Editorial pages focus on these public health topics and others.
Read recent commentaries about drug-cost issues.
News outlets report on stories related to pharmaceutical pricing.
Media outlets report on news from Massachusetts, Texas, New Hampshire, Missouri, North Carolina, Florida, California, Hawaii and Ohio.
While hospitals in Texas, New Jersey, Oregon, Virginia, and Massachusetts have the the highest percentage of “A” graded hospitals. Leapfrog grades are based on 28 factors, including responsiveness of staff, doctor procedures and outcome measures.
“What we do know is that these patients had fever and respiratory symptoms three to 10 days before their limb weakness,” CDC’s Dr. Nancy Messonnier told The Associated Press. “And we know that it’s the season where lots of people have fever and respiratory symptoms. What we need to sort out is what is the trigger for the [acute flaccid myelitis].”
“I see no one from the @nra next to me in the trauma bay as I have cared for victims of gun violence for the past 25 years,” one doctor wrote in response to NRA’s suggestion. “THAT must be MY lane. COME INTO MY LANE. Tell one mother her child is dead with me, then we can talk.”
A ProPublica investigation shines a light on Oregon’s unique process of reviewing the cases of defendants found not guilty by reason of insanity. About 35 percent of the people in that category were charged with new crimes within three years of being freed by state officials.
“It’s just earthshaking for all of us, you know?” said Chico resident Tammy Mezera. Other news on the fires report on the searches for victims, the technology being used to identify the dead, closures caused by poor air quality and the expected impact on everyone’s pocketbooks.
The Johnson & Johnson subsidiary that New Jersey says minimized the risks of opioid addiction in its marketing messages is based in the state. “It is especially troubling that so much of the alleged misconduct took place right here in our own backyard,”said Gurbir Grewal, the New Jersey attorney general, at a news conference announcing the legal action. “New Jersey’s pharmaceutical industry is the envy of the world, with a long history of developing vital, lifesaving drugs. But we cannot turn a blind eye when a New Jersey company like Janssen violates our laws and threatens the lives of our residents.” Meanwhile, Naloxone can be a lifesaving drug, but not all pharmacies are on board with offering it. News on the epidemic comes out of Oregon, Kansas, New Hampshire and California, as well.
Today’s early morning highlights from the major news organizations.
When she was in her early 20s, Nicole Veum says, she made a lot of mistakes.
“I was really sad and I didn’t want to feel my feelings,” she said. “I turned to the most natural way I could find to cover that all up and I started using drugs: prescription pills, heroin for a little bit of time.”
Veum’s family got her into treatment. She’d been sober for nine years when she and her husband, Ben, decided to have a baby. Motherhood was something she wanted to feel.
If she needed an epidural during labor, Veum told her doctor, she didn’t want any fentanyl in it. She didn’t want to feel high.
“I remembered seeing other friends,” she said. “They’d used it, and they were feeling good and stuff. I didn’t want that to be a part of my story.”
An epidural is a form of regional anesthesia given via an injection of drugs into the space around the spinal cord. It is typically a mix of two types of medication: a numbing agent, usually from the lidocaine family, and a painkiller, usually fentanyl.
The amount of fentanyl in the mix is limited, and little passes into the bloodstream, anesthesiologists say. But if a woman doesn’t want the fentanyl, it’s easy to formulate an epidural solution without it. Doctors either use a substitute medication or boost the concentration of the numbing agent.
“There’s no medical reason why someone should be forced to be exposed to opioids if they don’t want to,” said Dr. Kelly Pfeifer, a family physician and addiction expert who now works as director of high-value care at the California Health Care Foundation. (Kaiser Health News produces California Healthline, an editorially independent publication of the California Health Care Foundation.)
Pfeifer said there’s another situation to be aware of: pregnant women who are taking methadone or suboxone to manage opioid addiction. During labor, anesthesiologists often prescribe narcotics to help manage pain, but some of those commonly used — like Nubain — can immediately reverse the effects of methadone or suboxone.
“Suddenly, you’re in the middle of labor — which is already painful — and now you’re in the middle of the worst withdrawal of your life,” Pfeifer said.
For Veum, one of the worst wildfires in California’s recorded history is what interrupted her birth plan. She and her husband live in Santa Rosa, Calif., and she was in active labor when devastating fires ignited nearby on Oct. 8, 2017. What are now known as the “Wine Country Wildfires” burned more than 5,000 homes and killed 44 people.
“There was a ton of smoke in the hospital,” Veum said. “Like you could visibly see it outside — and smell it.”
Nurses told her everybody had to evacuate. Veum was transferred to another hospital, 5 miles away. And the special instructions for her epidural got lost in the chaos.
“Then, when they went to change the drug, I saw the tube said ‘Fentanyl’ on it,” she recalled. “And by that point I was starting to feel ‘the itchies’” — one of the familiar physical signs she would experience when starting to get high.
Most women without a history of addiction wouldn’t experience these sensations when given opioid anesthesia, said Dr. Jennifer Lucero, chief of obstetric anesthesiology at the University of California-San Francisco Medical Center. Anytime a woman who is not in recovery asks for an epidural without fentanyl (usually out of the mom’s concern for the baby), Lucero explains why it’s there.
The fentanyl allows the anesthesiologist to balance out the numbing agent in the solution, she said, so women don’t have as much pain from the contractions but can still feel the pressure and are able to move their legs a bit or shift in bed during labor.
Once she explains the trade-offs, and assures women that the opioid will have no effect on their fetus, most of her patients opt to keep fentanyl in the epidural solution.
But doctors have been trying to cut down on administering opioids in other ways during labor and delivery, namely in what they prescribe for pain after the birth.
For years, women who had a normal, vaginal birth were sent home with a 30-day supply of Norco, Percocet or another opioid, Lucero said.
“Some people would think they’re supposed to take them all,” Lucero said, while other women “would not use it, and it would just be sitting in the bathroom cabinet.”
While most people who get a bottle of pills when leaving the hospital won’t develop dependence or an addiction, some will. When a patient is prescribed opioids for short-term pain, the risk of chronic use starts to increase as early as the third day of the prescription, according to a report published last year by the Centers for Disease Control and Prevention. A study out this year suggests that every week of opioid use increases the risk of misuse.
As recently as 2017, postpartum women were routinely being prescribed three- to five-day supplies of opioids — even after an uncomplicated vaginal delivery. A study published that year of 164,720 Pennsylvania women on Medicaid who gave birth vaginally found that 12 percent of them filled an opioid prescription after they gave birth — even though most did not have a clear medical need for a painkiller, such as vaginal tearing or an episiotomy.
Now obstetricians are issuing new guidelines to patients, Lucero said, and they’re trying to prescribe limited amounts of opioids, and only post-surgically, to women who have had a cesarean section.
Nicole Veum ended up being one of those women. After she was transferred to the second hospital during the wildfire evacuation, she spent another 12 hours in the early stages of labor, but she wasn’t progressing. She agreed to a C-section.
After the birth of her son, doctors sent her home with a bottle of Percocet — another opioid. They told her that if she was worried about being able to maintain her sobriety, she could have her husband or a friend hold on to the bottle and control the dosage.
Pfeifer, the physician and addiction specialist, said that in a situation like that, sending Veum home with just a few Percocet pills, or even suggesting she take only ibuprofen, would have been fine.
“Any parent will tell you there’s nothing more stressful than the first week of being a parent and having a baby and being in sleep deprivation,” Pfeifer said. “And here you have a little bottle of Vicodin that you used to turn to, to make you feel better when you’re stressed.”
First the fires. Then the fentanyl in her epidural. Then the Percocet. It was Veum’s first test in seeing how her sobriety and motherhood would line up. She called a friend who was also in recovery. They talked it all through, and Veum was fine.
“I was OK. I was OK with it. It was just something that happened,” she said as her baby, Adrian, now a year old, plays with a new toy.
Veum is 32 now. She’s returned to school this fall to work toward her college degree, after a 14-year break. And she is loving being a mom.
“A lot of people, metaphorically, felt it as a baby coming out of the ash — the life coming from the ashes,” she said about her child born in the midst of the 2017 wildfires.
“And I feel that,” Veum said. “I feel like it was a big time for our community — and me personally — to be reborn in some way.”
KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.
Editorial pages focus on these health topics and others.
Opinion pages focus on how to help bring about an end to gun violence.
Media outlets report on news from Texas, New York, New Hampshire, Mississippi, Kansas, Missouri and Ohio.
Scientists are warning that Americans should undergo all recommended cancer screenings and adopt lifestyle prevention practices, such as healthy diet and exercise, which are beneficial in lowering both cancer and heart disease mortality. In other public health news: fecal transplants, a rare polio-like illness, concussions, microbes, contraception, and conversion camps.
“One kid in every classroom has some sort of food allergy,” said Dr. Scott Commins, an allergist and immunologist at the University of North Carolina at Chapel Hill. “You put it on that sort of scale, you realize that we’re dealing with a huge issue that doesn’t seem to be going away.” Meanwhile, the FDA is considering adding sesame to the list of possible allergens that labels have to carry.
Insiders have long worried privately about the lifestyle of people who work in the restaurant industry, which has one of the highest rates of illicit drug use and alcoholism and a tradition of masking mental-health struggles. In other news on mental health: farmers devastated by Florence are especially vulnerable to depression and judges are starting to favor outpatient treatment over hospitalization.
One NFL player, Mike Pouncey, complained to Aaron Hernandez, who was serving a life sentence for murder, that “they don’t even want to give me my Toradol shots anymore.” In another call, former Patriot Brandon Spikes recalled “how they used to pass [painkillers] out on planes.”
Getting a sedentary nation off the sofa — only 20 percent of us get the recommended amount of exercise a day — is a big concern for the government, which updated its guidelines Monday for the first time in 10 years. Since the first guidelines were issued, research has expanded the recognized benefits of movement, including reducing the risk of cancer, anxiety and depression and improving cognitive function and sleep.
Athenahealth has rejected the hedge fund’s attempts to push it into a sale previously. The all-cash deal between the companies values the medical billing software maker at $135 per share.
The death toll climbed over the past day to 42, surpassing the previous record. Hundreds still remain missing, and officials expect more grim news.
Today’s early morning highlights from the major news organizations.
When mental illness hijacks Margaret Rodgers’ mind, she acts out.
Rodgers, 35, lives with depression and bipolar disorder. When left unchecked, the conditions drive the Alabama woman to excessive spending, crying and mania.
Last autumn, Rodgers felt her mind unraveling. Living in Birmingham, she was uninsured, unable to afford treatment and in the throes of a divorce. Although Rodgers traveled south to her brother’s house in Foley, Ala., for respite, she couldn’t escape thoughts of suicide, which one day led her to his gun.
“I hit bottom,” she recalled. But she didn’t pull the trigger.
Rodgers told her brother about the close call. News of the incident reached her mother, who then alerted authorities to Rodgers’ near attempt.
Within days, Rodgers was handcuffed and hauled in front of a judge who ordered her to undergo mental health treatment — but not a hospital commitment. Instead, the judge mandated six months of care that included weekly therapy sessions and medication, all while Rodgers continued living with her family.
Rodgers entered assisted outpatient treatment, also known as involuntary outpatient commitment.
Since its inception, the court-ordered intervention has generated controversy. Proponents say it secures the comprehensive care that people with severe mental illnesses might not recognize they need. Yet other health experts question the effectiveness of the intervention and suggest it represents a quick fix in a mental health system that is not adequately serving patients.
“It’s a stopgap measure that works in the short term,” said Dr. Annette Hanson, director of the University of Maryland Forensic Psychiatry Fellowship, who co-authored a book on the intervention. “But it’s not a good long-term solution because you still have lots of people who need voluntary care who can’t get” it.
Assisted outpatient treatment requires a judge’s order. While the eligibility requirements and compliance standards vary by state, participants typically have a history of arrests and multiple hospitalizations. They stay in their communities while undergoing treatment.
The American Psychiatric Association endorsed its use in 2015, saying assisted outpatient treatment has generally shown positive outcomes under certain circumstances. To effectively treat patients, the position paper said, the APA recommends that the intervention be well-planned, “linked to intensive outpatient services” and last for at least 180 days.
A key advantage to assisted outpatient treatment, supporters say, is that it provides care for people who might not recognize the severity of their illness.
A court’s involvement also increases the likelihood of a participant complying with the program, a phenomenon called the “black robe effect,” they add.
“That is really what we’ve found to be the secret sauce” for success, said John Snook, executive director of the nonprofit Treatment Advocacy Center.
But many areas do not have the necessary community mental health services to provide assisted outpatient treatment effectively, said Ira Burnim, legal director for the Judge David L. Bazelon Center for Mental Health Law.
He also said the law already provides options for hospital treatment for people considered a danger to themselves or others. Any person recommended for assisted outpatient treatment for these reasons should be in a hospital receiving intensive inpatient care, Burnim said, not in the community.
“You know, when people don’t take their medication,” he said, “that’s a clinical problem, not a legal problem.”
Most States Allow The Programs
Assisted outpatient treatment gained popularity after Andrew Goldstein, who was diagnosed with schizophrenia but wasn’t taking his medication, pushed Kendra Webdale in front of an oncoming train in New York City in 1999, killing her. Webdale’s family fought for a change in the law after learning that Goldstein had repeatedly refused treatment while living on his own.
Today, 47 states and the District of Columbia have laws allowing localities to set up assisted outpatient treatment, according to the Treatment Advocacy Center, a nonprofit group that strongly supports assisted outpatient treatment.
Yet, there is no tally of the number of programs or the number of people involuntarily placed in one, said David DeVoursney, chief of the Community Support Programs Branch at the Substance Abuse and Mental Health Services Administration.
There is also little research on its effectiveness. Two randomized studies produced contradictory results about the intervention’s effect on hospitalization rates and the number of arrests afterward. However, other analyses have shown improved outcomes, particularly among participants in New York.
Despite the ambiguity, Congress created grants in 2014 that made up to $60 million available over four years to new assisted outpatient treatment programs. Additionally, the 21st Century Cures Act, passed in 2016 to accelerate drug development, allowed some Department of Justice funding for the intervention.
Experts acknowledge that the scarcity of mental health providers and treatment options causes many patients to go without care. Instead of doctors’ offices, many people with mental illnesses end up in jail — an estimated 2 million every year, according to the National Alliance on Mental Illness.
“What we say very often is basically we have a system that allows people to have heart attacks over and over again,” Snook said. “And then once they have that heart attack, we take them to jail. And then we wonder why the system isn’t working.”
A Morning Surprise
One recipient of federal funding is AltaPointe Health Systems Inc., a community health center that provides services to residents — including Rodgers — in two Alabama counties. The program has received nearly $1.1 million in federal funding, according to Cindy Gipson, assistant director of intensive services.
She said the center applied for the federal grant to reduce the number of hospitalizations among residents living with severe mental illnesses.
“We were having a lot of people who would go to the hospital, then be discharged,” she said. “And they’d do well for a couple of weeks — maybe even a month. Then, they’d go right back in.”
The program, which began in 2017, has served 71 patients, Gipson said. On average, patients stay about 150 days. And roughly 60 percent of referrals come from family members, she said. The majority of people entering have a history of multiple hospitalizations and arrests.
Rodgers said she had never been in handcuffs before the day the Alabama police officer came to her brother’s home and awakened her around 7 a.m. The sheriff gave her five minutes to change and brush her teeth. He then cuffed her wrists, placed her in the back of his car and drove her straight to court. After she was asked a few questions about how she was doing, Rodgers said, she sat down in front of a judge and learned about assisted outpatient treatment for the first time.
Despite how she entered care, Rodgers said the mandated treatment has brought her stability. She sees a therapist once a week, and once a month a nurse at the community health center administers a shot of the antipsychotic drug Abilify. She now is working part time cleaning condos and lives with her mother. She said she has learned strategies to not dwell on the past.
After her first six months of treatment, Rodgers and her care team decided to continue care through the rest of the year. She plans to return to Birmingham and find a better job after completing the program.
Right now, she said, “staying positive is the main thing I want.”
If patients return to Dr. Crystal Bowe soon after taking medication for a sexually transmitted infection, she usually knows the reason: Their partners have re-infected them.
“While you tell people not to have sex until both folks are treated, they just don’t wait,” she said. “So they are passing the infection back and forth.”
That’s when Bowe, who practices on both sides of the North and South Carolina border, does something doctors are often reluctant to do: She prescribes the partners antibiotics without meeting them.
Federal health officials have recommended this practice, known as expedited partner therapy, for chlamydia and gonorrhea since 2006. It allows doctors to prescribe medication to their patients’ partners without examining them. The idea is to prevent the kind of reinfections described by Bowe — and stop the transmission of STDs to others.
However, many physicians aren’t taking the federal government’s advice because of entrenched ethical and legal concerns.
“Health care providers have a long tradition of being hesitant to prescribe to people they haven’t seen,” said Edward Hook, professor at the University of Alabama’s medical school in Birmingham. “There is a certain skepticism.”
A nationwide surge of sexually transmitted diseases in recent years, however, has created a sense of urgency for doctors to embrace the practice. STD rates have hit an all-time high, according to the Centers for Diseases Control and Prevention. In 2017, the rate of reported gonorrhea cases increased nearly 19 percent from a year earlier to 555,608. The rate of chlamydia cases rose almost 7 percent to 1.7 million.
“STDs are everywhere,” said Dr. Cornelius Jamison, a lecturer at the University of Michigan Medical School. “We have to figure out how to … prevent the spread of these infections. And it’s necessary to be able to treat multiple people at once.”
A majority of states allow expedited partner therapy. Two states — South Carolina and Kentucky — prohibit it, and six others plus Puerto Rico lack clear guidance for physicians.
A 2014 study showed that patients were as much as 29 percent less likely to be re-infected when their physicians prescribed medication to their partners. The study also showed that partners who got those prescriptions were more likely to take the drugs than ones who were simply referred to a doctor.
Yet only about half of providers reported ever having prescribed drugs to the partners of patients with chlamydia, and only 10 percent said they always did so, according to a different study. Chlamydia rates were higher in states with no law explicitly allowing partner prescriptions, research published earlier this year showed.
Because of increasing antibiotic resistance to gonorrhea, the CDC no longer recommends oral antibiotics alone for the infection. But if patients’ partners can’t go in for the recommended treatment, which includes an injection, the CDC said that oral antibiotics by themselves are better than no treatment at all.
“Increasing resistance plus increasing disease rates is a recipe for disaster,” said David Harvey, executive director of the National Coalition of STD Directors. The partner treatment is important for “combating the rising rates of gonorrhea in the U.S. before it’s too late.”
The CDC recommendations are primarily for heterosexual partners because there is less data on the effectiveness of partner treatment in men who sleep with men, and because of concern about HIV risk.
Bowe said that even though she writes STD prescriptions for her patients’ partners, she still worries about possible drug allergies or side effects.
“I don’t know their medical conditions,” she said. “I may contribute to a problem down the road that I’m going to be held liable for.”
In many cases, doctors and patients simply do not know about partner therapy. Ulysses Rico, who lives in Coachella, Calif., said he contracted gonorrhea several years ago and was treated by his doctor. He didn’t know at the time that he could have requested medicine for his girlfriend. She was reluctant to go to her doctor and instead got the required antibiotics through a friend who worked at a hospital.
“It would have been so much easier to handle the situation for both of us at the [same] moment,” Rico said.
Several medical associations support partner treatment. But they acknowledge the ethical issues, saying it should be used only if the partners are unable or unwilling to come in for care.
Federal officials are trying to raise awareness of the practice by training doctors and other medical professionals, said Laura Bachmann, chief medical officer of the CDC’s office of STD prevention. The agency posts a map with details about the practice in each state.
Over the past several years, advocates have won battles state-by-state to get partner treatment approved, but implementation is challenging and varies widely, said Harvey, whose National Coalition of STD Directors is a member organization that works to eliminate sexually transmitted diseases.
The fact that some states don’t allow it, or haven’t set clear guidelines for physicians, also creates confusion — and disparities across state lines.
The Planned Parenthood affiliate that serves Indiana and Kentucky sees this firsthand, said clinical services director Emilie Theis. In Indiana, providers can legally write prescriptions for their patients’ partners, but they are prohibited from doing so in Kentucky, even though the clinics are only a short drive apart, she noted. A similar dynamic is at play along the South Carolina-North Carolina border, where Bowe practices.
California started allowing partner treatment for chlamydia in 2001 and for gonorrhea in 2007. The state gives medication to certain safety-net clinics, a program it expanded three years ago. However, “it has been an incredibly difficult sell” because many medical providers think “it’s a little bit outside of the traditional practice of medicine,” said Heidi Bauer, chief of the STD control branch of California’s public health department.
At APLA Health, which runs several health clinics in the Los Angeles area, nurse practitioner Karla Taborga occasionally gives antibiotics to patients for their partners. But she tries to get the partners into the clinic first, because she worries they might also be at risk for other sexually transmitted infections.
“If we are just treating for chlamydia, we could be missing gonorrhea, syphilis or, God forbid, HIV,” Taborga said. But if prescribing the drugs without seeing the patients is the only way to treat them, she said, “it’s better than nothing.”
Edith Torres, a Los Angeles resident, said she pressured her then-husband to go to the doctor after he gave her chlamydia several years ago: She refused to have sex with him until he did. Torres said she wanted him to hear directly from the doctor about the risks of STDs and how they are transmitted.
If he had taken the medication without a doctor visit, he wouldn’t have learned those things, she said. “I was scared, and I didn’t want to get it again.”
KHN’s coverage in California is supported in part by Blue Shield of California Foundation.