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Addiction, Cancer, Genetics, Public Health, Research, Stanford News

For some African Americans, light smokers may not have lower lung cancer risk than heavy ones

For some African Americans, light smokers may not have lower lung cancer risk than heavy ones

CigaretteAlthough the relationship between smoking and lung cancer has been established beyond any doubt, it’s still difficult to know how a patient’s ethnicity might play into risk assessment. But it’s clear that it has a role. Lung cancer is the leading cause of cancer death in this country, and it disproportionately affects African Americans. Doctors are struggling to understand the interactions between genes and environment that contribute to lung cancer risk in all populations.

Physician scientist Sean David, MD, DPhil, and a multidisciplinary team of colleagues recently published in EBioMedicine the results of a study suggesting that African Americans who carry a panel of risky genetic sequences may be at higher risk for the disease, even if they are light smokers.

The study involved analyses of more than 7,000 Women’s Health Initiative participants and nearly 2,000 participants in a lung cancer case-control study with collaborators from multiple institutions in the United States.

As David explained to me in an email:

All smokers are at heightened risk for lung cancer, particularly those possessing high-risk genotypes. Our study suggests that African American light smokers are not at lower risk than heavy smokers if they possess certain genotypes, but that smoking more cigarettes does markedly increase lung cancer risk in individuals without these high-risk genotypes. These conclusions reinforce the message that light or heavy smoking is a risky proposition for African Americans, who can benefit from smoking cessation and evidence-based lung cancer screening services.

The researchers identified six nucleotide changes that appeared to affect the relationship between cigarettes smoked per day and lung cancer risk in African American smokers – all on chromosome 15. Although the nucleotide changes, called single nucleotide polymorphisms, or SNPs, had been associated with lung cancer risk in previous studies, this is the first time the risk has been tied to daily cigarette exposure in African Americans.

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Addiction, Neuroscience, Stanford News

Brain connection influences gambling decisions

Brain connection influences gambling decisions

shutterstock_68220094Let’s say you had $10 and could place a bet with even odds to win or lose $3. Would you take it? What if you had a really good chance of winning a little and a low chance of losing a lot? Or a low chance of a big win with a higher chance of a small loss?

The choices you make in each those scenarios appear to come down to a tract of neurons in your brain. If that neuronal pathway has a lot of fatty insulation – an indication of a strong connection — you’ll make less risky decisions. A less insulated pathway makes it more likely that you will take a bigger risk.

That’s what psychology professor Brian Knutson, PhD, found when he used a relatively new technique to investigate the relationship between two brain regions known as the anterior insula and nucleus accumbens.

“Activity in one brain region appears to indicate ‘Uh oh, I might lose money,’ but in another seems to indicate ‘Oh yay, I could win something,’” Knutson told me.

The tract of neurons Knutson and his team discovered appears to provide a pathway for the more cautious region to dampen the enthusiasm of excitable region.

In my story about the work, I wrote about Knutson’s next steps:

Knutson said that finding the connection between the two regions won’t immediately lead to new interventions for people with gambling problems or other issues relating to risky choices, but it does provide a starting point for studying interventions.

“Now we can start asking interesting questions about impulse control and gambling,” Knutson said. “For example, does the connection change over the course of therapy?”

Previously: Genetics may influence financial risk-taking and Using neuroeconomics to understand how aging affects financial decisions
Photo by Shutterstock

Addiction, Medicine and Society, Pain, Research, Stanford News

Overprescribing of opioids is not just limited to a few bad apples

Overprescribing of opioids is not just limited to a few bad apples

8592523799_0cb9d8f3ff_zMore Americans are now dying of drug overdose each year than car accidents. And the biggest killer among those accidental deaths is prescribed opioids, according to the Centers for Disease Control and Prevention.

The CDC reports the amount of painkillers prescribed and sold in the United States has nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report.

With this public health epidemic of opioid overprescribing and overdose deaths, research has implied the problem is rooted in a small population of prolific prescribers operating out of corrupt “pill mills.”

A California physician was even recently convicted of second-degree murder in connection with the overdose deaths of three patients, in what prosecutors said was the first time a doctor was found guilty of murder for recklessly prescribing drugs.

The California Workers’ Compensation Institute found that 1 percent of prescribers accounted for one-third of schedule II opioid prescriptions and 10 percent accounted for 80 percent of prescriptions.

In a  research letter to JAMA Internal Medicine, the focus of a recemt press release, Stanford researchers investigate whether such disproportionate prescribing of opioids — such as morphine, oxycodone and hydrocodone — occurs in the national Medicare population as well.

The Stanford researchers examined individual prescriber data from the 2013 Medicare Part D (prescription drug coverage) claims data set created by the Centers for Medicare and Medicaid Services. Part D covers about 68 percent of the roughly 50 million people on Medicare, the federal insurance program for Americans who have certain disabilities or are 65 years or older.

While they found that up to 60 percent of opioid prescriptions do come from the top 10 percent of prescribers, they note this is no more skewed than Medicare prescriptions for any other drug.

Opioid prescriptions are concentrated among specialty services for pain, anesthesia, physical medication and rehabilitation. By sheer volume, however, the authors found that general practitioners dominate total prescriptions.

“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions,” writes lead author Jonathan C. Chen, MD, PhD, a Stanford Health Policy VA Medical Informatics Fellow; psychiatrist Anna Lembke, MD; psychiatrist Keith Humphreys, PhD and Nigam H. Shah, MBBS, PhD, a biomedical informatics specialist.

“Efforts to curtail national opioid overprescribing must address a broad swatch of prescribers to be effective,” the authors write.

Previously: Unmet expectations: Testifying before Congress on the opioid abuse epidemic, The problem of prescription opioids: “An extraordinarily timely topic” and Assessing the opioid overdose epidemic
Image by Trevor Butcher

Addiction, Ask Stanford Med, Health Policy, Public Health, Stanford News

Is a proposed ban on smoking in public housing fair?

Is a proposed ban on smoking in public housing fair?

smoking ban sign - 560

Cigarette smoking kills nearly half a million Americans each year, making it the leading preventable cause of death in the United States.

So the Department of Housing and Urban Development thinks it’s time to ban cigarette smoking from some 1.2 million subsidized households across the nation.

HUD Secretary Julián Castro unveiled a proposal last week intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” Castro said, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, PhD, JD, who is a core faculty member with Stanford Health Policy, has researched and written about this issue extensively, including in a 2010 article in The New England Journal of Medicine.

In a piece published yesterday, I asked Mello about her views on the federal smoking ban proposal. A sampling of the Q&A:

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents’ efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous “third-hand smoke” exposure that especially affects babies and small children.

Beth Duff-Brown is communications manager for Stanford Health Policy.

Photo by Getty Images iStock

Addiction, Behavioral Science, Neuroscience

Decisions, decisions: How evolution shaped our decision-making

Decisions, decisions: How evolution shaped our decision-making

Research in neuroscience, psychology, business and economics tells us that a plethora of influences can alter the decisions we make. The author explored some of these factors in a Worldview Stanford course and wrote about them in a Stanford story package, Decisions, Decisions. This post is the last in a series on what she learned. 

evolution

Our brains evolved to get the reward now and worry about consequences later. That, according to Stanford’s Keith Humphreys, PhD, is in part why addiction treatment programs so often fail.

“An alcoholic person will always choose the swift and certain rewards of a drink now over the possible threat of punishment at some future time,” he says.

In my story about how evolution shaped our decisions, I describe a program that allows people with drunken driving arrests to keep driving as long as they prove twice a day that they are sober:

Punishment is mild – a night in jail – but swift and certain if they are caught with alcohol in their bloodstream. And, according to a 2013 study, repeat offenses were down 12 percent where that policy was in effect.

Humphreys said he’d written about this program, to some skepticism. But when he explained evolutionary theory to an assembled group of law enforcement and lawyers he was surprised at how receptive they were.

“The rest of the conference everyone kept telling me that they had never thought about the neurological basis of why addicted offenders do what they do and why criminal justice systems which ignore this reality fail over and over again,” he said.

The story has more about a new initiative within the Stanford Neurosciences Institute in which Humphries and other faculty members are hoping to use neuroscience to influence addiction policies.

Previously: Decisions, decisions: How group dynamics alters decisionsKeith Humphreys: Drug-addiction treatment programs for military families are outdated and “24/7 Sobriety” program may offer a simple fix for drunken driving
Photo from Shutterstock

Addiction, Cancer, Events, Health Policy, Medicine and Society, Public Health

The devil you know: Experts discuss the public-health consequences of e-cigarettes

The devil you know: Experts discuss the public-health consequences of e-cigarettes

e-cigarettesHow do we reduce health risk in the face of harm that can’t be eradicated completely? That’s the question that the medical school’s dean, Lloyd Minor, MD, presented to the audience at Monday’s Health Policy Forum on e-cigarettes — a topic about which he said “intelligent and reasonable people can disagree.”

E-cigarettes are a heavily contested subject in the public-health community. Panelists at this event debated whether the recently developed devices hold promise to help long-time smokers move away from combustible cigarettes, or whether they carry the worrisome potential to re-normalize smoking.

All panelists agreed that those under 21 shouldn’t be using any nicotine delivery devices, and they shared a goal of minimizing general use of harmful health products. They disagreed, however, on what the advent of e-cigarettes means to the accomplishment of those goals.

David Abrams, PhD, a Johns Hopkins clinical psychologist specializing in health psychology, addictions, and tobacco-use behavior, described himself as a harm reductionist. He argued that as an alternative mode of nicotine delivery, e-cigarettes pave the way for saving lives by helping addicted smokers not use traditional cigarettes.

“I do think the evidence is very solid that they are dramatically less harmful than cigarettes…because they absolutely have very low, almost undetectable levels or trace amounts of the top eight carcinogens that are found in cigarettes and they have no carbon monoxide,” he explained.

But a lack of extensive research makes Stanford’s Robert Jackler, MD, and Bonnie Halpern-Felsher, PhD, question whether vaping is actually safe — and a prevalence of candy-flavored e-liquids leaves them concerned for the potential for harm to youth.

“Let me point out that you can smoke [combustible cigarettes] for many years before you get chronic destructive lung disease,” said Jackler, who leads a Stanford research team studying the impact of tobacco advertising, marketing, and promotion. “So while I agree… that they are safer, the presumption that they are safe for teenagers to adopt as opposed to combustible tobacco, we won’t know that for decades.”

In the meantime, he worries that “we’re experimenting with the lungs of teens.”

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Addiction, Health Policy, In the News

Stanford addiction expert: “The country needs to spring into action” on heroin epidemic

Stanford addiction expert: "The country needs to spring into action" on heroin epidemic

What’s underlying today’s heroin epidemic and what can be done about it? That was the focus of the opening hour of KQED’s Forum yesterday morning, and Stanford addiction expert Keith Humphreys, PhD, was one of the panelists who weighed in on the issues. He talked about the connection between painkiller addiction and heroin use, the differences between heroin addicts these days versus those in the 1970s, and the use of Naloxone, which can reverse the effects of opioids. Noting that California recently passed a bill that makes this medication available at pharmacies, he said, “I would encourage anyone who is at risk for overdose, or loves someone who is at risk for overdose to get Naloxone.”

Humphreys also referenced the relative lack of resources that goes into studying the heroin epidemic: “We don’t seem to have the will to take this problem on the way we need to… The country really needs to spring into action. We did on AIDS, and we are not doing it here.”

Previously: Heroin: The national epidemic and A focus on addiction, the country’s leading cause of accidental deathIncreasing access to an anti-overdose drug and A reminder that addiction is a chronic disease

Addiction, Behavioral Science, Genetics, Neuroscience, Research, Stanford News

Found: a novel assembly line in brain whose product may prevent alcoholism

Found: a novel assembly line in brain whose product may prevent alcoholism

alcohol silhouette

High-functioning binge drinkers can seem charming and stylish. The ultimate case in point: Nick and Nora of the famed Thirties/Forties “Thin Man” film series (you can skip the ad after the first few seconds).

But alcoholism’s terrific toll is better sighted on city streets than in celluloid skyscraper scenarios. At least half of all homeless people suffer from dependence on one or another addictive drug. (My Stanford Medicine article “The Neuroscience of Need” explores the physiology of addiction.) Alcohol, the most commonly abused of them all (not counting nicotine), has proved to be a particularly hard one to shake.

Alcoholism is an immense national and international health problem,” I wrote the other day in a news release explaining an exciting step toward a possible cure:

More than 200 million people globally, including 18 million Americans, suffer from it. Binge drinking [roughly four drinks in a single session for a man, five for a woman] substantially increases the likelihood of developing alcoholism. As many as one in four American adults report having engaged in binge drinking in the past month.

While there are a few approved drugs that induce great discomfort when a person uses them drinks alcohol, reduce its pleasant effects, or alleviate some of its unpleasant ones, there’s as of yet no “magic bullet” medication that eliminates the powerful cravings driving the addictive behavior to begin with.

But a study, just published in Science, by Stanford neuroscientist Jun Ding, PhD, and his associates, may be holding the ticket to such a medication. In the study, Ding’s team identified a previously unknown biochemical assembly line, in a network of nerve cells strongly tied to addiction, that produces a substance whose effect appears to prevent pleasurable activity from becoming addictive. The substance, known as GABA, acts as a brake on downstream nerve-cell transmission.

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Addiction, Chronic Disease, Pain, Stanford News, Videos

“People are looking for better answers”: A conversation about chronic pain

"People are looking for better answers": A conversation about chronic pain

2048px-Low_back_painChronic pain limits the lives of an estimated 100 million people in one way or another and costs our country half a trillion dollars per year, according to Sean Mackey, MD, PhD, chief of the Division of Pain Medicine. To address the needs of the many people suffering from back pain, the most common kind of chronic pain, Mackey and other doctors and researchers in the division recently held a free Back Pain Education Day.

The event was popular enough that all seats were filled more than a week ahead of time, and a video stream of the day’s speakers was viewed by almost 1,500 people during the conference and in the week following. Recordings of the day’s talks can now be viewed on the Division of Pain’s YouTube channel.

We don’t have a cure for chronic pain. What we have are exceptional ways [to help] people get back their lives

During a recent conversation, Mackey told me the big turn-out reflects the keen interest people living with back pain have in finding solutions. “People are looking for better answers: why they have what they have and what they can do about it,” he said. “We wanted to provide them with real-world tools that they can use to control their pain.”

Speakers at the event covered varied ground, including physical therapy approaches to pain management, new research in using acupuncture to treat pain, self-management strategies, mindfulness-based pain reduction and the important role of sleep in pain. (Recent research has shown that poor sleep can intensify and prolong pain.) One over-riding theme was the role of the brain, Mackey said, not just in terms how people experience pain, but also how it can help turn down or turn up pain.

Mackey cautions that a quick fix often isn’t possible, so people living with chronic pain need to think about long-term management. “It’s a chronic disease, like diabetes. We don’t have cures for diabetes, and we don’t have a cure for chronic pain,” he said. “What we have are exceptional ways to control the disease and ways [to help] people get back their lives.” Speaker Beth Darnall, PhD, the event co-chair, emphasized that pain psychology techniques can empower people to lessen distress and pain, and begin moving toward meaningful life goals.

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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

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