The Medical News Report

November, 2018

#82

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

Subjects:

1) Late Breaking News—3 subjects

  A. New heart valve procedure improves heart failure dramatically—The Mitraclip

  B. Trying to understand Medicare plans (Original versus Advantage Plan—sign up tim3--October 15-December 7)

  C. Expanded ages for the HPV vaccine—11-45—Gardasil 9 for adults

2) Supplements and Vitamins—a $30 Billion business annually—what you need to know

3) Sexting and Sexual behavior in youth and other consequences

4) Chronic Pain Series-Part 7—Summation and updates--Who is most likely to abuse opioids? New medications to fight opioid withdrawal

5) Health and Spirituality

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your physician, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

  Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, care instructions, possible side effects to look for, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

                                                               Thanks!! Dr. Sam

 

1. Medical Updates

   A. New Heart Valve procedure improves heart failure dramatically—the Mitraclip

   B. Understanding Medicare Plans—the Medicare Advantage versus the Original Medicare Plan—time to sign up

   C. HPV Vaccine--New FDA approved ages (27-45) -Gardasil 9

 

A. New Heart Valve procedure improves heart failure dramatically

 

Arrow points to the mitraclip for insertion onto the mitral heart valve

 

Over 2 million Americans suffer from a severe form of heart failure. There is a new procedure that involves placing a clip on the mitral valve leaflets to prevent further deterioration of the heart muscle which is caused in part by a leaky mitral heart valve as shown in diagram.

How the heart fails

  As the heart enlarges in heart failure, the enlargement distorts the mitral valve creating regurgitation of blood when the valve is closed at the time that the left ventricle contracts. Insufficient blood is pumped per heart beat out to the body making the heart work even harder and eventually the heart gives out and death occurs.

  Medication can help improve heart valve function up to a point, but if the mitral valve is faulty, medication can do only so much. Once the mitral valve regurgitation is relieved with the Microclip (as shown below), the heart muscle function can theoretically improve and heart function can improve if the heart is not too damaged.

  A clip (Mitraclip) can be placed on the leaflets of the mitral valve to work better and prevent blood from leaking back through the valve when the ventricle contracts. This procedure is performed by passing the clip through a vein in the groin via a catheter under fluoroscopy.  

  Because this is new information, I will report on this in the near future when there is more information. However, for now, if a person has severe heart failure and mitral valve regurgitation, this procedure was reported to be twice as effective with the Mitraclip plus medication than those with medication alone in preventing hospitalization within 24 months in the study published in the NEJM*. The mortality rate was almost half (29% compared to 46%).

*NEJM=New England Journal of Medicine

  For a review of heart failure and its treatment, click on: The medical news report #61

   

 

  Above left is the photo of the FDA approved Mitraclip with an inserter. The middle drawing is what a leaky mitral valve looks like. Note the two leaflets do not meet causing regurgitation of blood in the wrong direction. The right drawing is the Mitraclip in place allowing both valve leaflets to meet.

  Before the clip procedure, actual mitral valve replacement was far too risky in many of these patients, but this is far less invasive and better tolerated by patients in poor health from heart failure. The device alone costs $30,000. Expertise for these interventional cardiologists will take time for this to be offered across the country. JAMA, Sept. 2018

 

B. Understanding Medicare plans—Original  Medicare Plan versus Medicare Advantage Plan—how do they differ

  Regardless of what plan you sign up for, the enrollment period is October 15-December 7 unless you do not want to change plans (then you do nothing). If you are just turning 65, your window is up to 90 days prior to your birthday and 90 days after. There is a financial penalty if you do not sign up for the drug plan during that time period.

  Medicare plans are complex, however, I will attempt to cover some basics. By no means is this enough information, but hopefully will give some understanding of these complex plans.

Medicare Plans include 2 major plans-- an Original Medicare and Medicare Advantage Plans. Medicare consists of 4 parts—A, B, C, and D.

  Part A is hospital insurance, skilled nursing, some nursing home care, Hospice care, and some Home Health care services.

  Part B is provider insurance, laboratory, imaging,  durable medical equipment, mental health services, preventative services (Pap smears, flu shots, colonoscopy, etc.), and rehabilitation services (physical therapy, speech and occupational therapy).

  Part C is specific for Medicare Advantage enrollees

  Part D is the prescription drug plan for all Medicare recipients

Original Medicare (Part A and B)

  The original plan includes coverage for doctors, hospitals, and other services excluding prescription drugs. 2/3rds of recipients prefer this plan. To cover drugs, the recipient must sign up for Part D. Recipients must have signed up for Part A and B to qualify for Part D (drug plan).

  There are copays, coinsurance, and deductibles unless the recipient signs up for a Supplement to this plan that reduces or eliminates these fees when services are rendered. Part B only pays 80% of the cost, and the supplement covers the rest. The Supplement is optional based on the recipients need for frequent healthcare.

  There is no monthly fee for Part A, but there is a flat monthly fee for Part B. There is a monthly fee for the Supplement and Part D.  As stated, copays and deductibles will occur when services are rendered. The cost is based on what city and state a person lives.

  Recipients are eligible for Part D which is the prescription drug plan,, which is optional too. Coverage for generics and brand names are in 5 different tiers (1-preferred generics, 2-generics, 3-preferred brand, 4-non-preferred brand, 5-specialty drugs which are very high in cost), and as the tier goes up for the more expensive drugs, the bigger the copay by the recipient.  

  There is no monthly premium for Part A if a person has worked at least 10 years. The hospital admission deductible is $1340, and coinsurance costs begin after 60 days, and other costs occur; skilled nursing costs $167.50 per day after the 21st day.

 The monthly fee for Part B is $134 plus an annual fee of $184.

Comment

  For those in good health not needing frequent doctor visits, tests, and medications, Medicare Advantage should be considered. For sicker patients or those with chronic diseases or those who live in 2 different states, the Original Medicare Plan may be a better fit, but it is more expensive, however it will cover more services, and with a supplement, the monthly fees spread the cost over the entire year preventing major costs with an illness.

Medicare Supplements (Medigap) for Original Medicare Plans

  These supplement plans are allowed for the Original Medicare Plan that help pay for copays and coinsurance, and deductibles that Original Medicare does not pay.

  Supplemental plans are not provided to Medicare Advantage recipients. For the Original Plan recipients monthly fee for the Supplement is in addition to the monthly fee for Part B Medicare and varies on the different plans and carriers. This is a good idea for those who are seeing their doctors frequently, which would require frequent copays.

  Talk to more than one representative before deciding on a plan.

Medicare Advantage Plan—Part C Medicare

  Medicare Advantage (Part C Medicare rather than Original Medicare Plan) is the other major option (1/3 of recipients choose this plan), and payment to this system is based on a monthly flat fee per enrollee.

  The more enrollees in this program, theoretically, the lower the premium. There are even plans with no monthly premium, but the cost will come eventually. In fact, because of high enrollment in the Advantage Plan (20.4 million), it is estimated that the monthly premium will be reduced by $1.94 to $30 per month.

  Part C basically rolls Part A and B into this plan and can include Part D as well for medications. Advantage recipients also must pay for Part B Medicare ($134 per month).

  Medicare Advantage includes many HMOs and some preferred provider models-PPO (you can choose the doctor and hospital, but not all providers accept the Advantage plan). Be sure you understand the difference and check with your doctors to see if they accept the Advantage plans. This plan, because it is less expensive, has some narrowing of providers, and puts the cost on the backside of the plan rather than upfront (monthly) in the Original Plan.

  The Medicare Advantage enrollee is charged an additional annual fee not to exceed the premium costs of Part A and B Medicare models (although they are rising slightly). The Medicare Advantage enrollee must sign up for both Part A and B even though they are in the special category of Part C.   

  Medicare recipients have to qualify for specific plans in the Advantage plan based on their home zip code and those qualifications have to be explained by a Medicare representative. It is now time to sign up (unless you are not changing plans).

  Many of the Medicare Advantage plans have access to dental, vision, and hearing plans whereas the Original Medicare plans do not. Of course, finding someone who accepts these extra plans is always the question. Ask your providers exactly what plans they accept.

Part D Medicare—Prescription Drug plan

  Part D consists of 4 stages—deductible, initial coverage, donut hole-gap, and catastrophic.

Deductible—you must pay a certain up-front cost before Part D Medicare starts covering the medications.

Initial coverage—Medicare starts cost sharing these medications based on the 5 tiers of medications based on the price of the drugs (generic is Tier 1 and 2). Many of the tier 1 drugs (preferred generics) require no fee from the enrollee. The copays rise with the other tier drugs. This stage ends when the recipient hits $3750 of out of pocket cost. (It is complicated how this is calculated).

Donut hole (coverage gap)—The recipients must pay a higher % of the cost. Recipients will pay 35% of brand cost and 44% of generics. This begins after the recipient has reached $3750 out of pocket costs and remains until costs reach $5000.

Catastrophic coverage—This begins at $5000 out of pocket costs. Most plans require recipients to use their preferred pharmacies with this stage, otherwise there could be more costs involved. A small copay is required based on the medications.

  Of course there is the fine print, and these include certain inclusions and exclusions that apply to getting out of the donut hole, so ask the representative based on the medications a recipient takes.   

  Some Medicare Advantage plans may cover medications during the donut hole (gap) partially or completely, and some stand alone Part D plans may do the same. Some will only cover generic drugs. These questions need to be asked of the representative.

  These plans are not simple to understand, and it will take research and an unbiased Medicare representative to help you to decide what plan to sign up to and what carrier to use. Talk to more than one representative. Do your homework!! You can check out Original Medicare and Medicare Advantage by clicking on:

www.medicare.com

www.medicareadvantage2019.org/

 

 C. New FDA approval for the HPV vaccine (Gardasil 9) for adults (human papilloma virus)

 

HPV (human papilloma virus) most commonly is acquired within the first few years of being sexually active and the risk increases with each partner. It is thought that casual open mouth kissing and oral sex can transmit the virus as well as intercourse with 90% of the population being infected by one or more of the 100 plus strains. It is estimated that 10% of people get a chronic infection while the rest gets rid of the virus. It is these people who will potentially be diagnosed with an HPV cancer from 2 specific strains (16 and 18). There are high risk groups (LGBT, multiple partners, anal and oral sex, etc.).

  Even middle aged women may be getting infected by a new HPV infection rather than one that occurred 10 or more years ago. Without safe sex practices, this issue will continue.

  This vaccine provides a young person an 88% chance of not contracting a chronic HPV infection and ultimately a genital or throat cancer (cervical, vaginal, vulvar, and anal) and genital warts.  

  The FDA just approved and extended the use of the HPV vaccine (human papilloma virus-Gardasil 9) for men and women 27-45 years of age. Previously the vaccine has been recommended for all girls and boys 11-18 (some from 9-26) before becoming sexually active. Now it is FDA recommended from 11-45 years of age for males and females.  

Parents concern

  A Canadian study found that young girls who get vaccinated may actually be more careful about sex when older, with fewer partners, and better safe sex methods. Some parents were concerned that the vaccine somehow gave their children license to be more promiscuous, and the reverse is true, thanks to better education about being able to contract cancer through sex. Canadian Medical Association

  HPV (human papilloma virus) accounts for most of these cancers including cancers in throat (tonsil, base of the tongue, oropharynx). In fact, throat cancers are now the most common cancer caused by HPV. Although, most of the statistics for prevention of HPV cancers have come from genital cancers, it is logical to assume that throat cancers can be prevented in both men and women if vaccinated before they are sexually active. Time will tell as those who have been vaccinated are followed throughout their life.

  The new recommendations from the CDC now report that those from the ages of 27-45 can also be protected even if they become sexually active (and not yet infected by the HPV virus). If the person is infected with HPV, the vaccine will not be effective.  To date, there is not a good oral test  for those who have HPV.

  The period of time it takes HPV to cause a cancer in the genital area is estimated to be 15-20 years since cervical cancers peaks at 47 years of age, and infections are likely to occur in the early 20s. Throat cancers, however, are most commonly diagnosed between the ages of 50-65, but no one knows why it takes longer for the HPV virus to cause throat cancers than genital cancers.

  Regardless, getting vaccinated may very well save a young person’s life, so don’t procrastinate—get your children vaccinated and those up to age 45. The sooner the better!! Many physicians are just finding out about this change in age for vaccination. Let them know! Physicians must become more proactive in recommending this vaccine.

  For more information, go to the CDC’s website www.cdc.org and the website for the American Cancer Society www.cancer.org

  I will be reporting on uterine and cervical cancer in January.  

    

2. Vitamins and supplements—what you need to know

Facts 

  Dietary supplementation is a $30 billion business, with more than 90,000 products available without great evidence that many are effective at improving health. According to JAMA, 52% of adults take at least 1 supplement daily, and 10% take 4 or more. Vitamins and minerals lead the products consumed with 48% and 39% respectively.

  The FDA does not have jurisdiction over the vitamin and supplement industry, however, will become involved if a certain product starts causing harm to many.  

  Most double blind controlled research on vitamins and minerals have not proven clear value for the general public to prevent or treat any disease not related to a known nutritional deficiency. In fact, for healthy individuals, taking more than the RDA  (recommended dietary allowance) has negative consequences (ie. folic acid, beta carotene, vitamin E, selenium) including increasing the likelihood of mortality, cancer, and hemorrhagic stroke.

RDA—Recommended Daily Allowance

  Many vitamins and minerals are necessary for normal body function, and with testing, the FDA recommends a certain daily amount that has been deemed safe to consume on a daily basis. However, just because our government has recommended daily allowances does not mean the FDA recommends them to enhance health or prevent disease unless there is a true deficiency defined by testing. Most vitamins and minerals are in ample supply in most foods, and therefore, if a person consumes these supplements, they are already taking more than is recommended. There is a margin of safety with most of these supplements, therefore, most do not get ill. Mega- doses of any supplement is to be avoided.

Americans are wasting their money!

  A new study from a team of researchers from Toronto, Dept. of Nutritional Services did an analysis of a 179 clinicial trials and found none of the 4 most commonly consumed supplements had any value in changing cardiovascular disease or all-cause mortality (multivitamins, Vitamin D, C, or calcium).

Value of Folic acid

  An exception to the above is the intake of folic acid consumed with an anti-hypertensive medication in preventing stroke in patients with hypertension and without a history of heart attack reduced their risk of a stroke 20% by taking 10mg of enalapril (Vasotec)-an ACE inhibitor for the hypertension plus 0.8mg folic acid for 4.5 years.

  Another value is in pregnancy, folic acid can prevent spinal deformities in newborns. Folic acid can also help prevent the side effects of methotrexate, a disease modifier chemotherapy agent, used to treat autoimmune diseases (i.e. rheumatoid arthritis) and cancer.  

Deficiency Diseases

  Intake of natural sources of vitamins and minerals from food has been proven to be better absorbed. However, there are many groups of people that have dietary deficiencies, diseases that prevent absorption of certain products (intestinal disorders), diseases of the liver that would prevent storage of vitamins, and those that take medications that might interfere with absorption, function, or actually increase absorption to a toxic level. These patients may be advised to take supplements under a doctor’s supervision.

Contamination of supplements

  The FDA has reported contamination of many supplements that may cause side effects. It is estimated that 23,000 emergency visits last year were blamed on side effects of supplements especially erectile dysfunction and weight loss supplements. The FDA warns people to be very careful when taking dietary supplements especially if the person’s physician does not know it.   

Trouble with prescription blood thinners and supplements/certain foods that thin the blood too

  Certain prescription items that thin the blood (oral anticoagulants, Lovaza-Omega 3, aspirin, NSAIDs, etc.) should be carefully taken with supplements that also thin the blood unless discussed with a person’s doctor. Special attention should be given when surgical procedures are being planned. Be sure a surgeon is aware of all supplements, medications, and special diets high in certain foods and leafy green vegetables which might affect blood clotting, bruising, and bleeding.

   a) Supplements that have blood thinning properties from Walgreen’s app:

(St. John’s wart, Co-Q10, cranberry, dong quai (Angelica), garlic, ginger, gingko, ginseng, glucosamine, green tea, lyceum tea, melatonin, and soy products, turmeric, vitamin E, arnica, bilberry, chamomile, cinchona, clove oil, evening primrose, feverfew, kava, meadowsweet, motherwort, papaya, pimpkin seed, red clover, and saw palmetto. (NOTE-THIS IS NOT A COMPLETE LIST—from WALGREENS APP).

   b) Foods that have blood thinning properties

  Foods that contain omega 3 fatty acids such as fish (salmon and sardines) and flaxseed can thin the blood.

  Foods that contain higher levels of vitamin E such as sunflower seeds, peanuts, avocados, spinach, and turnips can increase the risk of bleeding in those who are on anticoagulants.

   c) Foods can interfere with medications 

  Foods with higher content of vitamin K can decrease the effectiveness of Coumadin (warfarin) and should be monitored with a blood test (prothrombin time). Vitamin K is used to reverse the effects of Coumadin. These foods include green leafy vegetables (kale, etc.), fermented foods (contain probiotics), Brussels sprouts, cabbage, spring green onions, broccoli, prunes, cucumbers, and dried basil. 

   If a person is taking dietary supplements and often enjoys these healthy foods, it is possible an increased risk of bleeding could occur (even a hemorrhagic stroke) when taking anticoagulants.

  For those not taking anticoagulants, these foods that thin the blood improve cardiovascular health.  

 

Doctor’s knowledge of nutrition

  Unfortunately, most doctors are not well versed in nutrition, therefore, it is prudent to seek professional advice from a nutrition expert when taking multiple medications that may be interfered with by consuming supplements. Do not rely on salespeople in a health food store.

Pregnant women

  Women during their pregnancy are given supplements of folic acid and other vitamins to prevent spinal neural tube congenital abnormalities. Infants and children are given certain supplements if not breast feeding.

Vitamin D deficiency-Sun exposure

  People who do not get regular exposure to sun (and those who always use sunscreen which blocks absorption of UV rays) may need supplements of Vitamin D. The number of cases of osteoporosis is much higher north of the Sunbelt (Vitamin D is required for calcium to be absorbed by bone). Sun exposure of 20 minutes 3 times a week is necessary to stimulate the skin to produce adequate amounts of Vitamin D. Of course, there are many Vitamin D fortified foods.

  Patients with multiple sclerosis can have Vitamin D deficiency because they don’t absorb it well. Most neurologists recommend Vitamin D supplements.

Chronic health issues and weight loss surgery

  Those undergoing bariatric surgery will have many nutritional deficiencies and require supplementation. Those with pernicious anemia requires vitamin B12 supplemention, and those with inflammatory bowel disease also require iron, zinc, B vitamins, vitamin D, and magnesium supplements.

  Those with osteopenia or osteoporosis require calcium, vitamin D, and magnesium supplements.

  Those with degenerative eye disease (macular degeneration, glaucoma) require higher doses of biotin and other special supplements.

Different doses for older Americans

  The recommended daily allowance (RDA) can be higher for certain vitamins and supplements for older individuals.  Those 50 and older may need more supplementation because they frequently do not eat broad nutritious diets and certain vitamins are not as well absorbed by seniors, such as vitamin B12.

  For those under 70, the RDA dose for vitamin D is 600IU/day (international units) and 800IU/day for those over 70. Also for those who do not get much sun exposure or live in the northern states, they may require supplementation depending on their choice of diet.

  Excessive vitamin D can cause excessive calcium absorption, nausea, vomiting, and constipation, etc.

Omega-3 supplements

  Fish oil capsules containing Omega 3 are recommended for those with elevated triglycerides and cardiovascular disease, but have been found to be ineffective in preventing heart attacks for most healthy individuals at the 1000 mg level.

  Prescription strength Omega 3 (Lovaza, Vascepa, and generic) requires 4,000 mg to lower high triglyceride levels (150-499mg/dl) and reduce cardiovascular events and death by as much as 25%, according to the Reduce-it Study.  Physician’s First Watch, Sept., 2018

  Consuming over the counter fish oil would require 18 capsules per day to take the equivalent amount of 4000mg of prescription Omega 3 and would be intolerant for most people (burping fish oil, gastrointestinal discomfort, etc.).  

Gastric Reflux medications

  Those who take proton pump inhibitors (reflux meds—Prilosec, Prevacid, Dexilent, Protonix, Nexium, Zegerid) can create added need for vitamin B12, calcium, and magnesium.

Recommended Daily Allowance

  The RDA list for vitamins and supplement based on age can accessed: www.healthsupplementsnutritionalguide.com

  It should be noted that taking more than the RDA is not recommended for the general public as there are significant side effects. If a person is eating a balanced general diet with adequate fat, protein, and carbohydrates, with so many vitamin and supplement fortified foods today, it is unlikely that a healthy person would have any deficiency in their diet.

 

3. Sexting and sexual behavior in youth--consequences

Sexting is child pornography! Sending or receiving them is a crime. Recent reports suggest as many as a third of teens are sexting and the rate is increasing. 

  Social media has changed the landscape for all but no one has been more influenced than the youth. It has created many relationship difficulties, bullying, disgrace, loss of jobs, etc and linked the underworld to this, not to mention sexual intercourse in the very young.

  Pornography has been around forever, however, personal texting with suggestive or even frank nude images (15%) by youths has escalated over the last decade.

  An article in Psychology Today, stated that a third of these youth had not considered the legal ramifications or the consequences of sexting. They reported that those who engage in this activity, 76% engaged in sexual intercourse.

  

Sexting can be defined in different ways to include photos, videos, and sexually explicit messages sent on a smart phone usually on a text.

  Why do the young sext? Curosity, peer pressure from a friend who engages in this activity, pressure from a potential or current sexual partner are some of the reasons cited. Young people who are “in love”, may feel they increase their intimacy by sexting. Some just do it out of impulse (we are talking about an immature youth).

  With 1 in 8 teens reporting either sending or receiving suggestive or nude images or messages over the internet, this has become a serious issue and has unknown consequences yet to be reported.

  There are many social media sites promoting sexting, and child pornography websites may be involved.

  JAMA recently reported on the influence of sexting and sexual behavior in young people. 39 studies were examined by the authors involving 110,380 participants (all under 18 years of age). Most of the sexting started at age 12 with equal numbers of boys and girls.

  There are two forms of sexting—sending and receiving, with and without consent. These photos have recked lives and lead to major reputation damage leading to significant psychological stress. 14.8% send sexts (81% of those in the photo did not give consent) and 27.4% received a sext (30% did not give consent) in this study.

  Sexting continues to increase in numbers. Sex education must add this issue to their curriculum. Receiving unrequested sexts incidence is higher than sending. It is suspected by the authors that there is significant underreporting especially in younger people ages 10-12.

  As children are given a smartphone, the problem arises. Smartphone apps has escalated the problem. The average age children are given a smart phone is 10.3 years of age. Clearly, sexting increases with age. Parents need to check their kid’s Twitter, Snapchat, etc. accounts. Parents--Be smart and practice tough love!!

  It is thought there is pressure from males to get females to send nude or near-nude photos. Boys frequently share their photos with their friends, and then it gets put out on social media. Revenge porn is the common name, revenge in mind or not. Others blackmail the person on the internet for various reasons. The consequences are so great and should be enough of a deterrent, but it has not decreased sexting.

  According to the Journal of Pediatrics, report that one in five middle school children with behavioral or emotional problems are sexting and four to seven times are more likely to engage in sexual activities.  

  As girls consent, it is of great concern that sexual activity including assault will follow. Parental responsibility is of great importance when that phone is handed over to such a naïve and easily influenced youth. Know what your child is communicating, as Snapchat has taken off because of the youth. There are sexting apps that parents need to know about. Go online!

  Children rarely reach out to parents for help once they feel concern for their activities out of embarrassment, fear of repercussions, ridicule, etc.

  

Parents smarten up. Don’t be naïve about your children. Peer pressure makes kids do stuff they would never do on their own, but to be accepted in a group, to be liked, to be desired even at a very young age is a very important issue that may encourage sexting.

  Check out the codes your kids know in this list below. These kids have their own coded language and parents will never suspect unless realizing the world out there is different than when the previous generation were kids. The internet has changed the game!

Legislators are trying to pass more laws to protect against revenge porn sexting (sending sexually explicit images of a person without their permission), and 40 states in the U.S. have some laws protecting against this. The pornography business is alive and well with young people so willing to share their bodies on the internet. There are even revenge porn websites.

 

Consequences-legal, physical, and emotional

a) Harassment by peers, cyberbullying, or blackmailing can and often occur. Loss of friendships, ridicule, being ostracized by classmates, humiliation, and embarrassment at a minimum may occur. The result of sexting gone wrong has led to suicidal thoughts and in extreme cases suicide.

  Middle school educators, parents, school mates, pediatricians, and health care professionals must be aware of this rising problem and take action when discovered.

    b) College reps and potential employers are now looking on the internet for clues to a candidate’s reputation and behavior.

    c) If the sexts are deemed child pornography, there are strict laws that apply. Being labeled a sex offender is for life.

    d) Sexually transmitted diseases skyrocketing linked to sexting

  STDs have increased for the fourth consecutive year. Nearly 2.3 million cases of gonorrhea, chlamydia, and syphilis were reported by the CDC in 2017 with over 200,000 added cases. Nearly half of the cases of Chlamydia occur in ages 15-24.  Reference-CDC

    e) Teen pregnancy and STD transmission to newborns

  In 2016, there were approximately 210,000 teen pregnancies in the U.S. age 15-19 accounting for 5.3% of all pregnancies. 89% occurred outside traditional marriage, the highest rates in any developed country. 1 in 6 had previous pregnancies. 77% are unplanned.

  A report by the CDC stated that there has been a doubling of infants born with syphilis rising 153% since 2013, the highest in 20 years, a significant percentage being stillborn.

    f) The impact of 2 parent households

  Teens with 2 parents living in the home greatly decrease the incidence of teen pregnancy and those in wealthier neighborhoods have fewer pregnancies. Of course, many of these are never reported.  

    g) Substance abuse and unplanned pregnancies

  86% of those with substance abuse had unplanned pregnancies. Fetal alcohol and opioid addictive syndromes are a serious complication because of these pregnancies. These facts are all tied into sexting, promiscuity, and risky behavior. About 14% of these teen pregnancies involve substance abuse

  Hispanics and blacks account for 62% of these pregnancies. Birth rates are highest in the South and Southwest, which would account for the racial prevalence.

  There is a Pregnancy Assistance Fund to help those stay in school, earn higher degrees, gaining access to healthcare, child care, and housing. Also funds are available for pregnant teenagers from domestic abuse.

  There are websites for to help parents with their children and sexting. CBN.com   

Psychology Today, JAMA-Feb, 2018

 

4. Chronic Pain Series—Part 7--Summation and Updateswho is most likely to abuse opioids ?; New medication to fight opioid withdrawal

  I began writing about the opioid crisis in 2016, and for a great summary about the crisis itself, I refer you back to that report: www.themedicalnewsreport.com/58

  This 7 part series has been more about using non-opioid methods to complement standard pain medicine and perhaps reduce the amount of opioids necessary to treat chronic pain. I have not discussed surgical management for pain, as I have discussed surgical management in many reports, and I refer you to the SUBJECT INDEX on the HOMEPAGE to search those specific surgical treatments for specific diseases.

1-Negative Consequences of Opioid reform

   a) Patients left in pain

  There have been negative consequences trying to curb opioid use including many physicians now refusing to prescribe opioids, states that have over-regulated doctors, and many patients who are going without adequate pain management resorting to less effective pain control and in some cases resorting to street drugs (heroin). These people are suffering especially those who need higher doses. Pharmacies are even lowering the amount of opioids that can be filled.

  It is stated that 26% of those who take opioids for as little as a few weeks become addicted. 1 in 500 die according to the Brookings Institute. These are important statistics to know, but it does not mean that many who suffer from chronic pain are not in need of increasing doses because the effectiveness decreases with time (called tolerance). There are many patients that are addicted by necessity because of legitimate pain including many who are not helped by surgery. These patients must not be discrimated against.

  b) Alternative Herbs

 There are many alternative herbs now being used inappropriately to treat pain including synthetic marijuana (K2, Spice), kratom, and Imodium (for diarrhea), etc.

  Even though many states have legalized marijuana recreationally or for medical prescription use, the federal government lags behind in legalizing medical marijuana  as it may have some value in treating certain types of pain. The federal government (FDA) has actually approved cannabidiol (the substance in marijuana that has little euphoric effect) for a special type of seizure disorder, so theoretically, research can be funded on marijuana and its many potential uses including pain managment.

   c) Homelessness, children going to foster care, and neonatal abstinence syndrome

  Family disruption issues are consequences from the opioid crisis. The epicenter of the opioid crisis began in the Ohio Valley, and there, the number of children losing their parents to drug overdoses and lack of parental guidance has become epidemic. But this is causing a big problem throughout our country. The foster care system is overwhelmed. Babies are being born with neonatal abstinence syndrome (NAS)—babies in withdrawal. These babies are having to be given methadone for up to a year to treat their withdrawal.

  Every 15 minutes a baby is born with this disorder thanks to mothers being addicted. The U.S. Federal government has pored $billions into the crisis, but the system fails at the local level. What future do these children face when they live in a cesspool of addicts?

   d) Withdrawal from opioids increasing

 Withdrawal from opioids has quadrupled in the last decade. People are desperate to kick the habit, but our system is lagging behind the demand to treat opioid addiction.  

2) Alternatives to opioids for chronic pain

  There are numerous non-opioid medications and many complementary therapies available (discussed in this series). There are national guidelines now available for physicians which can help standardize therapeutic approaches, but because pain is so complex, there will never be a “cookie cutter” approach.

3) Physician Education about chronic pain management with opioids

  It is critical for physicians to update their knowledge and be willing to use multple non-opioid options, if necessary, to relieve chronic pain syndromes. Some will work and others will not. Patients must comply with trying different techniques, and the insurance industry must assist by covering these methods (many of which are not).

  However, the burden of opioid prescription writing is now falling on fewer and fewer physicians, and this has created increased scrutiny on these doctors.  

4) Exploitation by alternative therapy providers

  Many of these alternative (complementary) therapies are exploiting this outreach to non-opioid options with false claims and fancy ads. Doctors have to help navigate patients through these methods. The goal is to complement opioids with complementary therapies.

  Physicians must take the time to interview patients with pain and assess their potential for abuse. But time per visit is limited, and patients need to insist on help or be referred.  

5) 6 factors increase the likelihood of opioid abuse:

  1) age less than 65 years of age (20% of 24-35 years olds die from opioids; rates are increasing the most for ages 24-44; those over 50 are catching up)

  2) history of depression

  3) family history of substance abuse

  4) the use of psychotropic medications especially benzodiazepines (anti-anxiety meds)  

  5) a history of abuse

  6) previous need for pain medications on several occasions. Medpage, 2018 

   A new study stated that 67% of opioid deaths are males and fentanyl is the new killer when added to heroin.

7) Drugs across the Mexican Border

  A huge factor in this crisis is the influence of illicit drugs coming in from Mexico, and without border security, we are toast.

 The graph below is a reminder of the impact opioids have had in our country since 2000!! Some reports say the crisis is starting to slow down, but we have no good data yet!

8) Treating overdoses and withdrawal

  Only one in ten addicts are treated!! Fewer physicians are willing to treat addicts even though there are new medications (to be discussed below) that are showing great promise in helping to treat these addicts. Physicians need to be certified to use them.

  It only takes an 8 hour course to be certified and receive a waiver under the Substance Abuse and Mental Health Services Administration to prescribe buprenorphine and Narcan. The federal government must step in and create many more treatment centers, because the crisis continues in local communities to treat and prevent relapse. This fight must include the local communities!

  Narcan is a well known antidote for acute overdoses of opioids (injectible or nasal spray), but very expensive. Any patient taking high doses of opioids should have it on hand and have a family member or friend be prepared to administer it in case of an accidental overdose.  

  Recently the FDA* approved another medication, lofexidine (Lucemyra) for severe opioid withdrawal (which has been used in the UK for 20 years). This medication treats withdrawal symptoms and has been much more successful in increasing the completion of a 7 day opioid abstinence program.   

* It took the National Institute on Drug Abuse 17 years to get Lucemyra approved by the FDA and $27 million dollars of taxpayers money—what a shame to take so long!!

  This medication joins buprenorphine as a treatment for opioid dependence. There is risk of dependency on this drug. 

Text Box:  
9) CDC releases guidelines for opioid prescribing

  The CDC has finally released guidelines for opioid prescribing.  It includes the need to assess risk in patients, counsel patients on opioid use, be familiar with the intitiation, dosing, modifying, and discontinuing of short and long acting opioids. If a patient starts to overuse opioids, the physician must know the steps for addiction therapy.

10) Consequences of non-fatal overdoses

  There are dire consequences for those who overdose. JAMA Psychiatry, June, 2018 reported on Medicaid data on 76,000 people who had experienced a nonfatal opioid overdose. 7% died within a year (24 times higher than the general population). 25% died of a drug associated death followed by cardiovascular and cancer deaths. HIV, chronic respiratory illnesses, viral hepatitis, and suicide were also much higher.      

11) What doctors need to know (worth reading as a patient)

  Here are some highlights of the strategy doctors are being taught: (*note that not all primary care doctors will agree to take the training and be willing treat these patients, which may require switching physicians).

1) Assessment of multiple factors including the patient’s threshold for pain, underlying psychological, spiritual, and physical factors, previous experience with painful conditions, underlying diseases, family history of abuse or addiction, concomitant use of benzodiazepines (anti-anxiety meds), history of sleep disturbance, and history of pre-adolescent sexual abuse.  

2) A critical look at all the options for pain management (reported in this series).

3) A holistic approach to treating patients with conditions that cause chronic pain is necessary.

4) Safe control of opioid use in selected patients--There will be certain patients that will continue to need higher and higher doses of opioids, and these patients must seek care from a provider who is particularly skilled with these patients (palliative care, addiction specialists, and pain management specialists).

5) In managing painful conditions, a comprehensive  assessment of the condition is necessary including the   pain score (0-10), type, position, intensity, onset, duration, what aggravates or relieves the pain, and how it affects the patient’s quality of life.  

6) It is important to assess what the patient’s goals are in relieving their condition and pain. They must have a realistic attitude about pain relief.

7) Assessment of the patient’s previous experience with pain medicine.

8) Assess the state prescription drug monitoring program, previous history of pain prescribing by multiple physicians, and even contacting these providers regarding specific patients.

9) Assessment of underlying conditions that might be aggravated by the use of opioids (other medications, lung and heart disease, obstructive sleep apnea, etc.) or conditions that are notoriously associated with abuse such as HIV, hepatitis, alcoholism, STDs, etc.

10) Social history of the patient should include their social network, work and legal history, marital history, etc.

11) The patient may need to agree to drug monitoring (urine tests), psychological counseling, and several treatment options to see what might be most successful.

12) There are risk assessment questionnaires for patients that help the doctor assess pain medication risk.  

13) Naloxone (Narcan) should be readily available in high risk patients as an antidote for possible overdose. This can be given as an injection, nasal spray, or intravenously. Prescriptions for Narcan can be given to caregivers who may save the addict’s life in case of an accidental overdose.

14) Close assessment for value of treatments with frequent visits to the primary care physicians, and other complementary therapies. Assess repeatedly for signs of abuse, misuse, or aberrant behavior, or true addiction.

15) Clinicians are encouraged to carefully assess prescribing both opioids and benzodiazepines concomitantly as addiction increases. Additionally, those who use sleeping pills, or drink alcohol must be assessed. 

16) In patients who develop addictive tendencies and continue to need increasingly higher opioid doses, should be considered for buprenorphine or in combination with  methadone, which have much less euphoric effect and yet are effective in relieving pain. 

17) Seniors must receive reduced dosage of opioids (one third to one half)

18) A bowel regimen should be considered for opioid patients, especially seniors. Opioids also cause urinary obstruction and must be carefully assessed and treated.

19) Patients must be instructed to safe-guard their medications from family members, because of theft.

20) Pregnancy status must be assessed as well, and if pregnant OBGYNs must assess for fetal influence from the opioids.

21) Informed consent for the patient being prescribed opioids is needed regarding the potential risks and side effects (headache, sweating, dry mouth, sweating, weight loss, cognitive and sleep abnormalities, itching, falls, fractures, loss of libido or sexual function, bladder and bowel dysfunction, and addiction). 

22) A patient-physician agreement document should be signed. Patients should use only one pharmacy, and never request pain medication from another physician, never share their pain meds, given instructions for disposal, locked up in a safe place, etc. 

23) Every doctor visit should include: 1) assessing degree of pain relief, 2) frequency of doses, 3) changes in pain or additional new symptoms, and 4) assessment of the ongoing therapies being used and value to improve quality of life, any side effects, falls, change in cognition, sleep value,  bowel and bladder effects, etc.

24) Long term effects of opioids include hypogonadism, and therefore, sex hormone levels may need to be tested.

   Too few physicians have obtained waivers to prescribe buprenorphine and Narcan. Only 16% of psychiatrists have waivers. There are only 3000 board certified addiction specialists in the U.S., and the majority of primary care doctors have not stepped forward to get the training to obtain the waiver to prescribe it. 

Medscape, CDC, April, 2018

 

5. Health and Spirituality

   

For many of us who are spiritual, we take strength and solace in asking for support and prayer from a higher power, friends, and families. Unfortunately, most physicians overlook the dimensions of spirituality in caring for their patients. They are trained to deal with illness from a purely clinical scientific standpoint. And yet history would point to a link between health, spirituality, religions, and cultures. The strengths of civilizations have been dependent on religions, good and bad!

  According to a 2016 Gallup poll, 89% believe in God or a higher power and 75% consider religion of considerable importance in their lives, as pointed out in a July, 2017 article in JAMA.

  Fewer people go to church regularly, but there are many alternatives such as social media links, you-tube religious videos, live religious services on TV, religious service streaming via electronic media, etc.  Social media has linked people in prayer chains and provided many religious experiences that have one thing in common….providing a group experience or family of like minds based on  religious beliefs. That experience can be invaluable when times get tough especially when health issues become complicated for family members, friends, and self.    

   In response to the JAMA article, comments were made about the lack of interest in physicians to have spiritual care training in half of young physicians, and a quarter felt that spirituality is personally unimportant. With that kind of attitude, finding physicians who even believe that spirituality is of any value in caring for patients will become more difficult especially when time is becoming so limited with a doctor visit.

   Most patients do not expect doctors to bring up any spiritual assistance in serious illnesses. Patients and families, therefore, will have to be proactive in asking for any spiritual interventions from the clergy rather than their physicians. There are, however, some physicians who are willing to pray with patients and families, but patients need to ask for it.     

  Recent studies (Nurses Health Study) suggest a link between religious participation and population health. Their study cited a lower mortality rate in women who attend regular religious services compared to women who do not (740 vs 1229 per 100,000 population). Social psychology teaches us that people need other people’s support regardless of its outward spirituality. When a person knows that other people care about them, they have more hope, and that is powerful medicine.

  Churches also supply an extended family who often pray for those on prayer chains, provide support, provide a sense of belonging, and promote giving to others. All of these are integral parts of the value of religious participation and promote social interaction, promote healthy behavior, optimism, and a sense that a person belongs to something greater than themselves. Having pastors visit patients in the hospital is powerful to those who are religious.  

  This same Nurses Study also cited a 6-fold reduction in suicide in regular church goers.

  The value of hospital chaplains has always been seen as an added value to those who seek spiritual assistance in a time of crisis. There was a time when every patient admitted to the hospital was asked if they wanted a specific religious clergyman to visit them. I wonder about that now. My personal experience when I have been hospitalized has been mixed.

  There can be struggles when considering death in children, end of life issues, and other times of serious illness in the family, and when those who believe in God feel abandoned and sense that God is not listening. They have trouble navigating their emotions when their prayers are not answered. God’s schedule does not always coincide with ours.

  All of these factors point to the need for physicians to consider some integration of religious access into their practices where appropriate or requested for patients who desire it.   

  Palliative care has integrated spirituality into their program and these providers feel it improves quality of life. And yet, it is reported that even though 80% of medical schools provide training in spirituality, it is underutilized because the course is offered only as an elective and not required.

  75% of cancer patients sought spiritual assistance especially with advanced cancer, but 90% did not receive any in this study.

  I propose that those who are religious in one way or the other speak up and ask for spiritual counseling when times are tough. I also propose that physicians include a spiritual history along with the social history which has always been a part of any History and Physical.  

  Are the churches supplying this service today? Some are better than others. I have personally experienced the lack of this.

  I would suspect there has been a de-emphasis on the part of the hospitals especially with 24 hour admissions. I also suspect they may depend on a patient to ask for a chaplain’s visit or feel it is inappropriate to ask such a multicultural country that we have become. There are also churches who have volunteers who visit patients in the hospital and can be an important connection. 

  I also suspect that the increasing secularism and over-concern for offending a non-religious person has played a role. Political correctness!!!

  Another aspect of the equation is that physicians could do well to tend to their own spiritual health. The medical community could do well to consider adding the spiritual welfare of their patients to their medical care regimen for those interested. At least ask!

 

This completes the November report, and next month the December report has these great subjects:

1) Medical Updates

a-What attire do you prefer for your doctors?;

b-Report card on the cancer screening rates of asymptomatic Americans;

c-Understanding Medicare spending;

d-Probiotics and prevention of C.diff intestinal infections

2) Bad actors in Big Pharma, Law, Insurance companies, and Medicine

3) Physician assisted suicide; End of Life care

4) Anti-depressants--The difficulty in stopping anti-depressants; Genetic testing and choosing the best anti-depressant; weight gain and anti-depressants

5) Attempts to reduce drug costs

 

Stay healthy and well, my friends!! Happy Thanksgiving to you and your families, Dr. Sam