mardi 31 mai 2016

At ‘Pain School,’ Veterans Learn To Manage With Fewer Pills

At ‘Pain School,’ Veterans Learn To Manage With Fewer Pills

Robert, a veteran who injured his back several times during a dozen years in the Navy, stopped using opioids to treat his pain and is now a student at the Bedford VA's Pain School. (Jesse Costa/WBUR)

Robert, a veteran who injured his back several times during a dozen years in the Navy, stopped using opioids to treat his pain and is now a student at the Bedford VA’s Pain School. (Jesse Costa/WBUR)

Today’s topic: stress. Psychologist Tu Ngo looks out at a small group of veterans seated around a classroom table. “Why would we be talking about stress when we’re here because of your pain?” she asks seriously, then smiles. “Lil’ pop quiz now.”

A man who’s sitting near the door, in case his PTSD flares up and he needs to leave, is ready with an answer. “Stress may increase your anxiety, the anxiety may increase your feeling of pain,” says Tom Schatz, “the feeling of pain may increase depression, etc. etc.”

“Very good, that’s a great description of the vicious cycle we know happens when you have pain,” says Ngo, who heads the pain program at the Bedford VA Medical Center. “Pain is a stress response, it’s a signal to the brain saying, ‘Hey, there’s something wrong.’ “

This is Pain School — a five-week, 15-hour course that covers more than a dozen parts of daily life that can make pain better or worse. The classes cover nutrition, sleep, exercise, breathing, visualizations, relaxation and, yes, stress.

“What happens in your body normally when you get stressed?” Ngo asks, urging her students to think about the specific ways stress may increase pain.

“Your muscles tense up,” answers Jasmine Navarrete, a disabled Navy veteran, “your respiratory rate has to increase.”

Other veterans mention a hike in temperature or blood pressure. “Right, yes,” Ngo says. “Then in usually about 20 to 30 minutes, your body comes back down again to what we call baseline.” But many of these veterans never can get down from the feeling of being on guard or ready to flee.

“If you have chronic pain, your system is in overdrive all the time,” Ngo says.

Constant pain can impair memory or concentration and make a veteran more anxious or irritable.

“But,” she offers, “there is something you can do to try and turn that stress response off.”

Ngo hands off to Kalin Clark, who outlines the antidote to stress: the relaxation response.

It begins, Clark says, with slow, deep breathing “and learning to control our heart rate with our breath.” Clark asks for a volunteer, someone willing to demonstrate the connection.

Navarrete’s hand shoots up. The Navy veteran — who deals with nearly constant back, knee and other joint pain — walks to the front of the room and sits down in front of a computer.

Clark slides a monitor onto Navarrete’s left index finger. That’s her dominant hand.

“See if you can follow this pacer. Take a slow inhale and slow exhale, and let’s see what that does to your heart rate,” Clark says, watching the computer monitor.

Navarrete’s belly rises and falls. Her shoulders drop. But waves on the screen jump. They’re not smooth. Clark looks at Navarrete’s hands, lingering on her shiny pink nails.

“It could be a nail polish issue,” Clark says, somewhat under her breath, “because I turned it on me and it was…” Her voice trails off.

While someone else takes a turn, Ngo tells the class that regulated breathing is one of many tools veterans will be introduced to in Pain School. It’s part of a pain management program the VA has been developing for almost two decades. It assumes patients will need help at many stages of coping with pain.

Losing That ‘Security Blanket’ 

One goal is to help veterans reduce or stop using opioids and other drugs to control pain. Ngo says Bedford currently has the third-lowest opioid prescribing rate among VA medical facilities in the country.

“We’re not curing your pain, we are not taking it away, but it’s a way of helping you to manage your pain and live your life and function better,” Ngo says.

Many veterans don’t buy it. Each time Ngo offers the Pain School, about half of the students drop out before it ends. We tried to reach some of the veterans who did not find this approach worthwhile, but no one would comment for this story.

Ngo says many veterans are scared to try something besides pain medications. “People are afraid to lose their security blanket as much as they know it isn’t working for them,” she says.

Research shows opioids relieve acute pain, but the Centers for Disease Control says there’s little evidence that they ease chronic pain, defined as pain that continues three months after an initial injury or ailment.

Some veterans who stay in Bedford’s Pain School know the limitations of opioids firsthand.

“The side effects were just too much for me to deal with, I couldn’t function at work,” says Robert, who asked that we not use his last name to avoid consequences on the job.

Robert injured his back several times during a dozen years in the Navy. When the pain is bad, he wakes up 10 to 20 times a night and can’t walk short distances — like from the car to the grocery store. Robert reached what he calls a breaking point a few years ago.

“You know, the thoughts that this is never going to go away,” he recalls with a deep sigh, “that this is my life from this point forward. That’s a pretty devastating realization.”

For Robert, it was time to try something other than opioids.

“The VA has been great about accepting that and not saying, ‘Here’s a pill, this is our only solution for you,’ ” Robert says.

At Pain School, Robert and the other students set weekly goals, activities to both manage their pain and push past it. Robert has pledged to take yoga classes and use an app that tracks calories to control his weight. He goes to physical therapy. He’d like to try acupuncture or one of the martial arts, all of which are offered through the Bedford VA.

“So far everything’s been really good,” Robert says. “The only thing that didn’t work was the medications.”

Pain Management Programs ‘Few And Far Between’

Bedford is one of 67 VA Pain Schools across the country, up from 33 in 2010. Through the schools and options such as hypnosis, chiropractic services, massage and tai chi, the VA is trying to shift the way patients think about pain.

“Right now, many patients feel like it’s a mechanical model of pain, where if you just take the part out and replace it or suppress the pain in the brain, that takes care of it. But it doesn’t,” says Dr. Rollin Gallagher, the national pain management director for the Veterans Health Administration

A better strategy, according to Gallagher, is pulling together a team that includes the patient, their primary care doctor and specialists to craft a plan that puts the patient in charge of managing their pain.

“Once you sit down and explain what pain is and how it works, what makes it worse and better, and how an individual can manage that interaction between mind, body and brain, I think it really does help them,” Gallagher says.

Gallagher says the consequences of ineffective pain treatment can be devastating: depression, disability, addiction and sometimes suicide. Veterans are even more at risk. Veterans report chronic pain at nearly twice the rate of Americans overall.

Gallagher says there’s some proof the VA’s approach is working. He points to opioid use, which is down 7 percent among all veterans in the latest three-year period.

Structured pain schools and the range of non-medical pain management options available through the VA are not available to most Americans.

“Pain management programs like the VA’s are pretty few and far between,” says Mara Laderman, senior research associate at the Institute for Healthcare Improvement. She says there are several reasons why. “Physicians have been trained to prescribe opioids for chronic pain, they’re slammed with packed schedules, and there aren’t a lot of physicians who are trained in pain management.”

But Laderman and others agree: Money may be the main reason most doctors, clinics and hospitals focus on medicine to relieve pain.

“We typically reimburse for the things we do to patients, and that means prescribing a medication, doing a procedure or surgery,” says Dr. Sean Mackey, professor of pain medicine at Stanford University. “We don’t reimburse for these types of programs. I provide a large number of these at Stanford, quite a large number of them, but I give them away for free.”

Mackey co-chaired work on a National Pain Strategy released earlier this year that calls for more research and education on the different types of chronic pain and effective treatments.

At the Bedford VA, nutritionist Joanne Maddock wraps up Bedford’s Pain School class with information about foods that provoke headaches or constipation. She says fish, dark chocolate and ginger protect against inflammation.

And remember, Maddock says, excess weight can increase pain.

“If we’re carrying around too much weight it’s a lot of stress on our joints, so if you can get to a good healthy weight you might feel better,” Maddock says. Veterans, she reminds the students, have higher obesity rates than do Americans as a whole.

A pharmacist will be in for the last class, to talk about how to balance pain medicine with all the other techniques students have learned. Some veterans will take more in-depth classes on stress or meditation, realizing there’s a lot to learn about pain.


vendredi 27 mai 2016

New Addiction Treatment Implant Will Hit The Market Next Month At $4,950

New Addiction Treatment Implant Will Hit The Market Next Month At $4,950

A graphic shows how the implant is placed inside the skin of a person's upper arm. (Courtesy Braeburn Pharmaceuticals)

A graphic shows how the new addiction treatment implant Probuphine is placed inside the skin of a person’s upper arm. (Courtesy Braeburn Pharmaceuticals)

There’s a new tool in the fight against the nation’s raging opioid epidemic.

The FDA on Thursday approved an implantable version of the drug buprenorphine, which staves off opioid cravings. Labels for the new device are rolling off printing devices today, and trainings begin Saturday for doctors who want to learn to insert the four matchstick size rods into patients.

The implant, called Probuphine, is expected to be available by the end of June.

“This is just the starting point for us to continue to fight for the cause of patients with opioid addiction,” said Braeburn Pharmaceuticals CEO Behshad Sheldon.

But one day after the FDA approved this first long-acting delivery method for buprenorphine, debate continues about how effective the implant will be and whether insurers will cover it.

A Game Changer … Or Set Up For Failure? 

The head of the National Institute on Drug Abuse calls it a game-changer because it will help addiction patients stay on their meds while their brain circuits recover from the ravages of drug use. And addiction experts say it will be much harder for patients prescribed the implant to sell their medication on the street, which is a problem for addiction patients prescribed pills.

“I think it’s fantastic news,” said Dr. Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital. “We need as many tools in the toolbox as possible to deal with the opioid epidemic.”

Wakeman, however, is concerned that the implant only delivers one dose — 8 milligrams of buprenorphine. She prescribes between 4 and 24 milligrams of buprenorphine pills, depending on how much a patient needs to fight opioid cravings.

“This is a wonderful tool for someone who doesn’t want to take a daily medication” or someone who can’t manage doing so, Wakeman said. “If you need to add daily medication on top of Probuphine, you lose the added benefit that would come with not needing that daily pill.”

Sheldon says Braeburn Pharmaceuticals is testing weekly and monthly injections of buprenorphine that would be available in many doses.

Wakeman plans to sign up for a four hour Probuphine training, which includes a lecture, a demonstration, and practice inserting the implant. The company does not know yet if it will be safe to insert multiple implants into the same spot in the upper arm. A study on the efficacy is underway.

In the meantime, some doctors say they will hold off on using the implant. Dr. Indra Cidambi, who treats addiction patients in New Jersey, says she’s worried patients will assume it’s enough, that they don’t need check-ups or the counseling that is part of most recovery programs.

“Probuphine is set up for failure in that way,” Cidambi said, “because the patient will be seen after six months and in the meantime they’re not going to be following up with therapy and that means it’s not going to be medication assisted therapy. It is medication maintenance only.”

Braeburn Pharmaceuticals and the FDA say they expect patients to be in counseling while prescribed the implant.

Insurers Not Sure Implant Is Worth The Cost

Blue Cross, the state’s largest health insurer, says it will cover the device, which will cost $4,950 and last six months — or about $825 a month. But some other insurers say they aren’t sure yet if the buprenorphine implant is worth the price compared to the buprenorphine pills, which cost $130 to $190 a month.

“Certainly the drug holds great promise for individuals struggling with opioid addiction. However there’s still a lot we don’t know about its effectiveness,” said Eric Linzer, senior vice president for the Massachusetts Association of Health Plans.

Braeburn CEO Sheldon says that the implant will be cheaper than another long-lasting treatment, Vivitrol, which is a form of naltrexone that is injected once a month and costs about $1,000 a month.

Braeburn Pharmaceuticals says it may refund money to insurers if the Probuphine implant doesn’t work to keep patients from relapsing, and offer rebates for patients who have to buy it on their own.


Coming Soon: The Magic Pill, A Daily Dose (By Podcast) Of Get Up And Go

Coming Soon: The Magic Pill, A Daily Dose (By Podcast) Of Get Up And Go

Co-hosts Dr. Eddie Phillips and CommonHealth's Carey Goldberg record The Magic Pill in a WBUR studio. Photo: Robin Lubbock)

Co-hosts Dr. Eddie Phillips of Harvard Medical School and CommonHealth’s Carey Goldberg record The Magic Pill. (Photo: Robin Lubbock)

Dear reader,

Your presence on this page suggests that you’re interested in health. So perhaps you’d be interested to know that WBUR is about to launch a short, lively podcast aimed at helping you do just about the very best thing you can do for your health: Move more. (The experts tell us not to use turn-off terms like “exercise” and “work out.” It’s not supposed to be work. It’s supposed to be fun and feel good.)

We’re calling it “The Magic Pill,” because exercise (Oops. I mean, physical activity…) is the closest thing we have to a magic pill for our health. If you’ve read some of our scores of “Why To Exercise Today” posts over the years, you probably already have that impression.

The Magic Pill will be a 21-day challenge, uplifting you every day for three weeks this fall with compelling stories, fascinating facts and gotta-move music — all in a “micro-podcast” of under 10 minutes. What better boost to help you start your day?

As a CommonHealth reader and public radio fan, you can help — we hope — in two ways:

• Sign up now for The Magic Pill — by clicking here. The 21-day challenge won’t begin until Sept. 1, so it won’t hinder any summer slacking.

• As we produce the podcast, we’ll be looking for stories from people who exemplify certain themes. For example, how does exercise affect your mood? Have you “fallen off the wagon,” and how did you get back on? Did you undergo a “conversion experience” to exercise or just make small, gradual changes? If you’d be interested in receiving our questions once a week or so and possibly sharing your story, please post a note in the comments below. Or if you’d like to nominate someone else as a fitness inspiration, please click here. And thanks!  

Popping A Daily Baby Aspirin? Caution: New Guidelines, Amid Controversy

Popping A Daily Baby Aspirin? Caution: New Guidelines, Amid Controversy

New recommendations from the USPSTF recommend aspirin for far fewer people. (M. Spencer Green/AP)

New recommendations from the USPSTF recommend aspirin for far fewer people. (M. Spencer Green/AP)

When an older woman arrived at a Cambridge medical clinic recently, Dr. Sarah Stoneking was surprised to learn that the patient was taking an aspirin every day.

The patient was nearly 80, and didn’t have a clear reason to take the medication. Aspirin in general, and especially in older patients, can have a lot of side effects, including serious bleeding.

Stoneking, an internist and also my colleague, suggested her patient stop taking the daily aspirin, but the woman refused. She thought aspirin “was a panacea,” Stoneking recalled, one that protected her from the strokes and heart disease that had affected most of her friends. “She took it religiously,” Stoneking said.

When I started residency three years ago, the benefits of aspirin, specifically 81 mg baby aspirin, seemed clear. Even the U.S. Preventive Services Task Force (USPSTF), a top panel of experts that issues guidelines, endorsed low dose aspirin for large swaths of the population: men aged 45-79, and women aged 55-79, who were not at high risk for bleeding or other side effects. In other words, about a quarter of the population could benefit from a daily aspirin. And recently, reports have suggested that aspirin may even prevent cancer.

But new recommendations from the USPSTF, published last month in the Annals of Internal Medicine, recommend aspirin for far fewer people. The guidelines say aspirin may benefit men and women, aged 50-59, who have a 10 percent or greater chance of having a heart attack or stroke in the next 10 years because of their risk factors for heart disease (such as uncontrolled diabetes, high blood pressure and smoking). Even for this population, the evidence for aspirin has been downgraded from “high” to “moderate” certainty.

This is the kind of thing that drives patients crazy. Millions of people take an aspirin every day, thinking they are doing something positive to protect their heart. Now, we physicians are back-tracking on those recommendations. What gives? This may feel like a flip-flop to patients, but it’s really a refinement in our recommendations; a reflection of new and better data.

The bottom line is aspirin “has benefits, but it also has harms, and the harms are important to understand,” says Dr. Kirsten Bibbins-Domingo, a professor at the University of California, San Francisco, chair of the USPSTF and co-author of its most recent aspirin guidelines.

Over the last six years, she says, new studies are helping to quantify the harms of aspirin. Those harms include internal bleeding, usually in the stomach, and, more rarely, in the brain. For those under 50, the benefits were not as clear, the USPSTF found. For people 60 and older, the risks were higher than previously understood. The updated guidelines, she said, support the concern “that too many people take aspirin.”

Dr. T. Jared Bunch, a cardiologist at Intermountain Healthcare in Salt Lake City, Utah, agrees. He sees a number of patients who take aspirin because they think it will protect them from heart disease, often without discussing this with their providers. His message: “Aspirin is a medication, and it needs to be viewed that way… If you don’t need to take it, don’t take it.”

Some researchers, like Dr. JoAnn Manson, a physician-researcher at Brigham and Women’s Hospital, believe that these recommendations leave too many people out. She is concerned that for men and women with moderate risk for heart disease there may be some benefit, and that the guidelines “really did not fully address how to handle that group.” For these patients, she says, the evidence is “quite strong” that even those at moderate cardiovascular risk may benefit from aspirin. Specifically, she says, this group includes men in their 50s and women over 65.

In addition to the benefits aspirin has for heart disease, there is growing evidence that it could prevent cancer, particularly colon cancer. Researchers like Dr. Andrew Chan at Massachusetts General Hospital, believe that aspirin could be used to prevent cancer generally: according to 2015 a study he co-authored in the Journal of the American Medical Association Oncology, regular use of aspirin could prevent nearly one in 50 cancers.

As a clinician, Chan says, he understands that the decision to recommend aspirin is complex. But with so many potential benefits, he thinks that “it would be a shame for us to be paralyzed by inaction” and not discuss aspirin with patients. “I think the public health impact [of aspirin] can be substantial” he said.

The researchers were all in agreement, however, that people should not be taking aspirin without speaking to their medical provider. Many people seem to think they can choose to take aspirin or not because it is over the counter, and there is a strong belief that “anything over the counter is safe” Manson said.

So to help you have the conversation with your doctor, here’s what most experts agree on:

  1. If you have had a heart attack or stroke caused by a clot, you should probably take an aspirin unless you have compelling reasons not to.
  2. If you are 50-59, and are at high risk for a first heart attack or stroke, you will probably benefit from 81 mg of aspirin if your risks of bleeding are not high and you do not have side effects. If you do not fall into this group, your provider will have to weigh risks and benefits carefully.
  3. If you are already taking aspirin, you should regularly review with your doctor if your risks for bleeding have changed, since these increase as you get older.

Manson also points out that there are several common misconceptions. For instance, some people wrongly think that taking a high dose of aspirin is better than a low dose of aspirin; or that coated aspirin will protect your stomach. In almost all cases, low dose aspirin is as effective as high dose aspirin for preventing heart attacks, strokes and cancer, and with fewer side effects. In addition, there is little evidence that coated aspirin will prevent stomach bleeds.

Regardless of new data, patients may be reluctant to quit taking their aspirin-a-day. It is difficult to change habits that people think are keeping them healthy. Stoneking, the Cambridge internist, was able to get her patient to reduce her dose from 325 mg to 81 mg. As for getting her to stop completely? “That’s going to be a longer conversation,” she said.

jeudi 26 mai 2016

Deal Would Take Controversial Hospital Pricing Question Off Ballot

Deal Would Take Controversial Hospital Pricing Question Off Ballot

It was to be a game of high stakes politics with hundreds of millions of health care dollars on the line. But on Wednesday the players negotiated a truce — with help from unified leaders on Beacon Hill — to prevent a November ballot question on hospital prices.

“It is my hope that this plan will avert a costly and divisive ballot initiative and lend assistance to our community hospitals,” said House Speaker Robert DeLeo in a statement.

The ballot initiative that brought DeLeo, Senate President Stan Rosenberg and Gov. Charlie Baker together aimed to close the gap between high and low cost hospitals. It proposed cutting $463 million in payments to the state’s more expensive hospitals and redistributing that money to struggling community hospitals and to consumers through lower premiums.

The Massachusetts Hospital Association opposed the plan. MHA President Lynn Nicholas is relieved to hear voters won’t be asked to adjust price differences between her members.

“The most important aspect of this resolution is not doing complicated public policy through a blunt instrument at the ballot box,” Nicholas said.

The ballot question was proposed by a health care workers union, 1199SEIU. Estimates showed the state’s largest private employer, Partners Healthcare, would have lost more than $400 million a year.

The influential union and the top employer have been in and out of offices on Beacon Hill for weeks, negotiating roughly a half dozen different plans that would have legislators instead of voters settle the hospital price gap problem.

The consensus deal announced Wednesday includes some more money for community hospitals — at least $20 to $25 million a year, divided between several dozen hospitals. Some hospitals would benefit and some would lose if an additional hospital assessment of $250 million is approved and distributed through Medicaid payments. The union says it is pleased.

“This agreement is the first substantive step toward leveling the Massachusetts healthcare playing field,” said 1199SEIU Executive Vice President Tyrék Lee, Sr.

The new payments would offer some short-term relief for struggling community hospitals. For the long-term solution, the agreement revives a “Special Commission to Review Variation in Prices Among Providers.”

“The language that we’re currently polling out of committee addresses immediate needs in terms of financing and at the same time establishes a provider price commission to take a look at the factors that are contributing to price variation,” said state Rep. Jeff Sánchez, a Democrat, on Wednesday night.

A similar commission that met five years ago struggled to see action on its recommendations. But Sánchez, who would co-chair this commission, says it’s time to bring stakeholders together again. Some hospitals that have called the payment gap in Massachusetts unfair say they look forward to participating.

“We are hopeful that the Special Commission will develop fair and transparent proposals to ensure that health care prices reflect consumer value to achieve lasting benefits for everyone,” said Andrew Mastrangelo, director of media relations at Lahey Health.

The ballot question alternative may be on the House floor for a vote Thursday.

There are pieces of the agreement that don’t make sense to the state’s leading health care consumer group.

“I think there’s a flag raised about how some of this compromise will be paid for,” said Amy Whitcomb Slemmer, executive director at Health Care for All. She notes that most of the money for struggling hospitals would come from the state’s Center for Health Information and Analysis (CHIA), the agency whose reports have detailed the wide variation in hospital prices and the effect on rising health care costs.

“We look to CHIA for unbiased, unvarnished information about what the health of our health care delivery system really is,” said Whitcomb Slemmer, “so I hope that funding shift or shortfall is made up in another way.”

The ballot question agreement would cut CHIA’s budget by $5 million, or 17 percent, in the first of five years and then $10 million or 35 percent for the next four years.

That’s the public agreement by which 1199SEIU says it would drop the ballot question. But sources familiar with the public deal say there’s a private arrangement, with Partners, that the union insisted on before it would back away from the ballot campaign.

Under the private agreement, sources say Partners would not interfere with union organizing efforts at some of its community hospitals, such as North Shore Medical Center, for example. But the union would not be welcome at Partners major teaching hospitals, Massachusetts General or Brigham and Women’s.

In a joint statement, 1199SEIU and Partners describe a new strategic alliance: “We have always respected the rights of our workers to choose whether to be represented by a union, or not. Future organizing efforts will be designed to ensure the rights of our workers to make free and fully informed decisions on this question through the process of a secret ballot election.”

Neither Partners nor 1199SEIU would answer questions, referring reporters to their statements.


mercredi 25 mai 2016

When The Therapist Has A Fear Of Elevators

When The Therapist Has A Fear Of Elevators

(Allen Lai/Flickr)

(Allen Lai/Flickr)

The cramped elevator in the office building where I practice psychotherapy makes me uneasy.

The carpet looks stained and worn, fraying in the corner. Faded yellow paint barely covers the walls. When the door slides open, a musty smell hits the nostrils of waiting passengers.

I rode this contraption for the first time nine years ago, the day I decided to rent my office. That first trip felt like a movie in slow motion. The machine noisily inched up its shaft, lurching and wheezing like a drunk asthmatic. The seconds dragged by. When the elevator reached the third floor, it grew oddly still. Nothing happened. While I waited for the door to spring to life, I felt my heart thumping in my chest. Silently, I willed that thick, motionless metal portal to move, imagining myself imprisoned in this tiny cell for hours, mouth parched and desperate for a sip of water.

Finally, the elevator car shuddered, and the door slid open. I bolted out, ran down the hall to my new office and tried to catch my breath.

Trudging Up The Stairs

For the next eight years, I avoided the elevator. Loaded down with a briefcase, laptop and lunch box, I trudged up the 40 stairs to my office in the morning and down again in the evening. Finally, my knees begged for a break, and my physical therapist recommended an alternative mode of transportation up to my office.

I had to face the machine.

As a psychologist who specializes in the treatment of anxiety disorders, I knew that I should be able to calm myself in the elevator. First, I turned to a well-accepted psychotherapeutic technique: correcting thought distortions. “Don’t jump to conclusions,” I whispered to myself as I crossed the threshold into that seemingly airless, small box. Then, like many of my patients whose minds automatically leap to the worst case scenario, I remembered a strong young man who came with his wife for marriage counseling. The session went well. However, the couple left my office and got stuck in the elevator. The husband pried the door open. Later that day, he called me, yelling about the “deathtrap” in my office building. “I know, I know,” I murmured sympathetically into the phone. Needless to say, they did not return for a second appointment.

When I look back on it, necessity paved the way towards improvement. I had no choice but to ride the elevator twice a day, five days a week. The psychological literature promises that repeated exposure to a feared object decreases anxiety. And it worked. At first, I remained vigilant to the machine’s jarring sounds and jolting movements. Then one day I stepped out of the elevator, and I realized that I had daydreamed about a recent vacation to France as this conveyor traveled from the lobby up to the third floor, almost oblivious to its noises and tremors.

Just In Case

But “almost” remains the operative word. Some nights before I step into this dingy people mover, I make one last trip to the ladies room and stick the cell phone in my pocket. I place a bag of trail mix in my purse. Then I fill the water bottle up to the top. Just in case it is a long night in that small cubicle. If I have plans with my son, who only comes to town every couple of months, I will lug my stuff down the steps, regardless of my aching knees. I want to be certain that I get out of the building.

A female patient recently asked me if I ever experienced anxiety. While I am cautious about revealing personal information to patients, I wanted to reassure her that she was not alone, and I nodded “yes” to her question. Her eyes grew wide. Perhaps she mistakenly thought that a psychologist must have licked her demons, if she had any in the first place.

When I told this young woman that the National Institute of Mental Health reports that almost a fifth of Americans have been diagnosed with an anxiety disorder, she smiled broadly and leaned back in the chair — just as I hoped she would. “Many of us learn to manage anxiety,” I added, “few people escape it completely.”


Of course, I still have setbacks. Some nights I stand in the hallway, trying to decide if I should turn right and flee down the steps or left and risk a ride in the elevator. Then I firmly remind myself that my fear about being trapped in this machine resembles a thought distortion called “catastrophizing,” expecting the worst to happen. Taking a deep breath, I think about how reliable this elevator has turned out to be. I stand up straighter, press the call button, and bravely stride into this lift for my trip to the first floor.

Recently, to my surprise, I began to see “my” elevator in a new light. Those yellow walls now look warm and friendly; the shabby carpet makes me think of the old, soft rug in my parent’s bedroom where I would watch TV. Then I noticed that the machine’s comfortable temperature warmed me when I came to work on a cold winter’s day.

Not a bad place to spend the night, if I had to.

Ellen Holtzman, Psy.D., is a writer and psychologist who practices in Wakefield, Massachusetts.

mardi 24 mai 2016

How Doctors Think About In-Flight Medical Emergencies

How Doctors Think About In-Flight Medical Emergencies

In-flight medical emergencies occur about 44,000 times a year worldwide, according to a 2013 report, and physicians assist in about half of the emergencies. (Courtesy of Chris Brignola/Unsplash)

In-flight medical emergencies occur about 44,000 times a year worldwide, according to a 2013 report, and physicians assist in about half of the emergencies. (Courtesy of Chris Brignola/Unsplash)

I am not a nervous flier by nature, but on the first flight I took as a newly minted doctor, I sat at uneasy attention. I was trying to relax, but my professor’s words kept echoing in my head: “When you get on a flight, you are no longer just another passenger. You’re the doctor on board.”

I’ve not yet witnessed an in-flight emergency, but many of my colleagues already have, and I know that for me and many other new doctors just finishing medical school this month, flying will never be the same.

Dr. Judy Kwok, a doctor in my training program, has been involved in two medical emergencies in the air. The first was on a flight to Hong Kong. She remembers the overhead call for a doctor filled her with “complete dread,” she told me. She walked to the front of the plane to see a woman sitting up but initially unresponsive. The woman looked sick. “What happened?” Kwok asked, amidst the chaos. Many passengers were offering opinions — most unhelpful.

The sick woman began to speak, but not in English. A passenger quickly stepped up to translate. Finally, Kwok got the story: The woman had chest pain. A medical student had also responded and took vitals. The flight attendants — who are trained to respond to these emergencies — also arrived to help. They offered her an emergency medical kit, stocked with basic supplies and medications mandated by the Federal Aviation Association. Concerned the woman might be having a heart attack, Kwok gave her aspirin and continued to monitor her.

The flight attendants radioed an emergency call center. Kwok asked if they could divert the plane, but was told by the physicians who staff the center that their flight was over Mongolia.

The nearest airport was two hours away. They kept going. A short while later the woman looked better and was able to answer questions, and the flight continued to its final destination.

“I tried to be calm in the moment,” Kwok said. “But when I got back to my seat, I could see I was shaking.” Kwok was not told what happened to the patient after landing, as there is no systematic way for providers to follow up with patients they assist on planes. In most cases, we never know if we did the right thing.

In-flight emergencies occur about 44,000 times a year worldwide, according to a 2013 study in the New England Journal of Medicine.

Dr. Christian Martin-Gill, the study’s lead author and assistant professor of emergency medicine at the University of Pittsburgh, said that health care providers could expect to be called on during an emergency on board a flight at some point during their career.

And in the majority of situations, they do, said Martin-Gill, who also staffs one of two call centers in the U.S. where doctors help direct care during flights. Physicians assisted in about half of in-flight emergencies, he says, and nurses or other providers in about a quarter.

Most of these emergencies were minor, with only one in 12 patients admitted to a hospital after landing. More than half of the emergencies were either fainting due to dehydration (37.4 percent), difficulty breathing (12.1 percent) or vomiting (9.5 percent). Only three in a thousand emergencies resulted in death.

(A side note: to avoid becoming an-flight emergency statistic, here’s some simple advice from Martin-Gill: “Drink a giant bottle of water.” By far the most common cause of medical emergencies is dehydration.  Also, if you have a chronic medical condition, carry a card in your wallet with your diagnoses and your list of medications, and consider alerting the flight attendants if you are concerned. )

While many providers are quick to jump in and help, others may hesitate because they are uneasy about working outside a medical environment without all the usual equipment and support, Martin-Gill said.

When I asked him if providers who do not manage emergencies on a regular basis, like a dermatologist, should assist in these situations, he stated, “Well, if someone had a rash, I could think of nothing better.” Moreover, all providers “start with basic training” and can be very helpful in communicating the situation to emergency physicians who staff the call centers who can then direct providers on the plane on what to do next. The providers on board “are our eyes and ears,” said Martin-Gill.

When responding to the call overhead, physicians are not alone.

Dr. Amit Chandra, an emergency medicine physician at New York-Presbyterian Hospital, points out that flight attendants are also trained to use defibrillators and that all U.S. flights are stocked with basic equipment. In addition, all U.S.-based flights — and some international flights — have access to the kinds of call centers where Dr. Martin-Gill works. And if nurses or paramedics who are more qualified step up to help, physicians should defer to them, Chandra added.

Kwok agrees. Her second emergency happened a year later, on a flight to Los Angeles. She awoke to see a man having a seizure a few rows in front of her and jumped up to help before she could even be called. “I think a lot of physicians are nervous to answer these calls because they think they have to do what they do in the hospital,” she said. “But really, your job is to decide if they are sick or not sick.” With one more year of residency under her belt, Kwok was able to direct those who offered assistance, including an army medic who had “really trained for this,” she remembered. This time, the pilots were able to respond to her concern for the patient and divert the flight. She and the medic stayed with the man after landing, until an ambulance arrived.

I wondered, would she ever decline to help?

“If I didn’t think I was capable of helping, if I wasn’t in a state that I would go to work, then yes,” Kwok explained. Otherwise, “when we see someone in need, we will respond, right?”

The flip side, of course, is that doctors are still people, and always being “on” can be overwhelming. We may be on our way to work at our hospitals or clinic, and staying with the patient after landing could mean missing a flight out. Even if the trip is for pleasure, not having time to relax is one of the primary contributors to the physician burnout epidemic.

When teaching about in-flight emergencies at a conference of emergency physicians, Dr. Chandra noted that some physicians expressed resentment at always having to be available. He was “surprised,” he said, and strongly disagreed. “This is why physicians have a special place in society. We are obligated to use our skills” when people are in need.

I agree. But is it OK for me to put my headphones on and have a drink?

Dr. Martin-Gill offered no hard-and-fast rules. “I don’t provide any general recommendations.” And flights are just one of the places where our professional obligations can bleed into our personal lives, from dinner parties to weddings, to shopping for groceries. Emergencies, Martin-Gill said, “can happen at any point in our lives as health care providers.” That’s the thing about in-flight emergencies: It’s just another reminder that you’re never not a doctor.

So if you see me on a plane, I might be watching the in-flight movie. But if you need me, sit back and relax: I’m here to help.


vendredi 20 mai 2016

Exercise Addiction: How To Know If You’ve Crossed The Line Between Health And Obsession

Exercise Addiction: How To Know If You’ve Crossed The Line Between Health And Obsession

Experts say it’s tricky to determine precisely how many people struggle with exercise addiction because it can masquerade behind socially acceptable intentions -- like getting fit at the gym. (Courtesy of Scott Webb/Unsplash)

Experts say it’s tricky to determine precisely how many people struggle with exercise addiction because it can masquerade behind socially acceptable intentions — like getting fit at the gym. (Courtesy of Scott Webb/Unsplash)

Lisa M. joined a gym as soon as she started college at Bridgewater State University, determined not to pack on an extra 15 pounds freshman year like her older sister.

“In my head there was that picture of my sister,” Lisa said in an interview. “I didn’t want that to happen to me.”

For the next six years, Lisa says, she never missed a day at the gym unless it was preplanned and she could make it up later. In order to fulfill her self-imposed exercise requirements, Lisa skipped Christmas Eve gatherings, birthdays, weddings and dates with someone she loved and “very likely lost” because of her illness, she says.

“Every aspect of my life was dictated by exercise and food and the need to control it all,” says Lisa, who asked that her last name not be used because she is still in treatment.

The thought of missing even one daily workout triggered massive anxiety, she says. And as her exercise obsession deepened, she began restricting her food intake too, mostly to salads and vegetables. She had “fear foods” she’d avoid: no cake, brownies or cookies, of course, but also, no cheese or pasta. Thoughts about food and exercise consumed her: “Any extra energy I had would go to…thinking about my next meal, my next snack, what I’d be able to eat next. I’d plan meals a week ahead.”

Her weight dropped to 112 pounds on a 5-foot-6 frame. She hasn’t had a period in six years. Now, as a result, Lisa, who is 25, has osteoporosis in her lower spine and hip.

“I worked so hard to be healthy, but I’m not,” she says. “And I did this to myself.”

Masquerading Behind Fitness

It’s hard to quantify precisely how many people struggle with exercise addiction, also known as exercise bulimia, exercise anorexia or driven exercise. It’s not new, but experts say the disorder may be on the rise — fueled, in part, by a selfie culture that privileges extreme healthy living, our near-worshipful embrace of the carb-and-gluten-free lifestyle and reverence for a virtuous diet and fit body.

“You’re applauded when you go to the gym and your arms look great in a sun dress,” says Paula Quatromoni, a registered dietitian, sports nutritionist and chair of the department of health sciences at Boston University. “But there’s a slippery slope between commitment to a healthy lifestyle and obsession.”

Quatromoni says compulsive exercise is “more and more common and happening at rates that are alarming if people paid attention.” Unlike vomiting or taking laxatives — telltales signs of an eating disorder — exercise addiction “masquerades behind these well-intended, noble endeavors — ‘I’m getting fit going to the gym,’ ” so it can remain secret for some time, she says.

Exercise, it goes without saying, can clearly offer tremendous benefits: a pathway to both physical and mental health. It can ease anxiety, make your body stronger and keep disease at bay.

The devil, as usual, is in the dosage, and in how you perceive it. Two women can look the same, for instance, work out the same amount and eat comparably, yet one might have a disorder based on her beliefs about exercise, and guilt over not doing it, while the other may pleasurably engage in exercise without a problem, therapists say.

That’s why diagnosing and treating exercise addiction can be tricky. Even determining prevalence is elusive. A spokesperson for the National Eating Disorders Association says there are “virtually no hard numbers” on excessive exercise but sent over a statement from the group’s CEO, Claire Mysko:

…for those predisposed to eating disorders, excessive exercise behaviors can quickly lead to dangerous results. When a person starts developing rigid habits, puts an over-emphasis on weight and/or body shape and feels compelled to ‘burn off’ calories, it’s time to seek the help of a professional to see if there’s something deeper going on. Eating disorders, such as exercise bulimia, are life-threatening illnesses, but recovery is possible, especially with early intervention.

A published review from 2012 estimated that about 2.5 to 3.5 percent of the general exercising public may be affected by exercise addiction.

A 2015 study found that “driven exercise” is a “common compensatory behavior in adolescents with bulimia and anorexia” and is associated with greater eating disorder severity and depressive symptoms. In other words, exercise addiction can make a dangerous eating disorder worse. The same study found that about 66 percent of adolescents with bulimia and 23 percent of those with anorexia also reported driven exercise.

“If you think about it like, ‘Oh my god, I ate this and now I have to do 45 minutes of cardio to counteract what I ate,’ that’s a problem. It’s basically an eating disorder that uses exercise as a purging method,” says Beth Mayer, a clinical social worker and executive director of the Multi-Service Eating Disorders Association, in Newton, Massachusetts. Mayer says about 20 to 30 percent of her patients have some kind of exercise obsession as part of their illness.

And while eating disorders in general and exercise addiction in particular are thought to afflict more women than men, it’s becoming clear that more men suffer with the disorders than previously acknowledged. They are simply not reporting their symptoms due to stigma and shame, experts say.

Punishing And Sneaky

The hallmark of the condition — generally considered one part of the constellation of problems related to eating disorders — usually involves exercising to punishing lengths.

But again, perception is key. If you feel driven to work out daily, for instance, for long periods of time — and do it even through illness and injury — that could signal a problem. And if you feel guilty, anxious or out of control when you miss a day’s workout, that should be another clue. Also, if your motive in exercising is simply to purge calories, you’ve probably crossed a line.

“It’s compulsive, it’s punishment, it’s sneaky,” is how 39-year-old Leanne describes her exercise addiction, which is one component of an eating disorder she’s struggled with for two decades. At one point, she was eating only between 200 to 300 calories a day, she said, and would sneak out of her Boston-area condo to the gym at night so her friends and neighbors wouldn’t ask questions or worry.

Now, even though she’s been working with a team of eating disorder specialists for several years, Leanne — who also asked for confidentiality because her work colleagues don’t know about her illness — says: “I would say I’m not recovered. I don’t eat three meals a day, for example. I’m better right this minute and making my way into more normal intake, but unfortunately, it’s very much like a roller coaster. It becomes about compensatory behavior: I had a full meal, panic, gotta go to the gym and run. I would probably say I have a long way to go.”

Genevieve, 23, calls the illness “mentally tormenting” because she was so driven to exercise, even when she was sick or visiting family on a school break. “I didn’t have a gym membership at home,” she says. “So I would end up spending my whole break coordinating which gyms I could go to to get a free trial, and patch it together. I couldn’t get myself to take the week off.” On her first Valentine’s Day with a boyfriend, she left him after five minutes to go to the gym.

Passing Out After 20 Miles

Athletes are particularly at risk, says Quatromoni, who started BU’s sports nutrition consult service for student athletes back in 2004. Now, she says, there’s greater awareness that many athletes suffer from eating disorders and use their sports training in unhealthy ways. Indeed, she says, athletes are two to three times more likely to develop an eating disorder, compared to the general public. “There’s the pressure to perform, their own expectations — and we have sports that are weight based and others where you are judged on how how you look and there are scholarship dollars tied to this,” she says.

College seems to be a particularly vulnerable time, she says, with 18- and 19-year-olds on their own for the first time, and not always sure of where to turn for help.

Quatromoni and one of her patients, an elite student runner named David Proctor, wrote a paper together last year that tracked his eating disorder and five-year recovery. Proctor, who at 18 had moved to the U.S. from the U.K to compete as a Division 1 scholarship athlete, began fixating on his weight after a coach told him to lose a few pounds. In response, “David began restricting his energy intake significantly, dropping more than 10 pounds in about two weeks, and weighing himself multiple times daily,” according to the paper. He became fixated on becoming lighter, which he believed would make him run faster. Here’s more about Proctor from the case study:

The real eye-opener came a few days after that first Christmas when I decided I would “make up” for the amount I had eaten on Christmas Day by eating absolutely nothing for two days, and then setting off for a 20-mile run on the third day. As anyone would expect, I did not feel well during this run and I ended up passing out at the side of the road, collapsing onto the pavement.

Rachel Monroe takes a gentler approach to exercise these days, like walking or doing yoga with her dog Rosie.

Rachel Monroe takes a gentler approach to exercise these days, like walking or doing yoga with her dog Rosie.

Rachel Monroe used to wake up routinely at 4 a.m. to exercise, “and stay on the treadmill long enough to burn the calories to justify what I’d eat that day.”

But after years of counseling and healing, Monroe, now a licensed mental health counselor specializing in eating disorders at the Multi-Service Eating Disorders Association, says she gets joy from moving her body in very different ways:: doing yoga, for instance, or walking her dog, Rosie.

“Right now, we are in a societal crisis with the craze about health and exercise — like you’re a good person only if you exercise and if you’re healthy,” Monroe says. “It’s not a moral obligation to work out. So many people who live in larger bodies are told they have to work out, and they are shamed if they don’t.”

Signs Of An Unhealthy Habit

So how do you know if your daily exercise routine has crossed into obsession? Monroe offered these signs of an unhealthy exercise habit:

  • Training even when injured or tired
  • Working out several times a day
  • Obsessing about training details
  • Feeling angry or threatened when routine is interrupted
  • Canceling or avoiding social activities and other responsibilities in order to exercise
  • Creating a daily schedule around working out
  • Repeated comments about being or feeling fat
  • Feeling anxiety and guilt when unable to exercise
  • Happiness reliant on productivity of workout

And here are Monroe’s tips to check where you are on the “exercise dependence scale”:

  • Tolerance: Needing more and more of the activity to achieve its initial effects.
  • Withdrawal: Increased agitation, fatigue and tension when not exercising.
  • Intention Effect”: Exercising for longer than intended on most trips to the gym.
  • Lack Of control: Difficulty scaling back the duration and intensity of exercise.
  • Time Spent”: Funneling exorbitant chunks of our day and night toward fitness-related activities.
  • Reduction Of Other Pursuits: Avoidance of social engagements that don’t involve exercise, canceling plans or showing up late for work in order to exercise longer.
  • Continuance Despite Injury: Not taking enough time off to heal despite your doctor repeatedly raising judgmental eyebrows.

‘It Feels Really Good To Feel’

The good news is that exercise addiction is very treatable, experts say.

Psychotherapy to address the eating disorder and exercise obsession (or really the underlying emotions and psychology driving the behavior) is standard; and patients report it can be helpful to work with a multidisciplinary team of providers, including a psychotherapist, nutritionist or dietitian, primary care doctor and, in some cases, a certified fitness expert.

Cognitive behavioral therapy and similar approaches can help people reframe their thinking around exercise, and eventually, gain more moderation and balance in their fitness pursuits. It can be frightening, overwhelming and anxiety-producing to break the cycle, therapists say, but the goal is to try to help people feel more at home and at peace in their bodies instead of seeing their bodies as something to perfect, manage or fight against.

Lori Lieberman — a registered dietitian and nutrition consultant based in Weymouth and Sharon, Massachusetts, who treats patients with eating disorders — emphasizes that treatment needs to be tailored to the individual.

“Exercise is not an issue — unless it’s an issue,” she says. “In other words, it’s the mindset, not necessarily the amount of exercise. It’s also essential that food intake supports their activity.”

In the midst of the illness, patients often continue to believe that working out is good for them.

“And while I understand the merits of exercise, it’s important to convey how counterproductive it is for them,” she says. “If you think you’re becoming more fit, think again. In some people, their metabolic rate goes down, muscle mass decreases, the risk of injury and osteoporosis increases.”

When patients are trying to recover, Lieberman says, it’s sometimes best to keep moving, but switch to something with gentler, like yoga or walking.

“People are often relieved to be told that they have to reduce or cut out exercise, they can’t give themselves permission to stop — it’s scary and overwhelming.”

For Lisa M., who is in treatment with Lieberman, life has changed in some striking ways.

“The big thing being that I feel,” she says. “I feel happy, I feel overwhelmed, I feel heartbreak, I feel sadness, I feel hopeful that I can get better. But I had felt void of it all for so long, and although I do not love the feelings all the time, it feels really good to feel. And the womanly curves coming back feel pretty great too.”

jeudi 19 mai 2016

Opinion: Why Medical Students Are Good For Your Health

Opinion: Why Medical Students Are Good For Your Health

(Monash University/Flickr)

While the presence of medical students may make some patients uneasy, one student explains how these future doctors can benefit patient care. (Monash University/Flickr)

If you have ever been admitted to a teaching hospital, you’ve probably encountered a medical student in your midst. You might wonder: Is this student actually here to help me, or am I a guinea pig here to help them learn? While the presence of budding doctors may make some patients uneasy, these students often grapple with their own anxieties about the transition out of the classroom and into the hospital room.

When I first started my clinical rotations, I felt apologetic about my presence in the hospital. Having spent the majority of the first two years of medical school in the classroom, I had limited real-life experience and seemingly little to contribute. I worried that I was an impediment to my clinical teams. Or worse, that my presence was a nuisance to patients. Then I met Jack and my view began to change.

Jack was a scrawny 3-year-old boy with a shaved head, huge smile and squishy cheeks. He was admitted to the hospital with worsening asthma. He arrived onto our hospital floor coughing and wheezing as his mom struggled to hold him still.

Our medical team — which consisted of three physicians and two students — determined during our evaluation that the child would need to receive albuterol, a drug used in asthma management, every few hours via an inhaler. As the student assigned to follow Jack, it was my job to examine him every one to two hours — more frequently than any of the physicians on my team — and report back on his status. Before I went home, I signed out to the overnight staff that he was breathing more comfortably.

The next morning, the overnight physicians reported that there had been some miscommunication between the physicians, respiratory therapists and nurses. Jack had not received several doses of his albuterol but had still slept through most of the night. One of the physicians had reevaluated Jack one hour before I arrived. He had been sleeping peacefully.

I jotted down these overnight events and went to see Jack. He was now wide awake, squirming in his bed and working hard to breathe.

The cardinal symptoms of an asthma attack were all there: his belly was heaving with each breath, the muscles around his ribs were straining to allow more air into his chest cavity and his nostrils were flaring.

I scurried back to our workroom and informed my team that Jack appeared to be worse. One of the physicians immediately went to examine him and decided to adjust his albuterol regimen.

To my surprise, the doctor thanked me for speaking up. I had recognized that Jack was in respiratory distress, and now he was being treated appropriately. I discovered that elusive feeling that every medical student desperately craves: to feel useful.

I know now that I can be useful by speaking up and asking questions. By doing so, I create learning opportunities for myself, making me a better clinician for my future patients. And occasionally, I might help my current patients.

Unfortunately, there’s not a ton of research on whether medical students actually improve patient care. Although a 2015 review found that patient satisfaction was not “significantly affected by medical student participation,” it also stated that attitudes varied widely and that the few existing studies may not be of sufficient quality to allow us to draw any conclusions.

I still believe we can help. Medical students have time to make extra trips to patients’ rooms, give them updates or listen to their detailed stories. Consequently, we can get to know patients better than others on the care team. We have the privilege of learning about their lives, wishes and fears. We then share this useful information with our teams so that we may offer better, more personalized care.

Over the next 24 hours, Jack’s breathing improved significantly. By the following morning, he was running around the room without wheezing and ready for discharge. On his way out, Jack waved me down.

“Thank you!” he shouted and ran away, his mother chasing after him. I smiled, with a burst of satisfaction inside.

Of course, not all patients are as happy-go-lucky as Jack. Being a patient in a hospital is a scary and disorienting experience. When strangers invade your space to poke and prod, it can be easy to feel as though you are the subject of a lab experiment. You may wonder if these people have your best interests in mind. Perhaps having additional people involved in your care feels unnecessary and diminishes your sense of privacy.

But I believe that medical students are good for your health. We keep an eye on you and report back to our teams. We advocate for you and wish to facilitate your healing. Having only recently donned our white coats, we might more easily see things from your perspective. And in a few years, we will be the doctors taking care of you. By trusting us, you help us become the skilled, knowledgeable and compassionate doctors that every patient deserves.

Andi Shahu is a medical student at the Yale School of Medicine.



The Promise And Price Of New Addiction Treatment Implant

The Promise And Price Of New Addiction Treatment Implant

Amid a raging opioid epidemic, there’s a plea for more treatment options. The Food and Drug Administration expects to have a decision on one by May 27.

It’s an implant. Four rods, each about the size of a match stick, inserted in the upper arm. This new device, called Probuphine, delivers a continuous dose of an existing drug, buprenorphine but with better results, says implant maker Braeburn Pharmaceuticals.

In clinical trials, 88 percent of patients with the implants abstained from opioids, as compared to 72 percent of those taking buprenorphine as a daily pill. (Buprenorphine is commonly referred to by its brand name, Suboxone).

“I felt completely normal all the time,” said Dave, a paramedic in a small town outside Boston who was on the implant during a clinical trial. He does not want his last name made public so that co-workers won’t find out he is addicted to opioid pain pills.

Dave, 47, has been in recovery for four years with the help of buprenorphine. Dave said he prefers the implant to the pills for several reasons. With the pills he would sometimes feel the drug wear off. He worried about his 2-year-old granddaughter getting into the bottle. And sometimes Dave would just forget to take his medication, which he’s supposed to do in the morning, 15 minutes before he has anything to eat or drink.

“With the implant you didn’t have to worry about that, you just, it was just there and you felt good all the time,” Dave said.

There’s a second reason the manufacturer says its implants are better than pills.

“Buprenorphine is the third most confiscated opioid by the DEA, so there’s certainly diversion going on,” said Braeburn Pharmaceuticals CEO Behshad Sheldon, referring to illegal sales of the prescribed drug.

But not with the implants, according to Sheldon. She says no one tried to remove their implant during trials so they could sell the drug inside.

An FDA advisory committee reviewed the implant in January and recommended approval.

Dr. Barbara Herbert, president of the Massachusetts Society of Addiction Medicine, is one of many providers waiting for the agency’s decision.

“Anything that might help people beat their opioid addiction is a good idea,” Herbert said.
But she has reservations.

Probuphine is only available in one dose, the equivalent of 8 mg per day. You can’t cut a rod in half as you might a pill or adjust the dose. Herbert said that could be a problem.

“We don’t want to overshoot and give people more buprenorphine than they need, because it makes them somnolent. And for some people they’re going to need more,” Herbert warned, which takes patients back to the challenge of remembering to take a daily pill. The company said the 8 mg dose will be effective for a large number of addiction patients.

Herbert is also concerned about price. Sheldon said the cost of the implants will be competitive with other treatments, including Vivitrol, a shot that is $1,000 a month. Herbert said at that rate, providers may be forced to turn patients away or cut back on other services. She questions whether the price will be justified.

“High profits in the middle of this epidemic are really unconscionable,” Herbert said.

Sheldon said there will be rebates and assistance with co-pays to make sure patients can get the implant. The device may mean fewer patients sharing needles and contracting infectious diseases which Sheldon says will save money for doctors and health insurers.

“If they don’t realize those savings we’re happy to rebate them even further,” Sheldon said.

Even at close to a $1,000 a month, demand for the implants, if approved, is expected to be high as more and more Americans struggle with an opioid addiction and more physicians approach addiction as a chronic disease.

Dave, the paramedic who is in recovery, said he’s thought about trying to wean himself off the treatment drugs.

“But then, the more I think about it, it scares the hell out of me, cause I’m scared of going backwards. I honestly don’t know what would happen,” he said.

The company will need to train doctors on how to insert the implant, if approved. Sheldon said she doesn’t know yet if reinserting the device into the same opening in the arm will work or if doctors would have to create a new scar for each six-month replacement.

And then there’s the problem of patient limits. Right now physicians cannot treat more than 100 patients with buprenorphine. The Obama administration wants to raise that cap, and Congress is considering legislation that would do so. Sheldon said one bill would exempt buprenorphine implants from the 100-patient limit, which could effectively increase the cap as well.

mercredi 18 mai 2016

Boston Medical Center Launches First Comprehensive Transgender Medical Center In Northeast

Boston Medical Center Launches First Comprehensive Transgender Medical Center In Northeast

Dr. Joshua Safer speaks at a press briefing at Boston Medical Center as Kate Walsh, president and CEO of BMC, Dr. Gerard Doherty, chief of surgery, and Dr. Jaromir Slama, chief of plastic surgery look on. (Jesse Costa/WBUR)

Dr. Joshua Safer speaks at a press briefing at Boston Medical Center as Kate Walsh, president and CEO of BMC, Dr. Gerard Doherty, chief of surgery, and Dr. Jaromir Slama, chief of plastic surgery look on. (Jesse Costa/WBUR)

Boston Medical Center CEO Kate Walsh was in a meeting a few years ago when something about gender identity and health came up. She turned to Dr. Joshua Safer, who was treating many of the hospital’s transgender patients.

“I said, ‘So you really believe patients are born in the wrong bodies?’ ” Walsh recalls, looking at Safer across a conference room table as she tells the story. “You said, ‘Yes,’ and that’s how we started on this journey to help people live the lives they were meant to live.”

The journey lead to the creation of The Center for Transgender Medicine and Surgery at BMC, the first such comprehensive service in the Northeast. It brings together services the hospital has been building out for several years: primary care, hormone therapy and mental health support, as well as chest and facial reconstruction procedures. Later this summer, as part of the comprehensive center, the hospital will begin genital surgery for men transitioning to women.

“This is very exciting for me to see us stepping up to do this,” said Safer, who will direct the center. “If you look across North America, there are only a handful of surgeons doing this sort of thing.”

That “thing” is sex reassignment surgery for transgender women. BMC will be the only hospital between Philadelphia and Montreal that performs the procedure. It will be covered by the state’s Medicaid program and commercial insurers in Massachusetts.

Nycii Vanderhoff. (Courtesy)

Nycii Vanderhoff. (Courtesy)

“That’s huge for me,” said Nycii Vanderhoff, 43, a transgender woman who lives in western Massachusetts and began reviewing her options for surgery five years ago. “I didn’t think I’d ever be able to get it.”

Vanderhoff said she couldn’t afford the procedure or the travel and recovery time in a city far from home. She put her name on the waiting list at BMC last year. That list has now grown to 100 patients.

Initially, BMC plans to perform one or two genital surgeries a month and then increase to one a week.

“It involves orchiectomy, removing the testicles,” said Dr. Jaromir Slama, a plastic surgeon who will work with a urologist during the typical five-hour procedure. “And we use the skin tube of the penis and some of the skin of the perineum to pretty much turn it outside in and that becomes the new vagina.”

Glands from the penis and tissue from the scrotum are used to create fully functioning female genitalia for transgender women.

The goal is a “fully functional vagina,” Slama said, which “means aesthetically functional and sexually functional as well. They should be able to experience orgasm.”

BMC will not offer female to male genital surgery right now because there are too many complications with the current techniques, Slama said.

The center reflects a shift within mainstream medicine about how to treat transgender patients.

“Up until a decade or so ago, the view among many providers was that this was probably a mental disorder and the fear was that doing hormone therapy or doing surgery might be abetting a mental disorder and the correct intervention would be to counsel people,” Safer said.

But Safer’s research traces the increasing evidence that gender identity is rooted in biology, “which makes it so logical that an option for people in 2016 is to change the external appearance to meet that gender identity,” he said.

Dr. Joshua Safer, a BMC physician who will be leading the transgender medicine center, says that through his research, he has found increasing evidence that gender identity is rooted in biology. (Jesse Costa/WBUR)

Dr. Joshua Safer, a BMC physician who will be leading the transgender medicine center, says that through his research, he has found increasing evidence that gender identity is rooted in biology. (Jesse Costa/WBUR)

That point of view may be gaining acceptance in mainstream medicine, but the debate is not settled.

Andrew Beckwith, president of the Massachusetts Family Institute, points out that the American Psychiatric Association still uses a mental health diagnosis to describe “people whose gender at birth is contrary to the one they identify with.”

“We believe that the proper treatment would be in the realm of mental health therapies and treatments, again not amputating otherwise healthy organs,” Beckwith said. “I mean in what other scenario would you amputate a healthy organ to conform to a troubled mind.”

“There is still a lot of opposition to the recognition of transgender medicine,” said Jamison Green, president of the World Professional Association for Transgender Health.

With a growing demand for transgender care in Boston, “it’s really important that a comprehensive center exists,” Green said, “to show others that it is possible to do this, to train more professionals and to inspire the other facilities in the region.”

At BMC, patients seeking male to female gender surgery must be at least 18 years old, have been on hormone therapy for a year and be approved by a panel of physicians.

For Vanderhoff, who says she doesn’t leave the house much to avoid harassment and threats, the surgery can’t happen fast enough.

“If my body, when I look in the mirror, is what I’m feeling on the inside, then I don’t have to worry about those issues as much,” Vanderhoff said. “I can just be just a person.”

mardi 17 mai 2016

Dartmouth Study Looks At When Doctors And Patients Clash Over ‘Unnecessary’ Care

Dartmouth Study Looks At When Doctors And Patients Clash Over ‘Unnecessary’ Care

A new Dartmouth study looked at whether or not doctors' actions are influenced by an interest in controlling health care costs. (Alex Proimos/Flickr)

A new Dartmouth study looked at whether or not doctors’ actions are influenced by an interest in controlling health care costs. (Alex Proimos/Flickr)

What happens when you want a test that your doctor thinks won’t help? Has a national campaign against high-cost, low-value care helped physicians have these tough conversations? And what drives doctors to provide care that they don’t think a patient needs?

These are the sorts of questions that researchers at the Dartmouth Institute for Health Policy and Clinical Practice sought to answer in a new study that came out Tuesday. The researchers surveyed clinicians at Atrius Health, Massachusetts’ largest outpatient care provider, with over a million patients, to determine what drives physicians to order tests they don’t think are in a patient’s best interest, and whether doctors were interested in controlling costs.

While nearly all doctors (96.8 percent) in the survey agreed that they should “limit unnecessary tests,” one in three thought that it was “unfair” to ask physicians to consider cost, and nearly one in three (30.7 percent) thought there was too much emphasis on cost. Primary care doctors were more likely to report being pressured by patients to order unnecessary tests, while surgeons were more likely to be concerned about malpractice.

Dr. Tom Sequist, one of the study’s authors, said in an interview that the researchers found a big gap between physicians’ desire to limit costly and low-value care, and their ability to do so.

“The thing that strikes me the most about this study is that over 90 percent of physicians said they were interested in reducing unnecessary cost, but only a third said they understood the role of cost in the system,” Sequist said. “It’s like saying, ‘I’m really interested in physics, but I have no idea how physics works.’ “

To fill the gap between physicians’ knowledge about cost and desire to help control it, the American Board of Internal Medicine launched the “Choosing Wisely” campaign. The website has compiled hundreds of recommendations against “low value care,” defined as care that has little benefit to the patient compared to the cost.

According to the Dartmouth researchers, there was low awareness of the “Choosing Wisely” campaign, with 59 percent overall reporting they did not know about the campaign. Of those who did, about two thirds (70.3 percent) found the campaign helpful.

The study brought back to my mind a tough patient interaction I had in my first year of residency. My patient, a Spanish-speaking man in his 50s, had seen me once before, for a routine physical. But then, a few weeks later, he returned, and I didn’t know why.

After reviewing various test results, he told me: “Why didn’t you check my prostate?” The man was an immigrant from Mexico, highly educated, and concerned that I had missed something. As far as he knew, a prostate exam was the standard of care for a man his age. I struggled to walk through the complex decision to not perform the test, which many medical organizations have recommended against. I found a handout, in Spanish, for him to read on the risks and benefits, and told him to come back when he’d made a decision. Then we ran out of time.

I never saw him again.

Should I have just ordered the test instead of talking through it with him? I still wonder.

The “Choosing Wisely” campaign offers four recommendations against screening for prostate cancer generally or in an elderly or sick populations. In their patient materials, they detail the risks and tell men 50-74 (the age group of my patient) to “discuss the PSA test” with their doctor. There are no materials in Spanish.

Like every test, the consequences of prostate screening are hard to know for a particular patient. Screening for prostate cancer can lead to severe infections and even unnecessary surgery, which may cause incontinence and impotence. Also, while the test itself is only around $40, if it’s positive, costs and risks start adding up. On the other hand, screening does lower your risk of dying of prostate cancer (though not your risk of dying overall) and the American Urological Association says it should be considered for patients aged 55-69.

I am comforted that the authors found that my situation is not unique; nearly three in four primary care doctors reported feeling pressure from patients to order unnecessary tests. But the study doesn’t address questions that linger over my particular interaction: If I deferred to his wishes and ordered the test, would I be doing my job as a physician? Did he think I was denying him care because of his ethnicity? More insidiously, since we know that physicians have strong racial biases, could cost-consciousness serve as a justification for providing less care for minority patients?

This study does suggest that physicians are more responsive to efforts to reduce unnecessary care than efforts to explicitly control cost. And physicians are not the only drivers of wasteful tests and treatments; as the authors say, “patients, regulators, and other stakeholders” contribute to the demand for low-value care. Maybe this could help reshape the “Choosing Wisely” campaign and encourage alliances with other cost-controlling efforts, but the true drivers of unnecessary care are still unknown.

I would love to have another discussion with my patient about this. If he ever comes back.

lundi 16 mai 2016

7 Things To Know About The Nation’s First Penis Transplant

7 Things To Know About The Nation’s First Penis Transplant

Surgical team members Dr. Dicken Ko, left, and Dr. Curtis Cetrulo address the media during a news conference at Massachusetts General Hospital, Monday. (Elise Amendola/AP)

Surgical team members Dr. Dicken Ko, left, and Dr. Curtis Cetrulo address the media during a news conference at Massachusetts General Hospital, Monday. (Elise Amendola/AP)

From The New York Times to cable TV to here at CommonHealth, the country’s first penis transplant made major headlines Monday.

The patient, 64-year-old Thomas Manning, had part of his penis surgically removed four years ago after doctors found he had penile cancer. The news marked a step forward in transplant medicine, but as a resident physician and future primary care doctor, I wondered whether such an elaborate and expensive “proof-of-concept” operation would mean anything for my future patients.

The facts behind the big story:

What did the operation aim to accomplish?

The goals of this operation, according to Dr. Dicken Ko, who co-led the surgical team, were threefold: to reconstruct natural-appearing genitalia, to allow the patient to urinate normally and, hopefully, to help him regain sexual functioning.

They have achieved the first goal, and they are hopeful that Manning will be able to urinate normally in a few weeks. Finally, they did extensive reconstruction of the nerves as well, and are hopeful that he will have normal sexual function in the future.

How was this patient chosen?

For Mr. Manning, the motivation to volunteer for this experimental procedure was straightforward. “Because they cut off my penis. Very simple. Very, very simple,” he said in a phone interview. Manning volunteered for the operation and underwent extensive psychological evaluation, according to his team.

The type of injury he had was also an important factor: Because part of his penis had been surgically removed — rather than injured in an explosion — the rest of the vessels and nerves were preserved, which facilitated the operation. This was important, Dr. Ko said, because they wanted to pick a patient who was very likely to have a successful outcome to be the first to receive the transplant.

How difficult was this operation?

The main technical difficulties of the operation had to do with the vascular reconstruction involved, which is when doctors sew together the small blood vessels of the patient to the donor’s vessels.

Before the operation, they had only a vague idea if the vessels were big enough to connect. They also performed a vein graft, which is akin to a heart bypass and allows greater blood flow. That vein graft was the primary difference between the technical aspects of this operation and the first successful transplant, performed earlier this year in South Africa.

Who else could benefit from this surgery?

For now, the surgeons on this team are focusing on cancer and trauma patients, especially veterans returning with combat wounds from Iraq and Afghanistan.

The technical challenges for soldiers injured by explosions are likely to be more daunting, as the injuries are generally more extensive and their own vessels and nerves are less well-preserved. Nonetheless, the surgeons emphasized how motivated they were to work with veterans.

In a statement, Mr. Manning himself said he hoped the operation could soon be performed on “service members who put their lives on the line and suffer serious damage as a result.”

When asked about the potential for use with transgender patients, Dr. Curtis Cetrulo, a plastic surgeon and the second team leader, said it could be possible in the future. The approach, however, would have to be completely different and would require “a whole new effort” to be successful, he said.

How expensive was this operation?

MGH estimated that this particular operation cost in the neighborhood of $50,000-$75,000, which does not include the salaries of the physicians, who donated their time. The hospital covered the cost.

For future transplant patients, this could be an important barrier. The drugs that patients will need to take for the rest of their lives to prevent rejection could be even more expensive. In hand transplants, for instance, the cost can be up to $2,000 a month and may not be covered by insurance.

What can we expect in the future?

The surgeons report that there are patients currently being screened for the operation at MGH, including a burn patient. Future operations, they said, will depend on the motivation of the patient and referrals from doctors, including primary care doctors, who right now may be unaware that this surgery is even possible.

This is one of the chief reasons that Manning stated that he had been so open about his operation with the press. In his statement, he said, “In sharing this success with all of you, it’s my hope we can usher in a bright future for this type of transplantation.”

What can the first transplant patients expect? 

Manning is reportedly doing well, but has not yet been discharged from the hospital. As Dr. Cetrulo clarified, “the surgical part has been successful,” but complications could arise.

Like other transplant patients, he will need medications to suppress his immune system for the rest of his life. These meds leave him more vulnerable to infections, and even certain types of cancer; ironically, patients on immunosuppressants are at fourfold increased risk of penile cancer.

Reached in his hospital room, Manning said he did not volunteer for the operation blindly. “I know I’m taking dangerous drugs, drugs that can kill me,” he said. “But what do I have to lose? I’m 64 years old, my life is pretty much gone, it’s over. So hey, I’ll take the shot. What, am I supposed to ask some kid who’s got another 40 or 50 years to go, to take it? It’s not worth it.”


Cancer Patient Receives Nation’s First Penis Transplant At MGH

Cancer Patient Receives Nation’s First Penis Transplant At MGH

In this photo provided by Massachusetts General Hospital, Thomas Manning gives a thumbs up after being asked how he was feeling following the first penis transplant in the United States. (Sam Riley/Mass General Hospital via AP)

In this photo provided by Massachusetts General Hospital, Thomas Manning gives a thumbs up after being asked how he was feeling following the first penis transplant in the United States. (Sam Riley/Mass General Hospital/AP)

Surgeons at Massachusetts General Hospital in Boston have performed the first penis transplant in the United States. The patient is a 64-year-old man from the South Shore town of Halifax.

Back in 2012, Thomas Manning suffered a serious groin injury when a heavy cart fell on him at work. As he was being treated for it, his doctors found an aggressive cancer growing in his penis, and amputated most of it.

“He’s really an incredible person that after that surgery, totally unprovoked, said, ‘Doc, if I can have a penile transplant, I’m your patient,’ ” Manning’s doctor, MGH urologic oncologist Adam Feldman, told reporters on Monday. “And it was really amazing and then shortly afterward was when the program started and I said, ‘You know … there just might be something here for you.’ “

It took more than three years for all the pieces to come together, but Manning has now received the country’s first penis transplant. Surgeons in South Africa and China have performed similar operations.

The operation at Mass. General took place overnight on May 8, and lasted more than 15 hours in total. The organ came from a deceased anonymous donor whose family gave special permission for the transplant.

Dr. Curtis Cetrulo helped lead the surgical team of more than 30, and said this operation was just a first step.

“We’re hopeful that with these successes going forward, that we’ll be able to open this up to other patient populations, such as wounded warriors returning from Iraq and Afghanistan who suffer these incredibly devastating injuries that can lead them [to be] so despondent that they consider taking their own lives, and often do,” Cetrulo said.

Surgical team members Dr. Dicken Ko, left, and Dr. Curtis Cetrulo address the media during a news conference at Massachusetts General Hospital, Monday. (Elise Amendola/AP)

Surgical team members Dr. Dicken Ko, left, and Dr. Curtis Cetrulo address the media during a news conference at Massachusetts General Hospital, Monday. (Elise Amendola/AP)

Eventually, Cetruolo said, if it’s deemed safe, the surgery could also be considered for transgender patients.

For now, one central challenge going forward will be to keep Manning’s body from rejecting the transplanted organ.

Dr. Dicken Ko, who co-led the surgical team, said they’ll also be watching to see if Manning’s urinary function returns once his catheter is removed, and whether sexual function returns.

“So there are multiple, multiple benchmarks before we can call this a wonderful perfect operation that is 100 percent successful,” Ko said.

Manning is still in the hospital, and reached by phone he said he seems to be getting better every day. He likes the idea that his operation could someday help wounded veterans.

“This one’s for them,” Manning said. “This one’s for them.”

And he said he’s being public about his surgery because he sees no point in the taboo around anything related to sex and sexual organs.

“And I’m not going to walk around feeling ashamed for nothing,” Manning said. “Sometimes bad things in your life happen, and you can go run and hide or you can face them. And if you want a success story you have to at least take the chance.”

Mass. General doctors say if all goes well, Manning could go home within three or four days.