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Addiction, Podcasts, Public Health

Heroin: The national epidemic

Heroin: The national epidemic

4132006028_1fbf0b4076_zWhen I think of New England, I don’t naturally conjure up an image of heroin. Yet today, many cities and towns in the bucolic northeast are facing a heroin epidemic. Clearly at odds with the image of the Atlantic Ocean lapping at seaside resorts, Maine, Vermont, New Hampshire and Massachusetts are each seeing disturbing trends. Illustrating the magnitude of the problem engulfing his state, Vermont’s Governor Pete Shumlin devoted his entire 2014 State of the State address to what he called “a full blown heroin crisis.”

Across the country too, heroin death are skyrocketing: According to the Centers for Disease Control, more than 8,000 Americans died of heroin-related overdoses in 2013 – nearly three times as many as those who died in 2010.

So what’s fueling the explosion of heroin use? Stanford addiction expert Keith Humphreys, PhD, told me in this 1:2:1 podcast that it’s largely propelled by the huge number of prescriptions for opioid pain killers. According to the National Institute on Drug Abuse, more than 2 million Americans abuse prescription pain killers – and Humphreys says when the pills run out, many turn to heroin as a cheaper alternative and an equivalent high.

Recognizing the rippling toll on communities and families across the nation, the Obama administration announced a new program in August to combat the trafficking and use of the drug.  The Washington Post first reported the plan, saying that the initiative will pair public health officials and law enforcement in an effort to shift the emphasis from punishment to the treatment of addicts.

After hearing the heroin crisis also popping up in conversations from several presidential candidates during their jaunts to New Hampshire, I turned to Humphreys to dig deeper into the issue. In addition to being a professor of psychiatry and behavioral sciences at Stanford, Humpreys also spent a year in the White House Office of Drug Policy as a senior policy advisor during the first year of the Obama administration.

Previously: Assessing the opioid overdose epidemicA focus on addiction, the country’s leading cause of accidental deathWhy doctors prescribe opioids to patients they know are abusing them and Do opium and opioids increase mortality risk?
Photo by Lauri Rantala

Medicine and Literature, Podcasts, Public Health, Science

Jonas Salk: A life

Jonas Salk: A life

Salk book coverIn 1954, Charlotte DeCroes stood in line with her fellow second graders in Kingsport, Tennessee and received the polio vaccine. Her Tennessee hometown was one of the test sites for what was then the largest and most significant clinical trial in the history of medicine. By the end of 1953, there were 35,968 reported polio cases, and the United States was desperate to solve this devastating illness. A survey at the time ranked fear of polio second only to fear of atomic warfare.

Fast forward to 2015. Charlotte Jacobs, MD, professor of medicine, emerita at Stanford, has written a highly acclaimed biography of the famed researcher/physician Jonas Salk, MD, who developed the polio vaccine. In this 1:2:1 podcast, she told me that her ten-year journey into Salk’s life was instigated partly because she couldn’t find a thorough autobiography on him, something she considered a historical lapse.

Jacobs has written a finely honed and balanced portrait – saluting Salk’s great accomplishment while not flinching from describing a man who was enigmatic, complex and all too human. She conducted more than a hundred personal interviews and spoke to two of his three sons along with his longtime private secretary. The dichotomies of his life are fascinating. While he was loved and lauded by the public and the media, he was a pariah in the scientific community – never appreciated, accepted or awarded. (His scientific colleagues thought he was a press hound, an impression that was fueled by the media’s adoring gaze – covers and feature articles in the most popular media of the time, including Life, Time, Colliers, Consumer Reports, Popular Mechanics and U.S. News and World Report.)

Today, with vaccine wars sweeping certain areas of the country, Jacobs reminds us of a time when a major public-health crisis engulfed the nation and of a hero who made a difference and changed the landscape of medical history. It’s worth remembering.

Previously: Charlotte Jacobs on finding “snippets during every day” to balance careers in medicine and literatureStanford doctor-author brings historic figure Jonas Salk to life and Prescribing a story? Medicine meets literature in “narrative medicine”

Health Policy, In the News, Medicine and Society

Medicare to pay for end-of-life conversations with patients

Medicare to pay for end-of-life conversations with patients

800px-Doctor_and_couple_talking_(1)Remember “death panels?” In the summer of 2009, in the midst of the debate about the Affordable Care Act, aka Obamacare, a small item in the legislation allowing Medicare to reimburse physicians for end-of-life conversations with patients unleashed a tsunami of criticism. Opponents charged that so-called “death panels” – anonymous Washington bureaucrats – would be making decisions about rationing health care and ultimately deciding who would live and who would die. As foolish as that charge was, the Obama administration choose not to fight the opposition and the payment proposal was dropped.

Now, the Centers for Medicare and Medicaid Services has announced a new policy. Beginning January 1, 2016, the government will reimburse voluntary end-of-life conversations that Medicare physicians have with their patients.

We asked Stanford’s VJ Periyakoil, MD, a nationally recognized leader in palliative care, for comment, and she said, “Medicare’s proposal to reimburse doctors to have a conversation with the patient about their values and preferences for care is a quantum leap forward towards the lofty goal of improving quality of care for all Americans at the end-of-life.” But she emphasized that this is just one part of the solution:

Advance care planning is not an event but a process. The key is having conversations in plural, over time as patients’ goals of care change as their illness progresses.

Early in the illness, most patients prefer to have a trial of high-intensity treatments including life support, and this is a very reasonable thing to do. However, there is a tipping point in the illness trajectory where we go from prolonging life with quality to prolonging the dying process. Beyond this tipping point, most patients, if given a choice, prefer to die gently and naturally at home minimizing the burden to their loved ones. But in order for this to happen, we need doctors who are well trained and highly skilled at conducting end-of-life conversations with their patients. We need to ensure that patients and their proxy decision makers are well supported to make end of life decisions. Finally, it takes significant support of both the patient and caregiver by a skilled team of clinicians to ensure a gentle and peaceful death at home.

Unless we have all these components in place, we can’t expect to see major and sustained improvements in end-of-life care.

Previously: “Everybody dies – just discuss it and agree on what you want”In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issuesA call to “improve quality and honor individual preferences at the end of life”Study: Doctors would choose less aggressive end-of-life care for themselves and On a mission to transform end-of-life care
Photo by National Cancer Institute

Medicine and Society, Stanford News

Actor Anna Deavere Smith on getting into and under the skin of a character

Actor Anna Deavere Smith on getting into and under the skin of a character

ADS - smallThe “skin” issue of Stanford Medicine magazine is out and online. In it, I have a Q&A with actor and playwright Anna Deavere Smith. TV audiences came to know Anna through her work as Nancy McNally, the White House national security advisor on the famed series “The West Wing.” And now, after seven seasons, she’s ending another acclaimed role, hospital administrator Gloria Akalitus on Showtime’s “Nurse Jackie.” Bur her seminal work has been in the theater, in two groundbreaking plays early in her career: “Twilight Los Angeles” and “Fires in the Mirror.” Her last theatrical piece, “Let Me Down Easy,” was a paean to the human body in its strength and fragility.

There are few actors who get into and under the skin of their characters more acutely than Anna. We thought it would be interesting (and different) for this issue of the magazine, which focuses on skin diseases, to talk with Anna and get another sort of take on skin. “In the early part of my career [my skin color] was a big stumbling block,” she told me. “There were stereotypes. As a woman, if you didn’t fit into the idea of a tragic mulatto or mammy it was really hard to situate yourself.”

Read on in the Q&A.

Previously: This summer’s Stanford Medicine magazine shows some skin and Let me down easy: A conversation with Anna Deavere Smith
Illustration by Tina Berning

Neuroscience, Podcasts

What the world needs now: altruism/A conversation with Buddhist monk-author Matthieu Ricard

What the world needs now: altruism/A conversation with Buddhist monk-author Matthieu Ricard

Ricard - smallerSandwiched between trips to the titans of Silicon Valley – Facebook, Google, Salesforce and LinkedIn – and prior to an evening conversation with Stanford neurosurgeon James Doty, MD, Buddhist monk Matthieu Ricard, PhD, met with me to talk about his new book, Altruism – The Power of Compassion to Change Yourself and the World.

Ricard is on a cross-country speaking tour spreading his belief of how “altruism is the vital thread that can address the main challenges of our time, from economic inequality to environmental sustainability, from life satisfaction to conflict resolution.”

The French native is an internationally bestselling author (an earlier book, Happiness, A Guide to Developing Life’s Most Important Skill, was a huge global success), a scientist with a PhD in molecular genetics, and a photographer. The new book is a tome and perhaps even a salve for these turbulent times when the seams of the world seem to be tearing apart.

Ricard is a gentle man. He resides in a monastery outside Katmandu that sustained significant damage when an earthquake devastated Nepal in April. (His foundation, Karuna-Shechen, is raising funds for disaster relief.) At the age of 20, he went to India to meet the great masters of Tibetan Buddhism. He returned again in 1972, to study full time and lead a contemplative life, often times in isolation for long stretches of time. I asked him if the life of solitude was difficult; he told me it’s a question he’s frequently asked.

In this 1:2:1 podcast, we spoke about the intersection of neuroscience and meditation and the enormous growth of mindfulness in the U.S. I wondered whether he thought mindfulness was becoming too commoditized. For instance, would the world be better off with mindful drone operators? He thinks not. I also asked him about his purpose in life. But the main focus of the interview is his new book and his view that now is the time to spread altruism as the world desperately needs it and is primed to respond.

Ricard left the Bay Area over the weekend moving on to Los Angeles, Washington and New York to spread the word and demonstrate altruism in action.

Previously: From suffering to compassion: Meditation teacher-author Sharon Salzberg shares her story and His Holiness the 17th Karmapa discusses the nature of compassion
Photo by Raphaele Demandre

Mental Health, Podcasts, Stanford News

New frontiers for psychiatric illness

New frontiers for psychiatric illness

brain statueI started my recent conversation with Stanford psychiatrist and neuroscientist Amit Etkin, MD, PhD, with the March 24 crash of the Germanwings aircraft. The pilot, now known to have had a history of depression, was on an apparent suicide/homicide mission, killing 150 passengers when he crashed the plane in the French Alps. I wondered, could this tragedy in any way serve as a teachable moment to help de-stigmatize mental illness? Was it possible at all in the midst of a senseless horror to also have any constructive dialogue about mental illness?

I guess I already knew the answer, but Etkin confirmed it. He told me that when a horrendous event occurs like this, someone has to accept blame, and “that already colors the conversation you will have.” It’s not like when an admired public figure discloses a mental disorder and a conversation about mental illness can potentially enlighten the issue.  The sheer tragedy, Etkin said, overwhelms any attempt to educate or lessen the stigma about mental illness.

We went on to talk about the plasticity of the brain and its ability to recover, and a lot about the progress in brain research and why he believes we’re well into a new area of discovery that will reap benefits. And I asked him what Freud would think about this moment in time in psychiatry. Would the father of modern psychiatry see progress in the field if he were transported to today?

Freud, as a clinician, would be disappointed that “we’re not even close to cures now compared to 100 years ago when he lived,” Etkin responded. Freud’s early work, said Etkin,”was to actually try to understand the brain basis with the very, very rudimentary science at the time, of the things he saw clinically. I think that would make him happy – that now there’s a connecting of things grounded in the brain that there wasn’t a couple of decades ago. This is really a relatively new development with brain imaging.”

Etkin does offer great hope and believes the advances in the treatment of mental disorders that are well underway will be transformative in the future:

I think we are now at the point in psychiatry and in neuroscience relative to behavior and emotion where we finally have some of the tools we need to answer the questions that we want to answer and [are] no longer as limited by not having had those tools… Asking questions with the right tools will allow very, very big questions to be answered.

Previously: Study: Major psychiatric disorders share common deficits in brain’s executive-function networkHope for the globby thing inside our skulls, My descent into madness – a conversation with author Susannah CahalanBrain study offers “intriguing clues toward new therapies” for psychiatric disorders and Searching for better PTSD treatments
Related: Brain power: Psychiatry turns to neuroscience
Photograph of a Federico Carbajal Raya sculpture by Victor Vargas Villafuerte

Cancer, Podcasts, Stanford News

Stanford neurosurgeon/cancer patient Paul Kalanithi: “I can’t go on. I will go on.”

Stanford neurosurgeon/cancer patient Paul Kalanithi: "I can't go on. I will go on."

Kalanthi and childEditor’s note: Paul Kalanithi passed away on March 9, after this post was published.

Frankly, I didn’t quite know how to begin my conversation with Paul Kalanithi, MD. How do you talk to a 37–year-old man about his terminal illness and facing death? A conversation with someone so young who’s the father of a small child is supposed to be ebullient, not dark.

Kalanithi, a Stanford Medicine neurosurgeon and fellow with Stanford Neurosciences Institute, was diagnosed with advanced stage lung cancer in 2013. His illness is terminal. While he’s hopeful that a treatment may extend his life, there is no cure. He faces big questions and small ones. And he wonders: “How do I talk about myself – in the present, past or future tense? When someone says, ‘See you next year,’ will I?”

It all began with back pain, night sweats, weight loss and fever. His neurosurgical training prepared him for what he reviewed on his CT scan. Metastatic cancer. He responded well to his initial treatment plan, but a second round of chemotherapy last spring led to a number of complications and setbacks. Though he finished his residency he’s now taking time off to recover and regain his strength. He remains hopeful about a return to neurosurgery, yet he has to prepare for an end. He’s spoken with a palliative-care expert. He’s mulling the existential questions and trying to grapple with moving on while not giving up. He takes comfort in the words of the Irish novelist and playwright, Samuel Beckett: “I can’t go on. I can go on.” They’ve become sort of his mantra.

Still, he knows he faces the inevitable and whether it’s a year, two years or five, terminal is the diagnosis. He’s trying to find a way to leave a trail of bread crumbs to his life so his child will know she was loved deeply when his presence is all but a shadow.

I spoke with him last November for a 1:2:1 podcast while he was in the throes of writing a book proposal. It was hard for me at points in our conversation to keep it together as our talk pried open my own grief over my brother’s death to cancer at age 48.

Kalanithi also wrote a beautiful piece for Stanford Medicine magazine. It’s magical. It’s lyrical. It touches the heart. And it’s clear, no matter what his health status, no matter what the outcome, he will live on.

Previously: Stanford Medicine magazine reports on time’s intersection with health, For this doctor couple, the Super Bowl was about way more than football, A neurosurgeon’s journey from doctor to cancer patient, Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness and No one wants to talk about dying but we all need to
Photo by Gregg Segal

Medicine and Literature, Patient Care, Podcasts, Stanford News

Abraham Verghese: “A saintliness in so many of my patients”

Abraham Verghese: "A saintliness in so many of my patients"

Verghese lookingThere’s a quiet dignity that envelopes Abraham Verghese, MD. You can imagine other authors whose books have scaled to the top to be taken with themselves, hardly humble, but that’s not the case here. When you get to know him, you realize he’s a man of great depth, with a wonderful soul and a deeply felt sense of humanity. When he talks about treating patients it’s with reverence (“There’s a saintliness I saw in so many of my patients,” he told me) – as if each time he crosses the threshold into a patient’s room he’s entering hallowed ground.

Verghese has written two searing works of nonfiction: My Own Country, a paean to the young men he treated for HIV-AIDS when it was just emerging as a human scourge, and The Tennis Partner, a loving eulogy to a best buddy whose life went off the rails. Then the blockbuster novel Cutting for Stone: atop the New York Times best seller list for two years and selling more than one million copies. It’s a sweeping tale of how time transforms family – jolting the reader from the first page, where a Roman Catholic nun gives birth to twins boys and dies on the operating table. I read it during the height of the global economic chaos in 2009 and was transported each evening, thankfully, to another world outside of monetary meltdowns and fiscal maelstrom.

In this 1:2:1 podcast, Verghese and I talk about time’s impact on medicine, novels and life. (Time is the theme of the current issue of Stanford Medicine magazine.) About life, he tells me, “There’s a poignancy to living because we won’t live forever… As John Irving says in one of his books, ‘Life is a terminal condition. It’s about to run out on all of us…’ There’s no exception to that. And I think, in a way, that’s what makes life so beautiful.”

This podcast is accompanied by a Q&A with Verghese in the magazine.

Previously: Stanford Medicine magazine reports on time’s intersection with health, Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED, Stanford’s Abraham Verghese honored as both author and healer, Abraham Verghese’s Cutting for Stone: Two years as a New York Times best seller and Abraham Verghese at Work: A New York Times profile
Photo by Jason Henry

Health Policy, Patient Care, Podcasts

Steven Brill’s Bitter Pill

Steven Brill's Bitter Pill

Bitter PillA New York Times review called Steven Brill’s book, America’s Bitter Pill, “a thriller.” Brill’s tome on the building of the Affordable Care Act (ACA), aka Obamacare, “a thriller?” I thought. What recent treatise on the inner workings of public policy has garnered that sort of description? Didn’t the term “thriller” belong to writers like Paula Hawkins, Dean Koontz, Gillian Flynn and James Patterson? But Brill’s meticulous narrative of how Obamacare was constructed is a public-policy thriller, and the suspense he writes about is how the law was brought from broth to soup.

While Brill is hardly a public-policy advocate (he’s a long time investigative reporter), he does laud the president’s herculean effort to give millions of Americans access to affordable health care. He just doesn’t believe that any of the big “players” in health care – hospitals, device makers, insurance companies or pharmaceuticals –  felt a pinch of economic pain, and he sees America’s health care system still as an old “jalopy” financially out of control and enriching special interests.

The seed for the book was spawned in a 24,000-word article in TIME magazine in April 2013. A year later, while reporting on the rollout of the ACA, Brill was diagnosed with an aortic aneurysm – flipping the story and putting investigative reporter onto the operating table as a very real person needing cardiac surgery.

As he told NPR’s Terry Gross:

At that moment I wasn’t worried about costs; I wasn’t worried about a cost-benefit analysis of this drug or this medical device; I wasn’t worried about health-care policy. It drove home to me the reality that in addition to being a tough political issue because of all of the money involved, health care is a toxic political issue because of all of the fear and emotion involved.

At the end of my conversation I asked Brill if there was one question he’d been surprised that he’d not been asked during his media blitz, which began with a rollout by Lesley Stahl on CBS’ 6o Minutes.  “Yes,” he said, “you just touched on it.” How would his book had been different if he’d not had an aortic aneurism, a cardiac operation and become a patient? So how would Chapter One have begun?

I hope you’ll listen to my latest 1:2:1 podcast to hear what he has to say.

Addiction, Health Policy, Parenting, Pediatrics, Podcasts, Public Health

Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization

Discussing the American Academy of Pediatrics' call to put the brakes on marijuana legalization

A wave of changes in state laws on the use of marijuana for medicinal and recreational purposes has stirred the American Academy of Pediatrics. It’s taken 10 years for the AAP to update its policy on the legalization of marijuana, and they released its new one on Monday.

74381759_e5a563cf3d_zThe organization still opposes legalization but it has opened the door to reform in several ways. First, recognizing that minority kids bear the brunt of criminal penalties for pot use, they call for decriminalization. Second, they call for the U.S. Drug Enforcement Agency to reclassify marijuana from a Schedule 1 listing for controlled substances to a Schedule 2. This action would effectively allow more research to be conducted and in turn scientifically determine where marijuana is most effective as a treatment. A review by the federal government is currently underway.

I asked Stanford pediatrician Seth Ammerman, MD, the lead author of the statement, what the AAP was trying to achieve with its policy redo and why such a restrictive stance on legalization since the train for legalization – recreational and medicinal –  seems to have already left the “coffee house.”

In this 1:2:1 podcast, Ammerman cites major two concerns. First, if legalized and commercialized, marijuana will become a big business, and the same marketing efforts by tobacco companies that encouraged teens to take up cigarettes will lasso them to pot smoking. “Well, aren’t kids smoking pot already?” I asked. Ammerman fully realizes that any teen who wants pot can readily buy it – legalization, to the AAP, is an imprimatur. Secondly, Ammerman cited, as does the new policy statement, the compelling and growing scientific evidence that the brain in formation continues to gel through the teen years and into the 20s. Marijuana, just like alcohol and any other drug, is likely to play a lot of bad tricks as the prefrontal cortex solidifies.

As described in the policy paper:

New research has also demonstrated that the adolescent brain, particularly the prefrontal cortex areas controlling judgment and decision-making, is not fully developed until the mid-20s, raising questions about how any substance use may affect the developing brain. Research has shown that the younger an adolescent begins using drugs, including marijuana, the more likely it is that drug dependence or addiction will develop in adulthood.

Ammerman says that the AAP will follow closely what happens in states where marijuana has been legalized both for health and recreation, and it will look carefully at what future evidence suggests. Clearly, there’s still a lot of smoke around this issue.

Previously: To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics
Photo by Paul-Henri S

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