid use disorder, we are collaborating with all of the region’s health care organizations to assure that this need is met, and we are providing education, technical assistance and peer support to other like-minded agencies across the state. As more integrated primary care settings embrace this aspect of our work as fundamental to the role of a primary care provider we will increase the impact and improve the health of Mainers everywhere.
September is National Recovery month and a fitting time to think about our the challenges we face in our country and our region related to substance abuse, to recognize the great work and resources we have and are building to meet this challenge, and to celebrate and support the people who are succeeding in recovery.
This observance, initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) is in its 28th year.
Some key facts that illustrate the importance of each of us improving our understanding of the problem and learning more about potential solutions:
- 1 in 10 adults in the US is in recovery from alcohol or drug use.
- 21 million Americans suffer with addiction (called a Use Disorder) and 17 million of those involve alcohol.
- In Maine, as in all of the US, alcohol is by far the most misused substance.
- Excessive alcohol use cost Maine nearly $939 million in 2010.
- Alcohol abuse and dependence appears to be increasing, especially among women and elders.
- We continue to lose an average of 1 person per day to overdose.
In Maine and locally we have a number of resources available but there is much more work to be done.
- The Lunder Dineen Health Education Alliance of Maine has worked with experts from across the state to develop the Time To Ask initiative, a pilot to improve primary care based screening for alcohol addiction and “at risk” use of alcohol. This will be accomplished through care team education and support, the use of evidence based screening tools, addressing shame and stigma, and making those conversations a routine part of health care.
- Wellspring is helping raise awareness with its 5K Race for Recovery on September 17 at the Bangor Waterfront.
- Wellspring will be opening the state’s first social detox center later this fall.
- The Bangor Area Recovery Network (BARN) provides a sustainable and reliable community recovery center that supports the needs of people affected by addiction.
- PCHC is engaged with a National Institute for Drug Abuse study, partnered with Dartmouth and NYU, of the use of a new screening tool for substance abuse.
- PCHC is actively working with regional healthcare partners to expand access to treatment for Opioid Use Disorder.
To learn more about this critical public health issue you can visit these sites:
As a student and early in my career I had the wonderful opportunity to work with my father, who was also a family doctor. If there was one lesson that he burned into my brain it was that when things weren’t going well for the patient “cherchez la médicament” – look for the medicine (he wasn’t French but he loved the phrase).
That is, at the top of our list of differential diagnoses we should include an adverse drug reaction. This is most especially in the elderly and in people who are on multiple medications. As the number of medications you take increases, your chances of having an adverse drug reaction or interaction increase steeply. And as people age their disease burden tends to increase and more medications are added. Guidelines for care also contribute to this problem. If you have diabetes, for example, there are certain medications most people should be taking to control sugars, to protect the kidneys and to reduce the risk of stroke and heart disease. If you also have high blood pressure or heart disease or COPD, there may be a different list and they add up fast. In addition:
- 40% of older adults living in their own home are on 4 or more medications, as are 21% of people with intellectual disability. In nursing facilities the problem is more pronounced.
- For every dollar Medicare spends on medications it spends $1.33 addressing medication induced problems.
- 10% of hospitalizations are due to adverse drug reactions and 2/3 of them are preventable.
So it’s evident that we should be working to eliminate unnecessary prescriptions and unsafe drugs or combinations of drugs. There are resources to help. The Beers list is a group of medications that simply should not be used in the elderly except in very unusual circumstances and there have been many publications on strategies for addressing polypharmacy. At PCHC we have the good fortune to partner with clinical pharmacists who can provide guidance to prescribers and education to our patients. And there are some common sense rules of thumb:
- Is the original indication for the medication still present or has it resolved? If it is resolved a trial off the medication is prudent.
- Is the drug still appropriate for the patient? Aging, declines in kidney and liver function, new conditions and the addition of other drugs can all impact this.
- If it’s an elderly or other vulnerable patient, is it a drug on the Beers list?
- Is the drug duplicating the effect of another drug the person is taking?
- Is there more than one drug from the same class?
- Does the risk outweigh the benefit?
My experience has been that people are thankful to eliminate unnecessary or risky medication. It is a process that requires communication, education and shared decision making and a prime example of the precept that less is more.
Although America’s health care system is often touted as “the best in the world” that is demonstrably untrue. A recent study published in Health Affairs magazine, however, indicates that we are a world leaders in one area of healthcare: inequality.
The difference between rich and poor as it pertains to access to care and health outcomes is dramatic in the US, and is among the most stark in the entire world. In fact, in comparing 32 rich and middle class countries only Chile and Portugal were worse. Some findings from the study, between 2011 and 2013:
- 38% of people in households making less than $22,500 a year reported being in poor or fair health.
- 12% of people in households making more than $47,700 a year reported being in poor or fair health.
- 1 in 5 people in the lower 1/3 of income earners skipped medical treatments due to cost (only the Phillipines was worse than the US).
- 1 in 25 people in the upper 1/3 of income earners skipped medical treatments due to cost.
Most alarmingly to me, 2/3 of Americans are aware that there are many Americans who do not have access to needed care, but only 54% of people believe that this disparity is unfair. That indicates a very significant apathy toward the plight of the less fortunate in this country, and may reflect the US approach of attaching health care coverage to employment, and our bias about the unemployed or underpaid.
It’s important to note that this study was conducted before many of the Affordable Care Act policies were implemented, and US studies after that implementation indicated some promising trends, especially in states where Medicaid was expanded. However, The American Health Care Act, proposed by Congress, would result in 23 million people in the US and 117,000 in Maine losing healthcare coverage and would remove many of the policies which expanded access to care. That is certain to worsen disparities between the rich and poor. The question is, does that matter to the American people?
One of the biggest safety concerns across healthcare settings is diagnostic error, and unfortunately diagnostic error is relatively common.
It accounts for 17% of preventable errors in hospitalized patients and one autopsy study conducted over 40 years indicates that 9% of patients had important medical conditions that went undetected. There are multiple factors which contribute to diagnostic error, flaws in the way we communicate and work together, lab and other diagnostic test errors, various members of the healthcare team working in isolation from each other (“silo effect”), and time pressure.
But our natural human tendencies and their influence on the manner in which we arrive at a diagnosis can also lead to errors. Those of us responsible for making a diagnosis and creating a treatment plan have to obtain and process information like symptoms, duration of illness, physical exam findings, environment, past medical history, current clinical circumstance and individual patient characteristics, then identify a potential or “provisional” diagnosis which adequately explains all of this information and which will inform additional testing and treatment. And it turns out that we have a tendency to develop mental short cuts or “rules of thumb” to arrive at those conclusions. In the lingo of cognitive psychology those shortcuts are called heuristics, and we are especially prone to using heuristics when the presenting symptoms are common. The Patient Safety Network recently listed some common areas of concern, referred to as cognitive bias, in our use of heuristics. They include:
- Availability heuristic – the diagnosis applied to a current patient is unduly influenced by experience with past cases, especially if the diagnostician had a positive or negative emotional experience with those cases
- Anchoring heuristic – relying too heavily on initial impressions, sometimes developed before even talking to the patient (based on chief complaint, initial vital signs and labs, past experiences with the patient)
- Framing effect – undue impact of subtle cues and collateral information (for example, staff tells you that patient always exaggerates their symptoms)
- Blind obedience – giving exaggerated deference to a specialist’s opinion, or relying heavily on a test result
As you might imagine there is a growing body of literature on this topic and much to be learned. But there are some strategies for mitigating the impact of cognitive bias. These include regular feedback on performance and open discussion of diagnostic errors when they are identified, more autopsies (these used to be much more common and were important learning opportunities – unfortunately this is unlikely to occur), and the development and use of evidence based decision support software. The creation of teams of clinicians who care for patients will also be an important improvement. But right now each of us involved in the care of our patients can reflect on our own processes for diagnosing, how our team functions and where we can work to limit the negative impacts of cognitive bias.