Opioids: Where Your Doctor Is Trained Impacts What He/She Prescribes for You

A new study by economists at Princeton University shows that where a doctor is trained effects the prescriptions he or she writes.

The study focused on opioids, and differences in prescription-writing between graduates of top and bottom-ranked medical schools. Key findings:

• Doctors graduating from lower ranked medical schools write a much larger volume of opioid prescriptions than those from top medical schools.

From 2006 to 2014, “If all general practitioners had prescribed like those from the top-ranked school [Harvard], we would have had 56.5% fewer opioid prescriptions and 8.5% fewer overdose deaths,” said Janet M. Currie, the Henry Putnam Professor of Economics and Public Affairs at Princeton’s Woodrow Wilson School of Public and International Affairs. Currie conducted the study with Molly Schnell, a Princeton Ph.D. candidate in economics.(1)

• Doctors who receive additional training in pain management write fewer opioid prescriptions than their peers.
• Doctors trained in the Caribbean write more opioid prescriptions than foreign-born doctors trained elsewhere outside the US.
• More recent medical graduates are writing fewer opioid prescriptions than are older physicians.  That again raises the question of how well some veteran doctors are keeping up with new trends and issues.

A counter-argument is that doctors lack good alternatives to opioids for management of pain.(3) However, according to the Princeton research, many doctors may simply not understand the choices they are making in writing a script or the options that may be available.

Why should the impact of training be limited to opioid prescriptions? Why shouldn’t it impact other treatment and drug choices?

What you need to consider:

The framed degree on your doctor’s wall is more than a decoration. You need to read it. If the degree is from a school with which you are unfamiliar, you need to get a conversation going about what other training he/she has taken. If the answers aren’t suitable, you need to consider finding another doctor.

A list of the top medical schools for primary care is available at

https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

In the 2017 rankings, the top 20 for primary care (there are separate rankings for research, but the focus in this article is on patient care) are (4):

1. University of Washington
2. University of North Carolina – Chapel Hill
3. University of California – San Francisco
4. Oregon Health and Science University
5. University of Michigan
6. University of California – Los Angeles
7. University of Minnesota
8. (tie) Baylor
9. (tie) University of Colorado
10. (tie) University of Pennsylvania
11. (tie) University of Texas, Southwest Medical Center (Dallas)
12. University of California – San Diego
13. University of Pittsburgh
14. (tie) University of Massachusetts – Worchester
15. (tie) University of Wisconsin – Madison
16. Harvard University
17. University of Nebraska
18. (tie) University of California – Davis
19. University of New Mexico
20. East Carolina State University (Brody)

 

---

Sources:

1. Molly Schnell, Janet Currie. Addressing the Opioid Epidemic: Is There a Role for Physician Education? NBER, August 2017 DOI: 10.3386/w23645
2. Princeton University, Woodrow Wilson School of Public and International Affairs. “Doctors trained at lowest-ranked medical schools prescribe more opioids.” ScienceDaily. ScienceDaily, 14 August 2017. <www.sciencedaily.com/releases/2017/08/170814134811.htm>
3. Malcolm Thaler, MD, “Why Is Opioid Addiction Happening to So Many of Us?” Live Strong, 29 August 2016. http://www.livestrong.com/article/1012275-opioid-addiction-happening-many-us/?utm_source=aol.com&utm_medium=referral&utm_content=opioid-addiction-happening-many-us&utm_campaign=AOL-Wellness
4. https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

 

Brain Injury and Football — No Place to Run

The latest evidence is pretty hard to ignore.

The research leader is Dr. Ann McKee, chief of neuropathology at the VA Boston Healthcare System and director of the CTE Center at Boston University. She examined the brains of 111 deceased NFL players. Of these, 110 had CTE, the degenerative disease caused by repeated blows to the head.

The marker for CTE is a protein found in damaged cells. Because it involves microscopic examination of brain cells, it can only be done after death.

However, families often don’t need that proof. While the victim is alive, they deal with issues such as early on-set dementia and suicide attempts.

The argument in the current report is that even if no one else in the NFL had CTE, the 110 proven cases would prove a statistically higher incidence of CTE among NFL players than in the general population. The bodies examined were a non-random sample of NFL players; families donated them because of concerns. However, the sheer number of cases makes the results statistically meaningful. There simply aren’t millions of NFL players.

And it seems likely that other players do have it. The skulls examined come from all playing positions on the American football field:

• Linemen
• Running backs
• Defensive backs
• Linebackers
• Quaterbacks
• Wide receivers
• Tight ends
• Place kickers
• Punters

Everyone who plays is at risk.

More generally everyone is at risk. The major causes of brain injuries are car accidents and slip-and-falls. The difference between civilians and sports players is repetition. People don’t collect (hopefully) 5 or 10 concussions driving, but then can in football, soccer, auto racing, bike racing and other activities.

Even a single concussion can be devastating.

Like the cigarette debate of the 1970s, it’s time for fans and owners to move from denial to action. What do we do to care for the injured? Deal with suicide risks? Cover the costs of dementia c are?

There’s also the ethical question of whether people have the right to do things that will shorten their life. There is still an active debate on the ethics of assisted suicide in the US; doesn’t this fall into that discussion? If you opt to do something that you know can kill you, does it matter what the method is?

---

Sources:

1. “110 NFL Brains,” The New York Times, 25 July 2017. https://www.nytimes.com/interactive/2017/07/25/sports/football/nfl-cte.html?emc=edit_ta_20170725&nl=top-stories&nlid=57250219&ref=headline
2. Gil D. Rabinovici, MD, “Advances and Gaps in Understanding Chronic Traumatic Encephalopathy,” JAMA, 25 July 2017. http://jamanetwork.com/journals/jama/article-abstract/2645082

Chipping Humans

To paraphrase Franklin, the person who would sacrifice liberty for safety will have neither.

We put microchips in pets so we can locate them. We can attach chips to keys so we know where they are.

Now a company in Wisconsin is microchipping employees.

At this point, the employees are volunteers and the benefits for doing this  include:

• Ease of accessing computers,
• Ease of access to secure areas, and
• Making purchases and vending machines using the chips.

The drawbacks?

• The employer can know where the  employee is 24×7. Spend too long at lunch? The company will know. Privacy? Forgetaboutit.
• The technology represents another level of electronic radiation exposure, and we don’t know about the long term effects of that.

The chips are tiny and can be injected under the skin with a syringe developed by a Swedish firm.

Obviously, the manufacturer wants to see this technology in widespread use.

“Eventually, this technology will become standardized allowing you to use this as your passport, public transit, all purchasing opportunities,” and more . . . . (2)

It’s easy to see where this is going. We can expect a push to implant chips in children, hospital patients and the elderly. That would make kidnapping obsolete and reduce medical errors. It also would make it easy to locate lost hikers and wandering dementia victims. However, it would also mean that with two generations, virtually the entire population would be chipped. Go to a political rally or demonstration? People will know where you are. Criminals will be able to know when a home is empty or when someone is visiting a bank or ATM. Of course, the police will be able to identify and locate the person who robs you.

Further, chips aren’t secure. Any technology can be reversed engineered — meaning that you could create a chip with someone else’s code and use it in a crime.

How do you feel about being chipped?

---

Sources:

1. Megan Trimble, “Wisconsin tech company to implant microchips in employees,” USNews, 24 July 2017. https://www.aol.com/article/finance/2017/07/24/wisconsin-tech-company-to-implant-microchips-in-employees/23045620/?brand=finance&ncid=txtlnkusaolp00002412
2. Angela Moscaritolo, “Wisconsin Company to Microchip Employees,” CNET, 24 July 2017. https://www.pcmag.com/news/355140/wisconsin-company-to-microchip-employees?utm_source=email&utm_campaign=dailynews&utm_medium=title

 

Internet Insecurity Redeux

This should have been expected.

Verizon’s cloud storage has been hacked, exposing personal information and passwords for 6 million customers.

The story is a bit convoluted. The Verizon data is stored on Amazon Cloud Services by a third party, NICE Systems. Someplace in the system, a configuration error allowed hackers to penetrate and obtain the confidential information.

Remember the mantra:

• Nothing on the Internet is secure or private.
• Nothing on the Internet is secure or private.
• Nothing on the Internet is secure or private. . . .

________________________

Sources:

1. Dawn Kawamoto, “Verizon Suffers Cloud Data Leak Exposing Data on Millions of Customers,” Information Week Dark Reading, 12 July 2017. https://www.darkreading.com/cloud/verizon-suffers-cloud-data-leak-exposing-data-on-millions-of-customers/d/d-id/1329344?elq_mid=79280&elq_cid=20204989&_mc=NL_DR_EDT_DR_weekly_20170713&cid=NL_DR_EDT_DR_weekly_20170713&elqTrackId=e47319f4a9254a7c8d50cb09f7c4e49f&elq=23e20c0e4ade4e49a933093d5178f627&elqaid=79280&elqat=1&elqCampaignId=27257

A Grim Reminder of the Link Between Heart, Lungs and Brain

Cerebral hypoxia is the medical term for an inadequate supply of oxygen to the brain. Brain cells can begin to die within 5 minutes of a cut-off or severe reduction of oxygen supply.

It’s a surprisingly common problem. That’s in part because of the variety of conditions that can cause oxygen deprivation. While oxygen deprivation (vascular dementia) is a more common cause of dementia among seniors than is Alzheimer’s, the condition isn’t limited to old age.

The BBC reports today that a 20-year old soccer player collapsed from brain damage after developing a heart arrhythmia during a friendly match played in Austria.(1) The brain damage appears to be severe and permanent.

Other causes for cerebral hypoxia include:

• COPD or severe asthma
• Drowning
• Strangling/choking/suffocation
• Cardiac arrest
• Head trauma
• Carbon monoxide poisoning
• Complications of general anesthesia
• Hyperventilation
• Consistent work in a nitrogen rich environment

Very low blood pressure can be a factor as well. That can result from medication, certain foods, frequent coughing (from congestion or allergies) and alcohol, and especially a combination of these factors.

Symptoms of hypoxia include

• Difficulty with complex tasks
• Poor short-term memory capacity
• Decreased motor control
• Cyanosis (bluish tone) of the skin
• Increased heart rate
• Fainting

The impact of cerebral hypoxia depends largely on whether the victim loses consciousness and for how long that occurs.  According to NIH,

During recovery, psychological and neurological abnormalities such as amnesia, personality regression, hallucinations, memory loss, and muscle spasms and twitches may appear, persist, and then resolve.(2)

However, it may take days or weeks before the full extent of damage from carbon monoxide poisoning becomes evident. Since carbon monoxide is odorless, that’s why monitors are so essential in the home. A simple act such as stacking boxes too close to a furnace can fill a home with this deadly gas.

——————————–

Sources:

1. BBC News, “Abdelhak Nouri: Ajax player suffers brain damage after collapse”
2. NIH, “Cerebral Hypoxia Information Page.” https://www.ninds.nih.gov/Disorders/All-Disorders/Cerebral-Hypoxia-Information-Page
3. Dementia.org, “Oxygen Deprivation Associated With Onset Of Dementia.” https://www.dementia.org/oxygen-deprivation-dementia

Life Planning Fail

In preparing for battle I have always found that plans are useless, but planning is indispensable. Dwight D. Eisenhower

Life happens, but that’s no excuse for not knowing where you want to go. That’s a particular issue in healthcare.

People don’t like to think about negative events that are going to happen in the future. They’ll still happen, just the same. For Americans, the difference between life expectancy and “healthy life expectancy” is nine years.  They won’t necessarily come as a block toward the end of life. If fact, you don’t know when they’ll come.

A new study points out that people are often faced with making snap decisions about healthcare without adequate information. (1) That’s due to the failure to anticipate something that’s actually rather likely to happen.

People get hurt and sick. The roughly 320 million Americans generated 130.4 million visits to Emergency Rooms in 2016.(3) What are the odds you’re going to need one?

If you don’t know where you want to go in an emergency, you may get stuck someplace you don’t want to be.

Even if you’ve never had an illness in your life, you will. Nothing on this planet is immortal.

Like it or not, here are some questions for which you need to have answers.

• Financial
  • How do I cover sudden and potentially large medical bills? What does my insurance not cover that I’m going to have to pay?
  • How do I cover normal bills if I’m out of work for a few months? Or longer?
• Medical
  • In an emergency, where do I want to go for care? (Related: is my doctor affiliated with where I want to go?)
  • If I’m hurt and need rehab therapy, where do I want to go for care?
  • Does someone have access to my Living Will if I can’t speak for myself? (Having one isn’t a question.)
  • Who will advocate for me with medical personnel if I can’t speak for myself?
• Living
  • Whose going to care for me if (temporarily or permanently) I can’t care for myself?

Seriously, this matters. We have several local hospitals, two of which are problems.

• The ER department at one of them has misdiagnosed my wife twice out of two visits. That’s a 100% rate of being wrong. Do we want to test them a third time?
• The nurses at another consistently ignore a severe allergy that causes anaphylatic shock. Breathing is really nice, but you don’t really appreciate it until you can’t do it. It turns out, the nurses don’t pay attention to wristbands. (One nurse at that facility told us that they assume the allergy bands refer to drugs and not to more mundane and potentially lethal issues like iodine and latex allergies.) Going to that facility is like going to a casino. You might get fixed and you might die. How lucky are you?

As you age, where you go matters more. With seniors, for example, if taken to an ER for a serious fall, there’s a 50% chance of additional problems within six months of the initial injury, including death. Some of that risk is the result of decisions doctors make about medication.(4)

There’s no need to overthink this. Do your homework, ask questions, make decisions, and then get on with the rest of your life. Just get it done.

Aristotle was  right. Anything taken to excess turns bad. That includes both planning and lack of planning.

———————————

Sources:

1. Emily A. Gadbois, Denise A. Tyler, Vincent Mor. Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives. Journal of the American Geriatrics Society, 2017; DOI: 10.1111/jgs.14988
2. American Geriatrics Society. “Hospitalized older adults may need more help selecting skilled nursing facilities.” ScienceDaily. ScienceDaily, 7 July 2017. <www.sciencedaily.com/releases/2017/07/170707211128.htm>.
3. Centers for Disease Control and Prevention, “Emergency Department Visits.” https://www.cdc.gov/nchs/fastats/emergency-department.htm
4. Jiraporn Sri-on, Gregory P. Tirrell, Jonathan F. Bean, Lewis A. Lipsitz, Shan W. Liu. Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients. Annals of Emergency Medicine, 2017; DOI: 10.1016/j.annemergmed.2017.05.023

Flame retardants, household dust, and thyroid cancer

A new report from Duke University finds an explanation for increases in the frequency of thyroid cancer in household dust.

“Thyroid cancer is the fastest increasing cancer in the U.S., with most of the increase in new cases being papillary thyroid cancer” [PTC], said the study’s lead investigator, Julie Ann Sosa, M.D., MA, professor of surgery and medicine at Duke University School of Medicine in Durham, N.C. “Recent studies suggest that environmental factors may, in part, be responsible for this increase.” (1)

Prior studies have shown that some flame retardants used in the home and in vehicles have a similar chemical structure to thyroid hormones and can disrupt thyroid function.

The study measured the content of household dust as well as the incidence of chemicals in blood samples taken from occupants.  The study used a post facto experimental design with test and control groups.  All of the 140 participants lived in their homes for more than 11 years.

This study established that these flame retardants

1. Appear in household dust in measurable quantities, where they can be inhaled by occupants and
2. The level of two of them found in dust and blood samples are associated with the probability of having PTC.

The two problem chemicals identified in the study as elevating cancer risk belong to a class of chemicals, polybrominated diphenyl ethers (PBDEs).

• Decabromodiphenyl ether (BDE-209). This is the most commonly used retardant, and appears to double the risk for thyroid cancer.
• Tris(2-chloroethyl) phosphate (TCEP).

Participants with high levels of TCEP in their house dust were more than four times as likely to have larger, more aggressive tumors that extended beyond the thyroid, according to the study.

Participants with high levels of BDE-209 in their blood were 14 times more likely to have a version of the cancer that tends to be more aggressive.

Why should you care?  These chemicals are used as flame retardants in plastics (including TV cabinets), furniture, drapery backing, some carpets and in consumer electronics, both in home and in automobiles.  Both exposure to these chemicals and the prevalence of thyroid cancer are increasing.

Note:  This research was funded by Fred and Alice Stanback, the Duke Cancer Institute, and the Nicholas School of the Environment at Duke University, and not by industry sources.

What you need to consider:

• Do you have a home air purification system? Not something that makes the air smell nice, but something that removes dust and other particles from what you breath. Maybe it’s time to invest or upgrade.
• Read the labels on what you buy.

 

---

Sources:

1. The Endocrine Society. “Exposure to common flame retardants may raise the risk of papillary thyroid cancer.” ScienceDaily. ScienceDaily, 2 April 2017. <www.sciencedaily.com/releases/2017/04/170402111311.htm>.
2. US Environmental Protection Agency, “Technical Fact Sheet — Polybrominated Diphenyl Ethers (PBDEs) and Polybrominated Bophenyls (PBBs),” January 2014.
3. Wikipedia, “Decabromodiphenyl ether.” https://en.wikipedia.org/wiki/Decabromodiphenyl_ether