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On November 17 The U.S. Surgeon General, Dr. Vivek H. Murthy released the first ever Surgeon General’s report addressing substance abuse and addiction.

Entitled “Facing Addiction in America” this remarkable 500 page document summarizes all that we know about this disease and its treatment and creates a hopeful roadmap for the future. As General Murthy points out:

  • 21 million Americans have a substance use disorder (for the vast majority it is alcohol)
  • 66 million people report binge drinking each year
  • 88,000 people die each year from complications of alcohol
  • 47,000 die from complications of drug use.

The total annual cost of all of this, including lost productivity, criminal justice and treatment is $442 billion. These ought to be compelling arguments for policy makers, healthcare systems, public health organizations, caregivers, and education systems to act. And the combined and collaborative effort of all of these sectors is exactly what the report repeatedly and convincingly recommends.

Dr. Murthy explains and emphasizes the neuro-biologic basis of substance use disorders (also known as addiction), highlights evidence based preventive education for all age groups, summarizes the evidence supporting effective treatment for Opioid Use Disorder and stresses the need for integration of screening for, and the diagnosis and treatment of use disorders in all health care settings. His vision for the future includes:

  • Reframing substance use disorders in a public health context, rather than a criminal justice context (although he acknowledges the effectiveness and supports the use of modest law enforcement interventions, such as the positive impact of OUI laws in decreasing deaths from drunk driving)
  • Expanding access to evidence based treatment
  • Implementation of broad prevention programs
  • Full integration of substance abuse/substance use disorder treatment services within the rest of healthcare
  • Coordination and implementation of laws requiring equal coverage for mental health and substance abuse under the Affordable Care Act (this may be threatened if the new administration repeals or retracts the ACA)
  • Ongoing research to guide the public health approach in the future

The Surgeon General’s recommendations for healthcare delivery systems include:

  • Promotion of primary prevention through safe prescribing practices
  • Effective and evidence based treatment of chronic pain
  • Use of important adjunctive tools like the Prescription Monitoring Program (where prescribers can see all controlled substances prescriptions a patient has received)
  • Evidence based treatment for substance use disorder
  • Integration of mental and behavioral health services with primary care
  • Payment reform to support these changes
  • Full use of Health Information Technology, including not just the electronic health record and disease registries, but innovations like computer based education and treatment and mobile apps

The collaboration of legislators and the administration, public policy leaders, health systems, mental and behavioral health providers, law enforcement and educators from across the state will allow us to continue to address this most important public health challenge of our time.

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The overproduction of stomach acid and our sensitivity to it is one of the most common reasons people visit a doctor’s office.  Of course, many lifestyle choices contribute to that as well (overeating, obesity, smoking, alcohol use, to name a few).

Drugs that suppress acid production have been blockbusters for a long time.  In 1990 the first Proton Pump Inhibitor (PPI), Prilosec, was approved for use for the treatment of ulcers, acid reflux and esophagitis.  PPIs are now the 3rd largest pharmaceutical seller, accounting for 113 million prescriptions in 2012, and $14 billion of revenue for their makers.  When they were first marketed PPIs were promoted as having very few adverse effects, and that has largely been true for short term use.  But with the addition of 5 other PPIs (Prevacid, Dexilant, Nexium, Protonix, and Aciphex) and long term experience with the use of these drugs, we now know that there are some very serious risks of harmful effects.  We also know that longer use, higher doses and advancing age further accelerate these risks.  The risks include:

  • Hip fracture and fractures of the wrist and spine – This risk is even higher if you have diabetes or kidney disease.
  • Heart Disease – In addition to causing an overall 21% increase risk of heart attack, PPIs reduce the effectiveness of a very important heart medication called Plavix (clopidogrel).  Certain PPIs, like Protonix, increase the risk of heart attack by 80%!
  • Iron deficiency – this occurs because suppressing acid interferes with the absorption of iron.
  • Clostridium Difficile infection – this is an increasingly common cause of severe and sometimes life threatening diarrhea.  It turns out that the acid in our stomach kills the bacteria that cause this disease.
  • Pneumonia – again, acid kills bacteria, and when those bacteria can live in the gut it increases our risk of lung infection.
  • Stroke – just this month a new study has been released indicating a 21% increase in the risk of stroke from PPIs.
  • Kidney failure – a study in April indicated a 96% increase in the risk of kidney failure from these medications.

Startlingly, it is estimated that 70% of people taking PPIs are using them for a non-approved indication.  In addition, if you have been taking a PPI for a long time and you stop it, there may be a rebound over-production of acid, causing worsening symptoms and making it more difficult to stop.

What can be done?

  • If you have been on a PPI for more than a year, and most especially if you are over age 50 or have other chronic diseases, talk to your doctor about other treatment options.  It makes sense to try to get off the PPI if your doctor, NP or PA thinks it is safe.
  • If you have acid symptoms, lifestyle adjustment is the best treatment.  Stop smoking, reduce or eliminate alcohol, avoid food that triggers symptoms, lose weight, exercise, don’t overeat and get adequate sleep.
  • For symptoms that occur less than once a week consider old standbys like liquid antacids.
  • H2 blockers like Zantac (ranitidine) are likely less risky if a prescription is necessary.

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Doctors, nurse practitioners and physician assistants who work as primary care providers have always been busy and through much of the history of modern medicine, that busy-ness was balanced by a high level of job satisfaction, well above average compensation, and a position of esteem in society.

But over the past decade that balance has been lost.  Health care providers, while still well respected, have lost some esteem from those we serve.  Compensation remains very good, but salaries for primary care specialties (family medicine, pediatrics and internal medicine) are among the lowest for physicians.   And now over 50% of family doctors suffer from burnout (loss of energy and empathy).  This is becoming a work force crisis and a lamentable loss for many of us who feel called to this work.  What went wrong?  One important clue is to look at how we spend our work time.

New research recently published in the Annals of Internal Medicine reveal  that our primary care workdays have become distorted.  Basically, for every hour primary care providers (PCPs) spend in face-to-face time with patients, they spend 2 hours working in documentation tasks, paperwork and work in the electronic health record (EHR).  This is how it breaks down for each day that we work providing primary care:

  • We spend 27% of our time in exam rooms, with patients.
  • We spend 49% of our time working on deskwork and documentation the EHR.
  • While we are actually in the exam room, we only spend 53% of our time talking with and examining the patient.  The rest of our time is spent working on documentation and other tasks.  So that really means that only about 14% of our time each day is spent directly interacting with our patients.

In addition to these very serious challenges we know that many PCPs also spend time at home completing their documentation each day.  This unrelenting time pressure, time spent doing work that we do not enjoy and time lost from that which motivates us and is a key source of resiliency (taking care of our patients) is at the root of our challenge in primary care.

As we work to transform the way we deliver primary care there is no doubt that PCPs will need to spend more time developing and managing treatment plans for our patients, and leading a team that helps to ensure that the panel of patients for whom we are responsible are staying as well as possible, and that new role will mean less traditional face-to-face time with patients.  But we will still spend most of our day caring for patients in our offices, and we must work to find sustainable models that allow us to be more present for our patients and to gain back our time to care for them in a way that improves outcomes, improves our patients’ experience of care, and once again becomes a source of energy and resiliency for those of us providing that care, by fulfilling the very motivation that drives us to do this important work.

Some examples from the study:

  • Physicians (this was the only group that was studied in this research) with dictation support averaged 31% face-to-face time, compared to the average of 27%.
  • Physicians with a documentation assistant (scribe) averaged 44% face-to-face time with patients.
  • Those with no documentation support averaged only 23% face-to-face time with patients.

Obviously these resources cost money and building and spreading a model that provides this kind of support must be done carefully and responsibly.  There may also be other areas which help to address our time imbalance, such as coding support and increasing clinical support staff.  What is clear is that we must attend to this challenge and work together to find impactful and sustainable solutions, so that we have an engaged and energized primary care work force to serve our patients in the future.

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Hepatitis C is a very important cause of liver disease and damage in the US and across the world.

Once infected, 80% of people will develop chronic infection and 20% of those will develop cirrhosis, and the risk of developing cancer of the liver is also increased.  75% of those who develop cirrhosis will die from the disease if left untreated.  Over 185 million people around the world are infected with Hepatitis C and 350,000 people a year die from it.  In the US it is estimated that 2.7 million people are chronically infected and the annual cost of treatment and lost work is estimated at $6.5 billion.  What is more alarming is that the number is expected to grow, and the majority of people infected with the virus have never been tested and are unaware that they have the disease.

There are a number of reasons why it is vital that people with Hepatitis C infection are identified and offered treatment:

  • Although treatment in the past was aimed at containing the disease and delaying progression, newer treatments can now reliably cure the disease.
  • Until recently there was a complicated protocol for determining who should be treated. New guidelines released by the Infectious Disease Society of America now recommend that virtually everyone with Hepatitis C should be treated.
  • Because the virus is spread through blood and body fluids, knowledge of infection can help protect sexual partners of those who are infected.
  • Treatment of the disease helps to reduce unintentional spread through blood exposure.
  • Those who are known to be infected can be counseled to eliminate other liver toxins, like alcohol and acetaminophen.
  • Those who are infected should receive vaccinations for hepatitis A and B.

Not everyone needs to be tested for infection with Hepatitis C, but those who should be tested include:

  • All people born between 1945 and 1965 due to a higher prevalence of the disease in this age group (this is a one-time test)
  • Current or former injection drug users, including those who injected only once many years ago
  • Recipients of clotting factor transfusions made before 1987
  • Recipients of blood transfusions or organ transplants before July 1992
  • Hemodialysis patients
  • Persons with known exposures to HCV, such as
    • health care workers after needle-sticks involving Hepatitis C positive blood
    • recipients of blood or organs from a donor who tested Hepatitis C positive
    • people with HIV infection
    • children born to Hepatitis C positive mothers

All of this will require that we who work in primary care to develop reliable systems to identify and test those at risk for Hepatitis C and that treatment systems are in place so that every infected person can be offered treatment aimed at curing the disease.

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Over the past 20 years the rate of teenage pregnancy has steadily declined, and with that trend the rates of pregnancy termination have declined as well.

This is a success largely fueled by the availability of contraception and improved patient education. Yet the U.S still has a teen pregnancy rate 7 times higher than that of most developed countries. There are 2.8 million unintended pregnancies in the U.S. each year, including 430,000 in young women aged 15 to 19 and 124,000 in those aged 15 to 17. We know that teen pregnancy is associated with delays in prenatal care, increased fetal exposure to alcohol and tobacco, poorer health outcomes for the newborn and negative impact on social and economic outcomes for the mother.

How can this be happening in an age in which we have highly effective contraception? The answer is in the actual effectiveness of these methods when used in real life settings. Take a look at the table below. For every hundred women using a particular technique for 10 years, it shows how many will have an unintended pregnancy:

Unplanned Pregnancy/100 Women over 10 Year Period

  • ⚪ Condoms: 86/100
  • ⚪ Pill or patch: 61/100
  • ⚪ Depo-progesterone (shot): 46/100
  • ✔️ Copper IUD: 8/100
  • ✔️ Hormonal IUD: 2/100
  • ✔️ Hormonal implant: 1/100

Most people are startled to learn, for instance, that birth control pills have a 10 year failure rate of 61%. Of course if the pill is taken properly and if no medications are prescribed which may interfere with it, its effectiveness is vastly better. But in real life things happen.
IUDs and implants are called Long Acting Reversible Contraception, or LARC, and have a much higher rate of success in preventing unplanned pregnancy. In addition the Affordable Care Act requires that all forms of contraception must be covered by insurance, without cost to the patient. Yet less than 5% of women choose LARC as their contraception method. There are several reasons for this; studies have shown that notwithstanding the ACA requirements for coverage many insurers do not properly cover all of the costs of LARC, which can be as much as $1000 (for the IUD or implant plus costs of insertion). Few primary care practices stock an inventory of LARC (due to costs) and delays in obtaining it result in lower rates of use. And many providers were incorrectly taught that LARC should not be used in teenagers or in women who have never been pregnant.
A large study carried out over 5 years has shown that with good patient education, same day availability and no cost to the patient 72% of adolescents will choose LARC, and that the use of LARC results in significantly decreased costs associated with pregnancy and significant decreases in the rates of pre-term birth. It should be no surprise that the CDC states that all clinicians should offer the full range of contraceptive services to patients who wish to delay or prevent pregnancy.

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Last month I reviewed the recommendations of the Prevention and Harm Reduction task force of the US Attorney’s Maine Opiate Collaborative.  This month I will share the recommendations of the Law Enforcement task force of the collaborative, which was made up of representatives of law enforcement agencies spanning the state.

And let me preface this by saying that in my interactions discussing this issue with law enforcement people, I have been struck by how knowledgeable, compassionate and innovative they are in working to address this challenge in an effective manner.  The recommendations are as follows:

  1. Train all existing and new law enforcement personnel on the science of substance use disorders. This is fundamental to an effective approach and, I think, shows tremendous insight on the part of the task force.  By the way, the same could be said for medical personnel and for policy makers.  The task force goes into some detail on how to accomplish this objective.
  2. Identify, investigate and prosecute the most dangerous drug traffickers. Hard to argue this point, and while we recognize the disease of substance use disorder, those who take advantage of the current prevalence of that disease to market drugs illegally ought to be held criminally responsible.  The task force recommends statewide intelligence sharing, implementation of software designed to meet some of this need, record sharing, information sharing, outreach from drug intelligence officers to local law enforcement and improved collaboration as strategies for advancing this goal.
  3. Support and encourage effective law enforcement pre-charge diversion programs. This refers to the need for a treatment and recovery resource in each prosecutorial district so that people arrested on drug charges could be referred for treatment of their substance use disorder.  They also recommend tracking data so that the effectiveness of these interventions can be monitored.
  4. Increase statewide access to effective problem solving courts. This includes the recommendation to seek state and federal funding to support facilities, case managers, judges, prosecutors, and treatment providers.
  5. Provide treatment for county jail inmates with substance use disorders and provide case management services for re-entry into the community. This is critical in order to stop the cycle of addiction, arrest, detoxification, release and relapse.  In addition, the 48 hours after release from jail is the time of highest risk for fatal drug overdose.  If a person with substance use disorder is established in a treatment program and, most importantly, if the treatment can continue seamlessly as they transition out of jail, we can break that cycle and help people enter long term recovery.

Next month, the recommendations of the Treatment and Recovery Task Force.

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Last fall, U.S. Attorney Thomas Delahanty, Attorney General Janet Mills and Commissioner John Morris formed the Maine Opiate Collaborative following Senator King’s roundtable forums on opiate abuse and the governor’s forum on the same topic.

The Collaborative consisted of three task forces:  Prevention and Harm Reduction, Law Enforcement and Treatment.  Each of these task forces, which consisted of content experts, people with broad experience, people in the medical field and people in recovery, developed a set of goals, objectives and strategies which were presented on May 6th.  Over my next three blogs I will do my best to summarize these recommendations.  Though some require formal government action, many can be undertaken by caring and motivated medical personnel, community leaders, community members, friends and family.  So let’s start with Prevention and Harm Reduction:

  • Goal 1 – Promote good public health and safety and reduce the harmful effects of opiate use.  Objectives include:
    • Increase the understanding of the harms associated with opiate use and to address the stigma associated with the disease of addiction and its treatment through education of the public at large.
    • Decrease the use of opiates by our youth.  This will require a concerted and ongoing effort on the part of parents and family, government institutions like CDC and the Maine Office of Substance Abuse and Mental Health Services, the Department of Education and others.  Healthcare providers, schools and communities need to address adverse childhood experiences and the impact they can have on wellbeing.
    • Work to address and prevent child abuse and neglect.
    • Reduce access to opiates, through more effective use of the Prescription Monitoring Program and increase efforts aimed at the safe storage and disposal of prescription opiates.
    • Decrease the number of drug affected babies born in Maine each year through pilots of the already established Snuggle ME project, screening for substance abuse in pregnancy and guidelines for best care of substance use disorder in pregnancy, and improved support for families with infants exposed to substances.
    • Decrease overdose deaths in Maine by increasing the availability of naloxone.
    • Increase opportunities for treatment and recovery for people with substance use disorder with recovery centers in each public health district and establishing collegiate recovery communities at all Maine colleges, through reducing barriers to housing, education and employment for people in recovery, providing broader access to recovery coaches and increasing access to treatment.
  • Goal 2 – Strengthen Maine’s public health infrastructure to reduce opioid use disorder and overdose deaths.  Objectives include:
    • Improving Maine’s ability to take a comprehensive approach to the problem by creating a high level position to coordinate efforts across the state and empowering the Substance Abuse Services Commission to work to implement the recommendations of the Opiate Collaborative, and develop the existing “2-1-1” program into an information and resource hub for people seeking services for opioid use disorder.
    • Increase local capacity to work on prevention strategies by supporting Maine’s public health districts in collaborating with schools, recovery and wellness coalitions, healthcare organizations, faith communities, law enforcement and others to promote healthy communities and address public health challenges.

It’s a lot of information and I have condensed it!  Yet all of this, and the recommendations of the other two task forces (to be summarized in future blogs) can help us to address the most important public health challenge for Maine today.  As Senator King says, there is usually no silver bullet for solving big problems, but there often is silver birdshot.

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Naloxone (Narcan) is a life-saving antidote for opioid (heroin, oxycodone, fentanyl and others) and PCHC is committed to making it as widely available as possible.

With 272 opioid overdose deaths in 2015, a 31% increase from 2014, we are faced with our most significant public health challenge in decades and we must respond at all levels; with life-saving measures like this, with law enforcement, with treatment and with education and prevention. And we must commit to doing all of this work with compassion and understanding. On May 6 the Opiate Collaborative Task Force will release a comprehensive set of recommendations for Maine. The easy availability of naloxone to reverse an overdose and to safe a life is a simple, common sense and compassionate piece of that puzzle. Dr. Karilynn Dowling, one of PCHC’s second year pharmacy residents, has done extensive work to help us prepare for this.  She is committed to this work and her summary follows:


Images from MICIS naloxone detailing materials.

28,000 Americans died from an opioid overdose in 2014. Nearly 19,000 of these deaths involved prescription opioid medications. The majority of deaths were unintentional.

Naloxone is an opioid reversal agent that rapidly reverses an overdose on opioids (prescription and/or street drugs). Naloxone is not just for substance abusers. It is for anyone who takes an opioid or knows someone who does. Naloxone is prescribed on account of risky medications, not risky patients. The concept is similar to EpiPens for people with allergies.

  • Naloxone is an emergency medication that acts within several minutes and wears off in 30-90 minutes.
  • The potential harm in giving someone naloxone is low, especially in comparison to its potential benefit as a life-saving medication.
  • If someone who is not overdosing on opioids is given naloxone, it will have no effect and will not harm them.

A person who is overdosing on opioids is heavily sedated or unresponsive, so naloxone is given by a family member, friend, or bystander. Naloxone can be given by an injection or through the nose (intranasally).

Intranasal naloxone is preferred because:

  • Studies have shown it is as effective as the traditional injection method for reversing an overdose
  • Time to draw up a syringe is removed and risk of needle stick is removed
  • It is easy for the general public to learn how to use

Images from MICIS naloxone detailing materials.Currently, naloxone is a prescription-only medication in the state of Maine. Naloxone may be prescribed to an individual at risk of experiencing an opioid overdose, a family member or friend of such an individual, or any other person in a position to assist someone who has overdosed. Naloxone can also be distributed through a community-based overdose prevention program under a doctor’s standing orders.

Intranasal naloxone is available in two forms. When someone has overdosed on an opioid, a bystander should call 911, administer rescue breaths, give naloxone (see below), and remain with the person until help arrives.

Naloxone for Opiod Overdose
KariLynn Dowling, PharmD
April 17, 2016

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It seems like every time I am asked to talk or write about a disease or healthcare challenge, when I look into disease management and maximizing health, good sleep is among the top recommendations.  Whether it’s an inflammatory disease, heart disease lung disease, diabetes, anxiety, depression, stress or chronic pain, adequate, restful restorative sleep improves health, supports a sense of wellbeing and contributes to better health outcomes.

But what are the effects if inadequate sleep?  Even if you don’t have a chronic disease or other health challenge, poor sleep can have a negative impact.  A recent post on the Cleveland Clinic’s website outlined some of these concerns.

  • Alertness – this is common sense but missing even 1 ½ hours of sleep decreases alertness and a number of brain functions like creativity, innovation and attention.
  • Memory – a lack of sleep decreases your ability to retain and to process information.
  • Relationships – not getting enough sleep can make you moody and impatient and that is not good for your interactions with others, at work and at home.
  • Quality of life – being tired makes you less likely to engage in enjoyable activities and you’re also less likely to exercise regularly.
  • Car accidents – drowsy driving leads to thousands of accidents, injuries and deaths every year.
  • Serious health complications – complications of long term sleep deprivation include heart failure, heart attack, stroke, diabetes and high blood pressure.  This is serious business.

So how much sleep should you get each night?  Updated research indicates that for most people the following guidelines apply:

  • Older adults, 65+ years: 7-8 hours
  • Adults, 26-64 years: 7-9 hours
  • Young adults, 18-25 years: 7-9 hours
  • Teenagers, 14-17 years: 8-10 hours
  • School-age children, 6-13 years: 9-11 hours
  • Preschool children, 3-5 years: 10-13 hours
  • Toddlers, 1-2 years: 11-14 hours
  • Infants, 4-11 months: 12-15 hours
  • Newborns, 0-3 months: 14-17 hours

There are a number of behaviors that make it more difficult to sleep, like too much screen time during the day and evening, alcohol use, tobacco use, lack of regular exercise and unhealthy eating.  There are also a number of things that can be done to improve sleep time and quality like “sleep hygiene” (see past blogs or google it), healthy eating, regular exercise and cognitive behavioral therapy for sleep.

So get some Zs and live a healthier and happier life!

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In addition to movie discounts and joke fodder for my children, my AARP membership sometimes also provides some interesting medical information.

It’s usually pretty reliable and often useful but a recent Facebook posting by AARP caught my eye.  It was entitled “10 Surprising Heart Attack Triggers” and it’s a very interesting list, but before we launch into it it’s important to be clear about the difference between and “association” and “cause and effect”.  Cause and effect means that we know that some factor causes a particular outcome:  smoking and lung cancer or influenza virus and the flu, as examples.  Associations, on the other hand, are observed patterns of relationship between a factor and an outcome and can lead to studies that prove or disprove cause and effect.  Some associations can be misleading (for instance measles vaccine does not cause autism but because it is administered at about the age when autism begins to become apparent many people and some unscrupulous physicians claim cause and effect).

So with that in mind, let’s look at some of these interesting “triggers of heart attack” from the AARP.

  1. Asthma that requires daily medication  Having asthma that is severe enough to require the use of daily medication is associated with a 60% higher risk of a heart attack.  No cause and effect here.  It could be that asthmatics are more likely to ignore symptoms of heart disease, thinking that chest tightness is part of their asthma.  Asthma is also a disease of inflammation, which can also contribute to heart disease.  And perhaps the medications themselves carry some risk.
     
  2. Taking certain drugs for heartburn  These drugs, called protein pump inhibitors (PPI) include drugs like  Nexium, Prilosec, Prevacid and Protonix, are associated with a 16% to 21% increased risk of heart attack.  Again, no cause and effect has been proven, but PPIs ma reduce blood levels of nitric oxide, which is a chemical which may protect the lining of our arteries.  There are other reasons that it may not be good to stay on PPIs for a long period of time (the subject for another blog) and it is recommended that people regularly try to substitute safer drugs, like ranitidine (Zantac) or cimetidine (Tagamet).
     
  3. Having migraines with visual changes  This is called a “classic migraine” headache and is typically preceded by visual changes like wavy lines or seeing spots.  Women of middle age and older with this problem in the prior year have a 91% increased risk of heart attack and a 108% increased risk of stroke.  Migraines are not well understood so this association is hard to explain.  But 18% of women fall into this category so it is important.
     
  4. Skipping the flu shot  Separate from the reduced risk of developing influenza, the flu shot appears to confer protection from heart attack in the ear following administration, a 50% reduction in fact.  Apparently some of the antibodies produced by the bod in response to the vaccine help to protect our blood vessels.  This is compelling and getting a flu shot seems like a “no-brainer” to me.  I know that anti-vaccine types will shudder to read this but really, it is safe and pretty effective.
  5. Weak grip strength  A recent study has found that for every decrease of 11 lb. decrease in grip strength there is an associated 17% increase in risk for heart disease.  This may be due to circulation problems to our muscles in the same group who have coronary artery disease.  This may be a useful tool to screen for risk of heart disease in people who are not having symptoms.  It’s being studied.

If you or a loved one have some of these “risks” it is not cause for panic.  But it might be a good reason to have a discussion with your primary care provider and to limit your risk for heart disease through healthy eating, exercise, blood pressure control and avoiding tobacco use.

Next month we’ll take a look at the other 5 “surprising triggers of heart disease”.