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Lifestyle and habits

Risky Rise of the Good-Grade Pill

At high schools across the United States, pressure over grades and competition for college admissions are encouraging students to abuse prescription stimulants, as noted in this New York Times article. Pills that have been a staple in some college and graduate school circles are going from rare to routine in many academically competitive high schools, where teenagers say they get them from friends, buy them from student dealers or fake symptoms to their parents and doctors to get prescriptions.

The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use. (By comparison, the long-abused anti-anxiety drug Valium is in the lower Class 4.) So they carry high legal risks, too, as few teenagers appreciate that merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony. Read more…

Trimming a Fat City

What about my right to Big Gulps? A prohibition New York Mayor Michael Bloomberg wants to implement – if it survives the fury he has whipped up and gets approval (which is expected) from a city health panel – is on the sale of sugary soft drinks above 16 ounces in restaurants, movie theaters and other places where a person is buying an individual serving, not an amount to be shared.

This Op-Ed piece in the New York Times reviews many down sides (it’s not an effective measure but rather a futile gesture; there’s worry over  encroaching upon personal liberties to name a few) but ultimately supports the measure: “Food ceased to be ‘a frontier too far’ when the fraction of American adults who qualify as obese climbed above one in three.” Read more…

Tightening the Lid on Pain Prescriptions

An article that ends with “I think we are dealing with a lost generation of patients”  sounds maybe just too depressing to read. But this article in Sunday’s New York Times, “Tightening the Lid on Pain Prescriptions,” which focuses on the effects of a Washington State law passed last year, provides a good summary of the opioid crisis nationwide and is well worth the read.

Opioid over-prescription is a subject MCNtalk has written about multiple times in the past year, and with good reason: High-strength painkillers known as opioids represent the most widely prescribed class of medications in the United States, and data suggests that hundreds of thousands of patients nationwide may be on potentially dangerous dosages.  Washington State has imposed new requirements on doctors to refer patients taking high dosages for evaluation by a pain specialist if their underlying condition is not improving. 

The clues were buried in the dullest of places: thousands of workers’ compensation claims.

A pain expert here in Seattle, Dr. Jane C. Ballantyne, said she now finds herself in the role of former believer turned crusading reformer.

“We started on this whole thing because we were on a mission to help people in pain,” she said of the medical profession’s embrace of opioids. “But the long-term outcomes for many of these patients are appalling, and it is ending up destroying their lives.”

The system is now examining how those changes have affected patients. Studies elsewhere suggest the benefits of lower opioid use may be significant for many patients. For example, Danish researchers have published a study indicating that chronic pain patients getting non-drug treatments recover at a rate four times as high as those on opioids.

So where does the “lost generation” fit into all this? Sadly, if the patients were taken off the medications, many would experience severe withdrawal or have to take addiction treatment drugs for years. Even avid believers in the new direction, like Dr. Ballantyne, suggest that it might be necessary to keep those patients on the opioids and to focus instead on preventing new pain patients from getting caught in the cycle. Read more…

“You can’t enjoy a meal when you know your mother is hungry”

Sadly, the title quote could apply to any number of situations related to life in sub-Saharan Africa, but in this case is taken from a physician in this article in the New York Times Magazine, “America Is Stealing the World’s Doctors.”

The premise of the article: In a globalized economy, the countries that pay the most and offer the greatest chance for advancement tend to get the top talent. South America’s best soccer players generally migrate to Europe, where the salaries are high and the tournaments are glitzier than those in Brazil or Argentina. Many top high-tech workers from India and China move to the United States to work for American companies. And the United States, with its high salaries and technological innovation, is also the world’s most powerful magnet for doctors, attracting more every year than Britain, Canada and Australia — the next most popular destinations for migrating doctors — combined.

Just how extreme is the situation? In Zambia, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the United States.

There are some hints at plans to address the problem:

  • There are 13 sub-Saharan medical schools receiving support from a United States-financed $130 million program; 
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria provided money to Zambia’s ministry of health (Zambia is featured prominently in the article) to recruit and retain doctors;
  • Western aid agencies, many financed by donors like Bill and Melinda Gates, have also hired local doctors at higher salaries.

But apparent solutions can create further problems; many of the doctors hired by aid agencies are doing research. They don’t see patients. Frustrated public health officials in Zambia and other developing countries call this the “internal brain drain.”

And there are other circumstances: a friend of mine was in the Peace Corps in Niger about a decade ago. a Nigerien friend of hers wanted to go to nursing school, so we agreed to spend the $300 to cover all his expenses in the program. But he decided to go to mechanics school instead to become a bush taxi driver. Why? He’d have a more secure income; in Niger nurses are hired by the government which clearly had no funds – and no history – of paying public workers (when I visited in 1999 the school systems were closed as the teachers had been on strike for months, not having been paid for at least the prior 6 months). In the scheme of things it was a minor situation to be sure, but nonetheless strikes an important chord: medical providers, like everyone else, are part of an economic system, though unlike many others their presence has immediate has life or death consequences for the community. There are no easy solutions, either in the article or in real life, though the answers probably lie somewhere in the simple phrase that is the title of Nobel Prize for Economics recipient Amartya Sen’s major work, Development as Freedom.

It’s a well written article and a situation worth contemplating. Read more…

A $250 Million Fraud Scheme Finds a Path to Brighton Beach

As announced last week by federal prosecutors, the Federal Bureau of Investigation, and the New York Police Department, a total of 36 people were arrested in New York’s Brighton Beach in a massive case of health care insurance fraud; the charges include racketeering and conspiracy to commit health care fraud, mail fraud and money laundering, as noted in this New York Times article.

While the outlines of the health care fraud scheme itself were relatively typical, its scope — a conspiracy to steal more than a quarter of a billion dollars over five years from private insurance companies — suggested a sprawling criminal organization designed to exploit New York’s “no-fault” auto insurance law, which requires vehicles registered in the state to carry insurance that lets drivers and passengers obtain up to $50,000 for accident injuries, regardless of fault.

“Today’s charges expose a colossal criminal trifecta, as the fraud’s tentacles simultaneously reached into the medical system, the legal system and the insurance system, pulling out cash to fund the defendants’ lavish lifestyles, “ said Preet Bharara, the United States attorney in Manhattan.

Mr. Bharara called the scheme the largest single no-fault insurance fraud case in the nation’s history, and court papers said it was the first in which prosecutors had brought racketeering charges.

The ring sought reimbursement for so many excessive and unnecessary medical treatments that it had to set up three separate billing processing companies just to handle the paperwork, according to court papers. Read more…

More Doctors “Fire” Vaccine Refusers

When this MCNTalk blogger was pregnant and interviewing a pediatrician, she told me that she couldn’t take our child on if we didn’t have our child vaccinated on the routine schedule. Though I didn’t necessarily disagree with her, this took me by surprise; I had thought we were doing the interviewing, after all. As it turns out, my pediatrician’s standard is not so unusual. Per this Wall Street Journal article, more and more pediatricians are choosing not to treat children whose parents don’t allow them to receive standard immunizations on a standard schedule.

Some interesting points:

  • 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.
  • 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.
  • 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.

Read more…

Some Good News in the Struggle with Obesity

Per this New York Times SchoolBook article, the rate of obesity dropped in New York City to 207 children per 1,000 in the 2010-11 school year, down from 219 five years earlier.

This means that 20.7 percent were still considered obese, but overall this is good news considering that, as the city’s health commissioner Dr. Thomas A. Farley, notes: “This comes after decades of relentless increases…What’s impressive is the fact that it’s [the obesity rate] falling at all.”

Across the country, recent studies have shown childhood obesity rates remaining flat or slightly increasing. Los Angeles County, which has also conducted a campaign against sugary drinks, had a decline of 2.5 percent during the same period, according to a study by the U.C.L.A. Center for Health Policy Research and the California Center for Public Health Advocacy.

The study was cautious in its language, warning, “A causal relationship cannot be inferred between the fitness interventions implemented by New York City in schools and the decrease in prevalence of child obesity described in this report.” But it said the decreases in obesity “might” indicate that changes in the school or home environment were important.

MCNtalk has talked about obesity rates, particularly among school children, extensively in the past year (Apple juice can pose a health risk; What is in the best interest of the child; Understanding the causes of obesity; Who’s really to blame for childhood obesity?), in general because it’s a serious problem for our nation’s health and in particular because of obesity’s impact upon the workforce, workers’ compensation, and disability problems. But then again maybe we blog about it a lot because it’s what people talk about a lot, especially through the holiday season with holiday meals and treats everywhere…and, oh yes, New Year’s resolutions.

The good news is that there are 6500 fewer obese children in the New York City school district now than there were five years ago. That’s a very, very important step for their lifelong health. The bad news is that while we may know how to talk about the problem all too well, we still have 20% of the NYC youth obese, not to mention those who are “just overweight.”  Read more…

OxyContin: the strange saga of Purdue and its $3 billion drug

“Their chemical composition is such that the U.S. is just a few carbon molecules from being a nation of heroin addicts.”

That’s a pretty harsh quote from this recent article from CNN. And it’s just the start in this latest entry about the U. S. and our dependence on prescription pain killers. Some facts to back up this assertion:

  • 254 million prescriptions for opioids were filled in the U.S. in 2010, according to Wall Street analysts Cowen & Co.
  • Enough painkillers were prescribed in 2010 to “medicate every American adult around the clock for a month,” the federal Centers for Disease Control reported on Nov. 1.
  • It estimated that “non-medical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.”
  • Opioids generated $11 billion in revenues for pharmaceutical companies, says market research firm Frost & Sullivan.
  • 15,000 Americans died of opioid overdoses in 2008
  • Two decades ago opioid sales were a small fraction of today’s figures, as such drugs were reserved for the worst cancer pain.

Why this recent spate of attention on Purdue Pharma, the makers of OxyContin? Last year they began selling a reformulated version that should help reduce the worst form of abuse. The original drug had a time-release mechanism that could be defeated by crushing the pill and snorting it, smoking it, or adding water to the powder and injecting it for a heroin-like high. By contrast, the new version breaks into chunks rather than a powder; if water is added, the result is a gelatinous goop. But at the same time, taking that step lifts a stigma from the drug and may make doctors more comfortable prescribing it, an outcome Purdue is hoping for. The result could be an even greater number of invisible addicts. Read more…

Apple juice can pose a health risk — from calories

This article on the dangers of apple juice should pose no surprise to anyone who understands the nature of weight gain. But it flies in the face of “common wisdom” that holds that if it is natural, it is good. Many schools have substituted fruit juices for carbonated sodas in vending machines. If the calories are the same or higher, the only change is that those who now put in their money are believing that they are engaging in healthful behavior by drinking juice. At least before they may have known that they were buying a high caloric sugary indulgence.

Once again, this article underscores the laws of thermodynamics as they pertain to weight: If you take in more calories from food, regardless of the kind of food, regardless of it being natural, organic, or highly processed, the person ingesting it gains weight. If one consumes fewer calories than one expends, again regardless of the source of such calories, one loses weight. Making a virtue out of the nature of food consumed does far less to address obesity related health issues than addressing quantity. Read more…

What is in the best interest of the child?

Per this recent article in The Wall Street Journal, family law practitioners and legal experts say mothers and fathers in custody lawsuits are increasingly hurling accusations at each other about the nutrition and obesity of their children, largely in attempts to persuade judges that their kids are getting less-than-optimal care in the hands of ex- and soon-to-be-ex-spouses.

It’s not a new thing for lifestyle choices to play a major role in custody battles. “It used to be constantly and consistently about smoking,” said Jeff Wittenbrink, a family law specialist in Baton Rouge, LA. “It’s only been recently where one parent thinks their kid’s not active enough, is gaining weight and eating sugary food.” And perhaps with good reason. According to the Centers for Disease Control and Prevention, approximately 17%, or about 12.5 million, of the nation’s children and teens are obese. Since 1980, according to CDC statistics, obesity rates have nearly tripled.

A handful of splashy news events have helped push the obesity-and-custody issue to the fore. In 2009, a 555-pound, 14-year-old South Carolina boy was removed to foster care after his mother was arrested and charged with criminal neglect. The state’s Department of Social Services had determined that without state intervention, the boy was at risk of serious harm.

Last July, David Ludwig, a prominent obesity expert at Children’s Hospital in Boston, co-wrote a highly publicized article in the Journal of the American Medical Association saying that “in severe cases of childhood obesity, removal from the home may be justifiable.”

Speaking generally of his experience with weight as an issue in custody disputes, one divorce attorney noted that “if one side is scratching to find something wrong with the other person, the courts might not give it the same weight. If all things are equal but one person only feeds fatty foods and the children have weight problems, I think it can become an important distinguishing factor.”

Whatever the outcomes of individual court cases, one would hope that someone is paying attention to the children themselves, and not just to their waistlines. And doing some work after the custody battles end to correct behaviors and address the health issues. Read more…