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Addiction, Health Policy, Public Health

Breaking Good: How to wipe out meth labs

Breaking Good: How to wipe out meth labs

methlabEarlier today I testified about methamphetamine laboratories to West Virginia Governor Earl Ray Tomblin’s Advisory Council on Substance Abuse. Like more than a dozen other states in the “meth belt,” my home state is suffering from a wave of explosions, fires, burns, poisonings and environmental destruction stemming from laboratories operated by small-time “meth cooks.”  Fortunately, as I told the Advisory Council, this is a problem that we already know how to solve.

Meth cooks make their drug using pseudoephedrine (PSE), which they extract from certain cold medicines such as Sudafed. The precise proportion of these cold medicines that are purchased to produce methamphetamine is not known, but it is clearly very large. A recent study published in JAMA found that per-capita consumption of PSE-containing medicines in counties with meth labs exceeds that of counties without labs by as much as 565-to-1.

In light of this connection, the states of Oregon and Mississippi returned PSE-containing products to prescription-only status, which was how they were regulated until 1976. Meth labs have virtually disappeared in both states.

Most state legislatures in the meth belt have introduced legislation to copy Oregon and Mississippi’s approach, but these bills have all failed. Part of the reason is intense lobbying by the companies that produce PSE-containing products, but another part is that some voters and legislators believe that cold and allergy sufferers will have a hard time getting relief if a prescription for PSE-containing medications is required.

This worry is not usually well-founded, as there are more than 100 over-the-counter cold medications available which provide relief to almost all people with stuffy noses, fevers and the like. However, in the rare case of an individual who truly needs a PSE-containing medication, innovative biochemistry has come to the rescue with the development of medications that contain PSE that is harder for meth cooks to extract.

These companies created cold medications (e.g., Zephrex-D) which use polymers or lipids to bond with PSE in a fashion that reduces the possibilities for conversions to meth. Even if the possibilities for PSE extraction are reduced by only two-thirds by these new medications, meth cooks would effectively be put out of business because their required materials would exceed the value of the drug they make. Meanwhile, consumers with chronic allergies do not suffer reduced access to PSE-containing products.

The public policy option available to meth belt states is thus something that should satisfy all parties. PSE-containing cold medications would be returned to prescription-status, with an exemption for such medications that independent laboratories prove yield only a de minimus amount of PSE for meth preparation.

It’s a rare opportunity for a clear win-win in public policy. That’s why I strongly encouraged Governor Tomblin’s advisors to pursue it with courage and enthusiasm.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. Dr. Humphreys has no financial or personal connections to any company that produces cold medications (extraction resistant or not).

Previously: Examining how addiction in the U.S. has changed over the last decade, Can an antidepressant help meth addicts stop using?, The Florida Governor’s questionable actions on drugs and Stanford Health Policy Forum focuses on America’s methamphetamine epidemic
Photo by 16 Miles of String

Emergency Medicine, Health Policy, Imaging, Pregnancy, Research, Stanford News

Studying the best approach to diagnosing appendicitis in pregnant women

Studying the best approach to diagnosing appendicitis in pregnant women

OLYMPUS DIGITAL CAMERAWhen it comes to pregnant women, managing abdominal pain and diagnosing appendicitis can be a tricky proposition for doctors. Current practice includes an ultrasound followed by further imaging if the diagnosis remains unclear, but some providers and patients are hesitant to use one common imaging tool – a CT scan. That’s because of its use of radiation, and its possible risk to the fetus.

Zachary Kastenberg, MD, is a general surgery resident at Stanford and reports that he and his colleagues encounter this issue relatively frequently in the emergency department. “We often find ourselves guiding expecting mothers and fathers through difficult, anxiety-provoking decisions with minimal evidence to support differing practitioner perspectives,” he recently told me, noting that acute appendicitis is the most common cause of non-obstetric surgery in pregnant women.

Kastenberg said he wanted to help “influence the management and diagnosis of abdominal pain in pregnant women and to inform practitioners regarding the relative risks of abdominal imaging and fetal radiation during pregnancy.” And so he and colleagues performed a comprehensive cost-effectiveness analysis of the diagnostic strategies for appendicitis during pregnancy. Using a computer-based model, the researchers examined the costs and short- and long-term risks of the interventions, and various quality-of-life measures across the lifetime of a cohort of 25-year-old mothers-to-be and their fetuses.

What the researchers found was that in the vast majority of cases, preoperative imaging is the most prudent choice for managing pregnant women with suspected appendicitis. They also determined that magnetic resonance imaging (MRI) – which doesn’t involve radiation – is the most cost-effective diagnostic strategy, and that CT – even when taking into consideration the potential risks of radiation-associated childhood cancer – is a cost-effective option when MRI isn’t available. The latter finding is particularly important for those hospitals (usually smaller or rural ones) that don’t have an MRI machine or access to skilled MRI interpretation at night or on weekends.

Kastenberg acknowledged that patients may still experience anxiety associated with radiation exposure. But he says he hopes the analysis “will give physicians the confidence to guide patients through an educated discussion of the risks and benefits of preoperative imaging, including CT, when confronted with this difficult clinical situation.”

Kastenberg is a post-doctoral fellow in Stanford’s Center for Health Policy and the Center for Primary Care and Outcomes Research. The research appears in the October issue of the Journal of Obstetrics and Gynecology.

Photo by Daquella Manera

Health Policy, Medicine and Literature, Patient Care, Stanford News

Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient”

Abraham Verghese on health-law battle: "We’ve worried so much about the process, not the patient”

In the ongoing political struggle over the implementation of the Affordable Care Act, a key component - the patient - remains under-discussed, argues Abraham Verghese, MD, a professor of medicine at Stanford. Verghese recently gave a talk at the University of Denver, and his thoughts on the new law, and his call for judicious use of medical tests and procedures, and attention to bedside manner, were among the topics of discussion. Barbara Ellis of the Denver Post reported in a blog piece earlier this week:

“We’ve worried so much about the process, not the patient,” Verghese said. “If the purpose of Obamacare is to help people get health insurance; if its purpose is to not punish people with pre-existing conditions; if its purpose is to promote quality health care … then what’s so bad about it?”

“Whatever Obamacare does, it will put a premium on not ordering medical tests willy-nilly,” he said. “It will force physicians to come up with a rational idea of what to do next.”

Verghese also talked about technology and how it can improve the quality of care, so long as physicians address the patient first. “A physical exam is a ritual. Someone is telling me their intimate details, allowing themselves to be touched,” he said, according to the Post. “That’s a ritual that’s important to patient care.”

Previously: Abraham Verghese’s Cutting for Stone: Two years as a New York Times best sellerA call for extended bedside-manner training and Can the use of devices among physicians lead to “distracted doctoring?”

Events, Health Policy, Mental Health, Patient Care, Stanford News

Upcoming Stanford Health Policy Forum to focus on mental illness

Upcoming Stanford Health Policy Forum to focus on mental illness

The horrifying mass murders at the Washington Navy Yard and Sandy Hook Elementary School were both committed by individuals with long-standing mental-health problems. The events galvanized a national discussion about how to improve the accessibility and quality of our mental-health system.

At the same time, these tragedies can paint in the mind of the public a false image of the mentally ill as universally violent and dangerous rather than human beings in need of assistance and compassionate care. That may account for why a shamefully large number of mentally ill people are behind bars. L.A. County Sheriff Lee Baca has found himself heading what he calls “the nation’s largest mental hospital:” The L.A. County Jail.

While protecting public safety is a critical concern, it’s important to maintain perspective when analyzing the role of mental illness in violent crime. Harold Pollack, PhD, of the University of Chicago puts it this way:

Millions of Americans suffer from some form of severe mental illness, or SMI. It’s important to remember that the vast majority of these men and women have never committed a violent crime and never will commit one. Indeed, the mentally ill are often victims of violent crime, a social problem that has not received sufficient attention.

To dig into these important issues in a productive way, the medical school’s next Health Policy Forum will be devoted to the topic “Serious Mental Illness: How can we balance public health and public safety?” Harold Pollack and Lee Baca will come to Stanford for the forum and will be joined by our own Laura Roberts, MD, chairman of the Department of Psychiatry and Behavioral Sciences. The policy forum is open to the public and will be held this Thursday from 11:30 A.M. to 1:00 P.M, at the Li Ka Shing Center. If you’re a local reader, we hope you can attend and join in the conversation.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Examining mental health policies in the wake of school shooting tragedy, Probing the underlying physiological causes of mental illness

Health Policy, Public Health, Stanford News

One in four California children live in poverty – and other bleak statistics from new Stanford index

One in four California children live in poverty - and other bleak statistics from new Stanford index

Stanford just released its new poverty index for California, and the statistics are grim. Among the eye-popping numbers: 25 percent of all children here live in poverty, as well as 30 percent of the state’s immigrant population. Expensive housing, especially in urban areas, and a weak job market are among the contributor factors.

A Stanford News story today discusses more of the findings and their significance:

Under the new measure, 22 percent of Californians live in poverty, and that figure would be even higher if not for the state and federal safety nets, including CalFresh, the state’s food stamp program; CalWORKs, the state’s cash assistance program; and the federal Earned Income Tax Credit.

If these programs were not in place, the child poverty rate would increase by another 12 percentage points, raising it from nearly 25 percent to nearly 37 percent of all children.

The research helps to establish that California, often thought of as the land of plenty, is “in fact the land of poverty,” [David Grusky, PhD, a sociology professor who serves as the director of Stanford's Center on Poverty and Inequality] said.  It also shows, he said, that those who “want to cut back the food stamp program have to own up to the poverty-increasing effects of that change.”

“We developed the California Poverty Measure because we can’t have a meaningful policy debate in this state without knowing how proposed changes in policy will affect the lives of real Californians,” he said.

Previously: Doctors tackling child hunger during the summer, U.S. Census Bureau releases new data on income, poverty, and health insurance coverage and Food stamp use shows scope of child poverty

Health Policy, Mental Health, Patient Care, Stanford News

Addressing psychiatric “bus therapy” and its underlying problems

Addressing psychiatric "bus therapy" and its underlying problems

4756317503_2afb86be75In the current issue of JAMA Psychiatry, Stanford’s Smita Das, MD, PhD, MPH, a researcher in psychiatry and behavioral sciences, and Judith Prochaska, PhD, MPH, an associate professor of medicine with the Stanford Prevention Research Center, have an editorial (subscription required) on the resurgence of “bus therapy” – the practice of under-resourced state psychiatric hospitals handing patients a one-way ticket out of town to become another state’s responsibility.

Das and Prochaska write that the problem of patient dumping isn’t new; rather, it gained attention during the 1970s after mental health disorders were deinstitutionalized but measures weren’t established to meet the needs of displaced people seeking care.

The piece notes that the problem has been exacerbated by cuts to non-Medicaid state mental health spending in 29 states and Washington, D.C. during 2009-2012, and that one particularly struggling state – Nevada – has bused more than 1,500 patients in the last five years to California, most of them to San Francisco or Los Angeles. (The New York Times also recently reported on this issue.)

The authors set the scene with a typical case of a psychiatric patient relegated to bus therapy and sent to San Francisco:

He is brought to the county psychiatric emergency service, which, hectic and often over capacity, treats nearly 6000 patients annually (of which 39% are not San Francisco residents). The patient needs housing, a psychiatrist, case manager, primary care provider, and transfer of Medicaid or general assistance—a package known colloquially as the San Francisco Special. Placements are challenging—the county hospital reduced its acute in-patient psychiatry capacity 50% in the last 5 years owing to budget shortfalls—yet out-of-state visitors are not turned away.

In the editorial, Das and Prochaska argue that current reshaping of health care spending and guidelines makes for an ideal time to address patient dumping and find solutions to the practice’s underlying causes, and she suggests increasing mental health budgets, transitional interventions, and proven methods of health-care delivery such as telemedicine and group therapy to serve patients and reduce provider burnout.

“This is a relevant and timely issue as the country is experiencing healthcare changes and feeling the impact of low resources in mental health,” Das said in an e-mail. “We hope more providers, administrators and policy makers take note of ‘bus therapy’ as an example of one of the many signs that we need to pay more attention to mental health.”

Photo by Vincent Desjardins

Health Policy, In the News, Nutrition

A discussion of the confusion surrounding “natural” foods

A discussion of the confusion surrounding "natural" foods

Natural foodIf you’ve ever wondered how an organic food item differs from a natural food item, you’ve got good company. This weekend in the San Francisco Chronicle, nutrition and public policy expert Marion Nestle, PhD, MPH, of New York University, addressed a reader’s question related to food labels and how they could be changed to make them easier to understand.

Nestle discusses the the complexity and controversy that surround food labels on her blog, Food Politics, and offers some ideas on how they could be changed for the better in her Chronicle column, Food Matters (subscription required).

From her blog post:

While “natural” does not necessarily mean “healthy” or even “healthier,” it works splendidly as a marketing term and explains why many junk-food manufacturers are switching from expensive organic ingredients to those they can market as “natural.”

The FDA isn’t fixing this situation because, according to a statement in response to a petition by Center for Science in the Public Interest, it’s “not an enforcement priority.”

Manufacturers of highly processed foods could not be happier with this nondecision.

In her blog, Nestle noted that people often use “organic” and “natural” interchangeably. She wrote, “if the public really can’t tell the difference between “natural” and “organic,” the closer the definition of “natural” is to that of “organic,” the less confused they will be.”

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Want kids to eat their veggies? Researchers suggest labeling foods with snazzy namesWill redesigning food labels help consumers revamp their eating habits? Organic vs. natural: Tips for parents who want to go green“Natural” or not, chicken nuggets are high in fat, sodium and Study finds fast-food menu calorie counts confusing for consumers
Photo by qmnonic

Addiction, Health Policy, Public Health, Public Safety

How police officers are tackling drug overdose

police car

Drug overdose is now the most common cause of accidental death in the United States, primarily because of the vastly increased availability of pharmaceutical-grade opioids (e.g., Oxycodone, Vicodin). The size and impact of the epidemic can be lessened by a range of public policies, including one that the White House has been touting: Equipping first responders with naloxone hydrochloride.

In opioid overdose, breathing slows to a very low level or even stops completely, which deprives the brain of oxygen. Death or permanent organ damage can be the horrifying result. Enter naloxone, an old, off-patent (and hence inexpensive) medication with a powerful ability to force opioids out of brain receptors. Overdose is thus rapidly reversed.

Naloxone does not cure addiction. Nor does its effect last more than 30-90 minutes. However, that window of time can be used to get the overdosed person to a hospital and subsequently it is hoped into addiction treatment.

Police officers and fire fighters are often the people who discover people who have overdosed. They typically call for medical backup in such cases, but even if the EMTs take only 15 minutes to arrive, that can be too late. Training in how to recognize overdose and to then administer naloxone allows those first responders to save lives that would otherwise be lost.

Police in Quincy, Massachusetts began carrying naloxone in their cruisers in October of 2010, and have been reversing about one overdose every ten days since. Police and firefighters in other parts of the country are now copying Quincy’s successful approach.

The Obama Administration’s embrace of improving naloxone’s availability is one of many signs of how quickly U.S. drug policy has moved in a public health direction. Only a few years ago, drug policy officials in the G.W. Bush Administration condemned the use of naloxone. Today, Obama drug policy officials give out awards to successful naloxone access expansion programs. The result will be fewer overdose and more chances for people with addictions to receive the help they need to become healthy and productive.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington.

Previously: Do opium and opioids increase mortality risk?
Photo by Scott Davidson

Addiction, Cancer, Chronic Disease, Health Policy, Research, Stanford News

Stanford study: Higher tobacco taxes associated with reduced alcohol consumption

Stanford study: Higher tobacco taxes associated with reduced alcohol consumption

beer-cigaretteTobacco and alcohol are a troublesome pairing. Since smoking enhances the addictive effects of alcohol – and vice versa – people tend to drink and smoke more when these drugs are used together. But new research suggests that it may be possible to exploit the link between tobacco and alcohol to reduce their use.

A Stanford-led team of researchers found that increases in tobacco taxes were associated with lower alcohol consumption among certain groups of people. This finding suggests that an increased tobacco tax may simultaneously reduce smoking and alcohol consumption.

I corresponded with the study’s lead author, Stanford postdoctoral student Kelly Young-Wolff, PhD, to find out more about the recently published study and how the findings might be applied to efforts to control cigarette and alcohol use.

“Cigarette taxes have broad population reach and have been recognized as one of the most significant policy instruments to reduce smoking,” Young-Wolff told me. “Given the high co-occurrence of drinking and smoking, we hypothesized that the public health benefits of cigarette taxes would extend beyond smoking to reduce alcohol consumption.”

Using data from a prospective, longitudinal survey of U.S. adults, the team tested their theory by examining whether increases in cigarette taxes were associated with reductions in alcohol consumption across two periods of data collection (2001-2002 and 2004-2005). State tobacco taxes increased between the first and second time period for about half of the participants (10,936 of 21,473 people living in 31 of 46 states included in the study), which gave the researchers a way to assess whether or not higher tobacco taxes were associated with alcohol consumption.

In their study, published online last Friday in Alcoholism: Clinical and Experimental Research, the team found that smokers living in states with increased tobacco taxes tended to drink less. The result was most pronounced for male smokers – particularly among groups of males who drank heavily, were young, or had lower incomes.

Since tobacco and alcohol use is linked, it’s unsurprising that they rank first and third (respectively) on the list of most preventable causes of death, according to the Centers for Disease Control. “The co-occurrence of smoking and drinking is of particular clinical significance given evidence that health consequences increase with combined versus singular abuse of alcohol and tobacco,” explained Young-Wolff. Yet, despite the known link between tobacco and alcohol use, relatively few studies have explored ways a tougher tobacco tax could affect the use of these two addictive substances.

The new results suggest that the beneficial effects of increased tobacco taxes could spread beyond the sale, purchase and use of tobacco products. “Our finding that increases in cigarette taxes may have the added public health benefit of reducing alcohol consumption among vulnerable segments of the population is promising, and it highlights the importance of research that targets the interactions of tobacco and alcohol,” Young-Wolff explained.

This study could set the stage for researchers to investigate other possible second-hand benefits of increased tobacco taxes, such as reductions in alcohol-related violence, drunk driving, and alcohol-related illness and death, Young-Wolff continued. “Our results add to evidence of the public health benefits of cigarette taxes, which have already been shown to reduce smoking, and can be brought to the policy debates to more fully capture the public health effects of cigarette taxes for prevention and treatment.”

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Stanford professor shares potential downside of an increased tobacco tax, Kicking the smoking habit for good and How have U.S. tobacco regulations affected smokers?
Photo by Office on Women’s Health

Addiction, Cancer, Health Policy, In the News

Stanford professor shares potential downside of an increased tobacco tax

Stanford professor shares potential downside of an increased tobacco tax

Cigarette lightOver on the Huffington Post today, Stanford professor Keith Humphreys, PhD, raises several issues related to the proposed increase of federal tobacco taxes. The thrust of Humphrey’s argument is that a heftier tobacco tax may reduce the observed smoking rate, but it won’t reduce the actual use of cigarettes in America.

According to Humphreys, the U.S. policy on illegal drugs and its effect on illegal drug use provides useful insights on how an increased tobacco tax could influence cigarette use. And he describes in his article how extremely high tobacco costs could expand black markets:

Extremely high cigarette taxes are widely evaded. Professor David Merriman of the University of Illinois at Chicago organized teams of apparently non-squeamish research assistants to gather discarded cigarette packs from garbage cans and sidewalks in 100 Chicago neighborhoods. He discovered that 75 percent had no tax stamp, indicating a black market or grey market provenance.

An across-the-board increase in federal tobacco taxes would not only expand black markets in high-tax areas, it would also do nothing to address the widespread smuggling of cigarettes to high tax states from states where cigarette taxes are ridiculously low. Such smuggling is not driven by cash-strapped college kids with a few cartons in their backpacks. Organized crime groups, and even terrorist organizations, are the big players in the lucrative trade.

The challenge for federal tax policy on cigarettes therefore is to avoid feeding black markets in high-tax states, to shrink cross-state tobacco smuggling operations, and, to increase tobacco taxes in those states where taxes have room to grow without creating black markets. A flat increase in the tobacco tax cannot serve all three goals, but a more creative tax policy could.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Smoking rates increasing in the developing world, Study shows anti-tobacco programs targeting adults also curb teen smokingStudy shows smoking bans decrease kids’ exposure to secondhand smokeAustralia enacts world’s first ban on branded cigarette packaging and A conversation about the FDA’s new graphic health warnings for cigarettes
Photo by My Huy Streetphotography

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