More on The Opioid Abuse Epidemic -- it's really serious

Mostly what we hear about the epidemic is overdoses and overdose deaths. In Massachusetts, as the linked article tells us, the incidence of opioid-related deaths jumped by 33% from 2012 to 2014, and in fact killed more people than car crashes and guns combined.

This has happened due to an unfortunate confluence of two events. Back in the early '90s, the zeitgeist pendulum swung (I made up that phrase but I think it's okay) toward a perception that physicians had been too reluctant to prescribe opioids, backed by a factual belief that when people took them for pain, addiction rarely resulted. Alas, it does result unacceptably often if prescribing is not carefully managed and monitored. It is now contrary to consensus guidelines to prescribe opioids for chronic non-cancer pain, but it still happens quite often.

The second unfortunate event was the U.S. invasion of Afghanistan. The Taliban had banned cultivation of opium resulting in a constricted world supply, but once they were removed from power, Afghans started growing more opium than ever. As a result, heroin is abundant and cheap. It's expensive and relatively difficult to obtain illicit prescription opioids, so addicts often turn to heroin. But, you don't know the purity of what you buy on the street so overdoses are common.

A new study by Tolia et al identifies another ugly consequence. The proportion of babies born with "neonatal abstinence syndrome," i.e. born addicted to opioids due to their mother's use, increased from 7/1,000 births in 2004 to 27/1,000 in 2013. They didn't use a total national sample and they don't calculate the dollar cost, but neontal intensive care units are really expensive and the babies spent an average of 19 days there in 2013, accounting for 4% of NICU days, and more than 20% in some centers. (BTW, just to bust the stereotype, 76% of the mothers were white.)

Now, do get a grip. In the past there has been excessive hysteria over this. The babies generally recover without lasting harm, although their social circumstances may compromise their future health and well-being. They used to take the babies away from the mothers, but as far as I know doctors and child protection agencies are wiser now. In fact the rate of breast feeding in these circumstances has increased, according to the study. The babies do better when they are breast fed and that also implies that the mothers are immediately gotten into treatment. But . . .

That prevalence is really shocking. In more familiar terms it is 2.7%, in other words almost 3% of women giving birth in the U.S. are exposing their unborn babies to opioids. To me, there is definitely a wow factor to that.

Trials and tribulations

The good people of metropolitan Boston just saw two highly publicized trials end in guilty verdicts, while another is just beginning in Colorado. These are very different cases.

I didn't have much to say about the Aaron Hernandez trial. It was only a headline event because of the fame of the defendant. The mountain of commentary on the guilty verdict either consisted of rants on the obvious -- yes, he's a bad guy -- or preposterous overinterpretation that implied collective guilt of all New England Patriots fans or some such. Get a grip. Nobody knew that he was a psychopathic murderer until he got caught at it, upon which the Patriots instantly severed all ties with him and the fans lined up to dump their replica jerseys. This isn't even an object lesson in athletes getting coddled and having impunity -- he didn't get into any serious trouble at the University of Florida nor was he a disciplinary problem with the Patriots. His coaches thought he was immature and impulsive, so they watched him carefully. They knew he was a pothead but obviously that wasn't hurting his athletic performance. So this is just a one-off story of a warped individual.

Dzokhar Tsarnaev's guilt was never in doubt, so now we're in the phase when the jury has to decide whether to give him the needle. Seventy percent of Massachusetts residents don't want him to be snuffed. His lawyers even made the argument before the jury the death is preferable to life in the supermax, so why go easy on him? They're probably right, in fact. Don't click on this link if you are prone to nightmares. The question, then, is why the prosecutors are so determined to get him killed ten or fifteen years from now instead of letting him go insane and kill himself in twenty? It's a mystery.

In the case of James Holmes in the Aurora movie theater massacre, the issue is legal insanity. Here too, I'm kind of missing the point. He is indisputably insane in the vernacular sense. Everybody agrees on a diagnosis of paranoid schizophrenia. But there's this weird philosophical issue with not guilty by reason of insanity, which doesn't have to do with whether he is mentally ill but with whether he could "appreciate the wrongfulness of his actions," whatever that means. Who cares? He's obviously dangerous and he needs to be locked up but what's the point of killing him? I don't get it. The state is wasting millions of dollars on this absurd exercise.

The Merchants of Death Won't Die

I'm not sure whether you common rabble are allowed to read this (I have a cookie on my computer that gets me in whether it's subscription only or not) but anyway, Jonathan Gornall in the BMJ updates on the status of the tobacco industry. While smoking prevalence is down considerably in the wealthy countries over the past few decades, the industry is finding new customers elsewhere. In 2012, 2.47 trillion cigarettes were smoked in China. And the U.S. is still a profitable market, with 287 billion smoked that year. That's not to mention cigars and smokeless tobacco.

The industry counterattacks fiercely whenever governments propose tobacco control measures, such as plain packaging or tax increases. They use both lawsuits and political cronyism. Gornall reports that since 2010, 38 British member of parliament have been guests of Japan Tobacco International, one of the big 4 companies that dominate the global market, at pop concerts, cricket games, Wimbledon tennis, and other events. Eighteen members of the House of Lords are members of a cigar club through which they are regularly entertained by the Tobacco Manufacturers Association.

One wonders whether equivalent corruption is going on in the U.S. But in any event, there isn't any other legal product which, when used as directed, kills half of its consumers. There will never be any shortage of psychopaths to serve as executives of the tobacco companies, but they are murderers. Let us be clear.

Is one of these things not like the other one?

As you are no doubt aware, federal prosecutors have spent the past few days trying to convince a jury in Boston to order the snuffing of Dzhokhar Tsarnaev. (The defense will try to convince at least one juror not to go along with it starting on Monday.)

I followed the proceedings pretty closely, because I lived in Boston more than half my adult life and worked just a few blocks away from the scene. Had I not moved away just that year, I might have been there. So it is kind of personal. And I do have to say, if there's every a case where prosecutors can get a death sentence from a jury, this is it. The testimony of the injured, and loved ones of the dead, was horrific and heartbreaking. The utter depravity of setting off bombs, packed with shrapnel and designed to maximally maim and kill, in a festive crowd of completely innocent strangers is as far out as it gets. Tsarnaev appears to have no remorse, did not look at the witnesses, and showed no emotional reaction at all to the agony and terror paraded before him.

On the same day, the administration announced that a drone strike on the Afghanistan-Pakistan border (they don't say which country it was actually in) back in January killed two hostages, and American and an Italian, who they did not know were present. Okay, it's a tragic accident, they only meant to kill some other people of who's identities they weren't sure. (Turns out they also killed a couple of other U.S. citizens who were al Qaeda members, but they didn't know they were there either.)

Now, you might argue that there is no moral comparison. The Tsarnaev brothers intended to maim and kill innocent people, whereas when the U.S. does it it's collateral damage, not intended at all. Sure, the U.S. in Afghanistan has had a bad habit of bombing wedding parties and kids gathering firewood and blowing up houses full of civilians, but it's an accident.

Here's the thing: if you know that among the consequences of your actions will be a substantial number of "mistakes" that kill and maim innocent people, then you do in fact intend it. Any consequence of your actions that you can predict will happen, you intend. And you are responsible.

A talk some guy gave last week

In case you're interested. It's about cultural competence in health care. Sponsored by our Minority Association of Premedical Students.

What is to be done?

Julia Belluz, in Vox, struggles with how to respond to frauds, quacks and cranks such as Oz and RFK Jr. The problem is well known and I have discussed it here. Debunking them on the facts is ineffective in dislodging their followers. In fact, confirmation bias is so strong that telling people why their beliefs are wrong just makes them believe more deeply. And when you try to debate the fraudsters, it a) gives them attention and publicity and b) gives them an opportunity, as Oz is threatening to do no his program, to actually legitimize themselves by creating a simulacrum of legitimate controversy.

She asked for advice from various people, but I'm not sure how helpful it is in the end. They call for the corporate media not to create a false impression of balance ("Shape of the earth: views differ") but I'm pretty sure they're going to keep doing it. It's a reflex. One calls for shaming the enablers, e.g. Oprah viz a viz Oz, but that's not going to work. Oprah is in his corner.

They warn against creating martyrs, but that's the whole problem in the first place. Then there's this:

Just last week, Robert F. Kennedy Jr., a well-known vaccine denier, attended a Sacramento viewing of an anti-vaccine documentary, and told his audience that mass inoculation is akin to "a holocaust."

I asked Dan Kahan, a professor of law and psychology at Yale, how he would suggest covering this event. He said it was important to consider the broader context here: "The fortunate truth of the matter is that there's tremendous confidence by the American public in vaccines," he said. "We have had 90 percent coverage for well over a decade. There are enclaves of people who are concerned. But most parents vaccinate and don't give it a second thought."

So any reporting on vaccine deniers like RFK Jr. should reflect that this is a minority view, Kahan explained. Otherwise reporters risk creating an appearance of significant conflict when there isn't really any — signaling to the unconcerned that they should potentially worry, which could have a negative impact on vaccine rates.

Well sure -- but to report on it, even while calling it a minority view, is to run into all of the above problems. I mean, that's how Kennedy presents himself -- as a brave crusader against a corrupt establishment. He'll be the first to tell you he has a minority view, that's what he's proud of.

But, I can't give up. Truth is the greatest cause.

Pay no attention to the man behind the curtain

No doubt you have heard about the physicians who wrote to Columbia University's  dean of the medical faculty demanding that the school fire Mehmet Oz. The university responded with some banalities about academic freedom.

The physicians who wrote the letter seem a bit dodgy; some of them have ties to the GMO industry and the letter seemed to focus inordinately on that subject. But that's neither here nor there. The question is, should Columbia remove Oz from the faculty.

Honestly, I'm of two minds about this. It is generally against my religion to see professors fired because of controversial public statements. Free inquiry is the raison d'etre of the university and our bedrock value is that the cure for error is open investigation and debate. That said, there is a respectable argument that the Oz affair is not about academic freedom.

Oz does not do research on the fraudulent products and useless practices he promotes on his television show. He does not debate them at conferences or in the pages of medical journals. And there often no scientific or ethical controversy, as in this case or numerous others. I mean come on, a "psychic" who communicates with the dead?

No, what Oz does is lie to people, for money. I'm not saying he is paid by the hucksters and charlatans whose products he pushes, but he is paid to host his TV show and he evidently figures that this trash is what attracts viewers. He abuses the prestige of his medical degree and the Columbia faculty in order to make money by lying to people, potentially causing them substantial harm. That's contrary to his oath as a physician and yes, you can fire people from the faculty for egregiously unethical behavior.

Still, there is a real problem of slippery slopes and drawing lines and hard cases making bad law. There are some defensible claims that nevertheless deeply offend many physicians, whose own reputations and livelihoods depend on practices that are attacked by people out of the mainstream. For example, Robert Whitaker claims that there has been a massive epidemic of mental illness caused by psychiatric medications. He's not in academia, but suppose he had a supporter who was on a medical faculty and had a radio show promoting Whitaker's ideas? Could the school fire the the supporter? They might make the same accusations against him or her that I make against Oz, but I don't think the situations are comparable. Whitaker might not be right about everything, but he's not a nut. He does have some points worth pondering, and the challenge he presents to psychiatric practice deserves consideration and can potentially improve it.

So Columbia doesn't want to open a can of worms. I can understand that. But they should at least disassociate the school from Oz's worst frauds.

Upper class twit of the century

I have no idea why Robert Kennedy Jr. can't let go of his obsession with the utterly false claim that vaccines cause autism, especially since he apparently doesn't know any autistic people and doesn't associate with the families of autistic people or their advocates. Dig this recent quote:

"They get the shot, that night they have a fever of a hundred and three, they go to sleep, and three months later their brain is gone. This is a holocaust, what this is doing to our country."

Then, in attempting to apologize, he said this:

"I want to apologize to all whom I offended by my use of the word [holocaust] to describe the autism epidemic. I employed the term during an impromptu speech as I struggled to find an expression to convey the catastrophic tragedy of autism, which has now destroyed the lives of over 20 million children and shattered their families."

Many people with autism are severely disabled, but others are not, nor are their families shattered. And of course, vaccines have absolutely nothing to do with autism.  He's been on this jag for years, since writing an article for Mother Jones, since retracted, claiming that the CDC and pediatric establishment were engaged in a conscious, malicious coverup.

So okay, we know he's a destructive nut. But here's what we should not have to put up with. Last week, I got a fundraising mailing from the Natural Resources Defense Council. It purported to be from Robert Kennedy Jr., whose name was featured prominently on the envelope and who signed the letter inside. As far as I know, he is still the NRDC general counsel.

The NRDC does good work which I would support. But. They don't just employ this malignant clown, they seem to be proud of it. Apparently his name trumps his loathesomeness and stupidity. So no, I cannot support, endorse, or encourage the work of the Natural Resources Defense Council. Until Kennedy no longer has any association with them.

This time, it's personal

The Government Accountability Office finds that 1/3 of people in nursing homes with dementia are prescribed anti-pscyhotic drugs -- and that is excluding people who actually have psychoses for which these drugs are indicated.

Why is this wrong? Because these drugs are prescribed essentially to put people into a stupor who would otherwise be a problem for the staff. The term for this is "chemical straitjacket." And, they present a high risk for premature death and other side effects.

Why is it personal? My father spent a long time in a nursing home, with dementia. Once my mother found him slumped over in a chair, nearly unconscious, and drooling. It turns out they'd given him seroquel (which is heavily advertised on TV by the way, as a treatment for depression, which also should be against the law, but that's for another day) because he had wandered into the kitchen. They couldn't be bothered just to have somebody watch him.

I drafted a letter for her to give the nursing director, stating that he was not under any circumstances to be prescribed antipsychotics. The ND said okay. A few months later, it happened again.

There is  a black box warning on the label for these drugs, saying that they are not approved for symptoms of dementia and are dangerous and harmful to elderly people with dementia. But the nursing homes continue to use them. This is the sequel of an illegal, off-label marketing campaign which apparently has burrowed so deeply into the culture of nursing homes that it has so far been impossible to eradicate. Lots of awful things happen in those places, but this must stop.

If you have a loved one with dementia, make sure the Nursing Director knows your wrath will descend should this crime occur.

More on Republican governors who hate their own consitutents

Brad DeLong could use a copy editor, but the point is well worth taking. He discusses info-graphics from Price and Evans about the geography of Medicaid expansion.

Medicaid expansion has a powerful positive impact on state level economies, as well as (obviously) on the well-being of the beneficiaries. Delong tells us that on one dollar of federal money coming into the state leads to a six dollars increase in the regional economic product. Among other effects, it puts money into the pockets of physicians, who used to be big contributors to Republican politicians. Sayeth DeLong:

The only way I can find to understand the pattern of Medicaid expansion nullification is a truly extraordinary unconcern on the part of Red State politicians with their poor–whether working or non-working–and substantial insulation as a result of the rise of right-wing billionaires from financial pressures put on them by the doctors who used to be the financial fund-raising bedrock base of the Republican Party. Plus remarkable unconcern with the the health of their state-level economies. But even if they do not care about the well-being of their citizens, they should care about competing for the votes of the non-working and the working poor, shouldn’t they? Or do they just think that the poor are low-information voters, and that those who pull the lever for the Republicans will not be unhornswoggled by looking across the Missouri-Illinois or the Tennessee-Kentucky or the Mississippi-Arkansas or the Texas-New Mexico state line and thinking: “Hmmmm…”

The ineffectiveness of the voice of the doctors I just do not understand. It goes against all theories of rational-choice political economy, it does.

I have expressed similar bafflement here in the past. How can you screw over your own state, hurt working poor people and health care workers -- who include both low wage and highly affluent people -- and harm your state's overall economy, and get elected and re-elected? One despairs for democracy.

Land of the Free and Home of the Benighted

I don't know if you've heard of mitochondrial replacement therapy (MRT), but it's legal in the UK and not in the US. Why is that?

So, first a bit of biology. This will make more sense to you if you are not a creationist. Somewhere back in the mists of time -- long before the universe was created 6,000 years ago -- actually somewhere around 2 billion years ago, it seems that 2 (or possibly 3) simple prokaryotic cells entered into an endosymbiotic relationship. We don't know exactly how this happened. Prokaryotic cells don't have a nucleus and are otherwise relatively simple in their internal structure. There are two major kinds, called archaea and bacteria. The most straightforward explanation of the origin of the eukaryotes is that an archaeal cell somehow engulfed a bacterium, but didn't digest it. Instead, the bacterium reproduced and its progeny started living happily within the cytoplasm of the archaea and its descendants. The endosymbiotic bacteria gradually lost most of their DNA -- they didn't need it because their environment was properly managed by the archaeal DNA, which is now our nuclear DNA -- and they settled down to a few jobs, including the production of adenosine triphosphate (the cell's fuel) and some other essential functions.

The eukaryotes went on to evolve and produce the metazoa -- that's the animals, including us -- and plants, which evidently absorbed another prokaryote, which happened to be photosynthetic, and is today the chloroplast of the plant cell. Anyhow . . .

Some people have defective mitochondria. These can only be inherited from the mother, because the cytoplasm of the ovum becomes the cytoplasm of the zygote. Got that? The sperm don't contribute any mitochondria to the embryo. Having defective mitochondria can be a real bummer. Because mitochondria perform various functions in various tissues, and at different times of life, the manifestations of mitochondrial disease are myriad.Anyhow . . .

These diseases aren't curable, but it is now possible for a woman with defective mitochondria to give birth to a healthy baby. There are actually two ways to do it, not much to choose between them really. Method A is that you produce an ordinary zygote by standard in vitro fertilization, then you take a donor oocyte from a woman with healthy mitochrondria, remove it's nucleus, and insert the nuclear from the zygote. Presto, you have mommy and daddy's nuclear DNA in cytoplasm containing healthy mitochondria. Note that the only characteristic the baby will inherit from the egg donor is healthy mitochondria. Otherwise, the baby will be just like any other baby of those two parents -- each of them has contributed half of the DNA that makes us who we are.

The other method, which as I say is six of one, half dozen of the other, is to replace the nucleus of the donated oocyte with the nucleus of an oocyte from the mother, and then fertilize it. Doesn't matter.

It turns out that people in the U.S. find this ethically unacceptable. Some of them don't get past the "three parents" weirdness factor. That really isn't true, but lot of corporate media reports just say it is because the reporters are ignorant.

The other reason is because people seem to think that method A constitutes abortion. Really. I mean, you have a zygote, which as far as they are concerned is already a baby. Note that it isn't even a blastocyst. Part of it -- the cytoplasm -- is destroyed, even though the nucleus goes on to make the baby that otherwise would have happened, only healthy. They would rather have a sick baby than toss away that microscopic bit of slime. Because Jesus said so.

Ponder that.

The Affordable Care Act: Greatest Thing Since Oxygen

Sure seems like it anyway. Urban Institute calculates that:

• The projected cost of expanding Medicaid under the ACA is now $94 billion less than the forecast made at the time the ACA became law.
  
• The projected cost of providing subsidies to consumers to help purchase health plans in the marketplaces is now $125 billion lower than the forecast made at the time of the ACA’s passage.
  
• In total, CMS projects $2.5 trillion less in public and private health care spending between 2014 and 2019 compared to projections made in 2010.
  
  
   Now, as you may recall, Republicans predicted several different disasters including destruction of jobs, ballooning federal budget deficits, exploding costs .. . oh yeah, death panels. In fact, the act has succeeded beyond the wildest dreams of its proponents, and the news just keeps getting better. But . . . 
  
  
  It continues to be underwater in popularity. People just don't know what's going on around them. That is the fault of 1) Democratic politicians who are too chicken shit to stand up and forthrightly brag about the success of their own policies and 2) the corporate news media who merely act as stenographers and take dictation from Republicans. It's getting really old.
  
  
  
  

Cutting off your nose

From the Robert Wood Johnson Foundation:

States that expanded the number of people eligible for Medicaid are seeing big budgetary savings without reducing services, a new report shows. Prepared by researchers at Manatt with funding from the Robert Wood Johnson Foundation, the report identifies $1.8 billion in budget savings and revenue gains across eight states by the end of 2015—a direct result of Medicaid expansion. Researchers say the savings come from less state spending on programs for the uninsured; more federal dollars coming to the state for newly eligible Medicaid enrollees—including funds to cover typically expensive beneficiaries like pregnant women and the disabled; and increased revenue from existing insurer and provider taxes. In some states, budget savings should offset the cost of expanding Medicaid through 2021.

The eight states studied are Arkansas, Colorado, Kentucky, Michigan, New Mexico, Oregon, Washington and West Virginia.

The report highlights specific sources of savings for each of the states. Across the eight states, for example, $68 million will be saved through 2015 as a result of more pregnant women now being covered with enhanced federal funding. States are also seeing savings from behavioral health programs. The highlighted states will save $472 million through 2015 on mental and behavioral health care spending, now that more state residents with mental or behavioral health care needs are covered by Medicaid.

“States that expanded Medicaid are finding that it was a win-win proposition. More people have health insurance, which reduces the states’ costs for caring for the uninsured. Savings to state budgets are in the hundreds of millions of dollars,” said John Lumpkin, MD, senior vice president at the Robert Wood Johnson Foundation. “When states expand who is eligible for Medicaid coverage, they see the federal government cover more of the costs of caring for patients who historically have been expensive to care for.”

Meanwhile, Rick Scott Flip-Flops, Opposes Obamacare's Medicaid Expansion. Obama could discover cold fusion and Republican governors would refuse to allow the electricity to be used in their states.

Well, Stayin' Alive

In Democracy (which you should bookmark) Diane E. Meier has a review of Atul Gawande's "The Way We Die Now." The irony, if that's the right word, is that the central issue is how long we live.

In 1900, life expectancy at birth in the U.S. was 47.3 years. Alzheimer's, cancer, heart disease, osteoarthritis and osteoporosis, chronic kidney disease, frailty and infirmity -- very few people had to worry about all of that. And if you did get cancer or heart disease or dementia or kidney disease? At least the good news is that you didn't have to live with them for very long.

So our problem is that we have created a new stage of life, a decade or two or more of ever elaborating co-morbidities and physical and mental decline. Not everybody's fate, to be sure. Some of us are fortunate enough to keep the wonderful one-hoss shay together and then just not wake up one morning, but most of us are not. 

Gawande's main complaint is that nursing homes and other services for the elderly are designed to emphasize safety and medical management; but when we're sick and old, we're still people, and environments built with those goals foremost are not pleasant places for humans. We need to stop making a fetish of longevity and instead make life about living.

It seems weird, then, that quantity of life seems to be the highest value, indeed a trump card over every other value, for so many deeply religious people. This position, which to me is ethically inexplicable and just weird, is causing all sorts of problems and frankly, in the long run, it's completely unsustainable. Like burning fossil fuel. But they don't believe that either.