Tagged Mental Health

Disappointment Surrounding Alzheimer’s Treatment Has Reached Almost Mythical Heights. But Is There A ‘Cabal’ Behind All Those Failures?

For some experts it is increasingly apparent that there is another, more disturbing reason for the tragic lack of progress being made in Alzheimer’s research. A group of researchers had been so determined that one approach would work, few tried anything else. In other pharmaceutical news: AbbVie announces $63 billion deal to acquire Allergan, an analysis finds drugmakers often commit to follow-up studies after approval but few of them are new; and more.

In Secret, Seniors Discuss ‘Rational Suicide’

Ten residents slipped away from their retirement community one Sunday afternoon for a covert meeting in a grocery store cafe. They aimed to answer a taboo question: When they feel they have lived long enough, how can they carry out their own swift and peaceful death?

The seniors, who live in independent apartments at a high-end senior community near Philadelphia, showed no obvious signs of depression. They’re in their 70s and 80s and say they don’t intend to end their lives soon. But they say they want the option to take “preemptive action” before their health declines in their later years, particularly due to dementia.

More seniors are weighing the possibility of suicide, experts say, as the baby boomer generation — known for valuing autonomy and self-determination — reaches older age at a time when modern medicine can keep human bodies alive far longer than ever before.

The group gathered a few months ago to meet with Dena Davis, a bioethics professor at Lehigh University who defends “rational suicide” — the idea that suicide can be a well-reasoned decision, not a result of emotional or psychological problems. Davis, 72, has been vocal about her desire to end her life rather than experience a slow decline due to dementia, as her mother did.

The concept of rational suicide is highly controversial; it runs counter to many societal norms, religious and moral convictions and the efforts of suicide prevention workers who contend that every life is worth saving.

“The concern that I have at a social level is if we all agree that killing yourself is an acceptable, appropriate way to go, then there becomes a social norm around that, and it becomes easier to do, more common,” said Dr. Yeates Conwell, a psychiatrist specializing in geriatrics at the University of Rochester and a leading expert in elderly suicide. That’s particularly dangerous with older adults because of widespread ageist attitudes, he said.

As a society, we have a responsibility to care for people as they age, Conwell argued. Promoting rational suicide “creates the risk of a sense of obligation for older people to use that method rather than advocate for better care that addresses their concerns in other ways.”

A Kaiser Health News investigation in April found that older Americans — a few hundred per year, at least — are killing themselves while living in or transitioning to long-term care. Many cases KHN reviewed involved depression or mental illness. What’s not clear is how many of these suicides involve clear-minded people exercising what Davis would call a rational choice.

Suicide prevention experts contend that while it’s normal to think about death as we age, suicidal ideation is a sign that people need help. They argue that all suicides should be avoided by addressing mental health and helping seniors live a rich and fulfilling life.

But to Lois, the 86-year-old woman who organized the meeting outside Philadelphia, suicides by older Americans are not all tragedies. Lois, a widow with no children, said she would rather end her own life than deteriorate slowly over seven years, as her mother did after she broke a hip at age 90. (Lois asked to be referred to by only her middle name so she would not be identified, given the sensitive topic.) In her eight years at her retirement community, Lois has encountered other residents who feel similarly about suicide. But because of stigma, she said, the conversations are usually kept quiet.

Lois insisted her group meet off-campus at Wegmans because of the “subversive” nature of the discussion. Supporting rational suicide, she said, clashes with the ethos of their continuing care retirement community, where seniors transition from independent apartments to assisted living to a nursing home as they age.

Seniors pay six figures to move into the bucolic campus, which includes an indoor heated pool, a concert hall and many acres of wooded trails. They are guaranteed housing, medical care, companionship and comfort for the rest of their lives.

“We are sabotaging that,” Lois said of her group. “We are saying, thank you very much, but that’s not what we’re looking for.”

Carolyn, a 72-year-old member of the group who asked that her last name be withheld, said they live in a “fabulous place” where residents enjoy “a lot of agency.” But she and her 88-year-old husband also want the freedom to determine how they die.

A retired nurse, Carolyn said her views have been shaped in part by her experience in the HIV/AIDS epidemic. In the 1990s, she created a program that sent hospice volunteers to work with people dying of AIDS, which at the time was a death sentence.

She said many of the men kept a stockpile of lethal drugs on a dresser or bedside table. They would tell her, “When I’m ready, that’s what I’m going to do.” But as their condition grew worse, she said, they became too confused to follow through.

“I just saw so many people who were planning to have that quiet, peaceful ending when it came, and it just never came. The pills just got scattered. They lost the moment” when they had the wherewithal to end their own lives, she said.

Carolyn emphasized that she and her husband do not feel suicidal, nor do they have a specific plan to die on a certain date. But she said that while she still has the ability, she wants to procure a lethal medication that would offer the option for a peaceful end in the future.

“Ideally, I would have in hand the pill, or the liquid or the injection,” she said. She said she’s embarrassed that, as a former nurse, she doesn’t know which medication to use or how to get it.

Maine recently became the ninth state to allow medical aid in dying, which permits some patients to get a doctor’s prescription for lethal drugs. That method is restricted, however, to people with a terminal condition who are mentally competent and expected to die within six months.

Patients who aren’t eligible for those laws would have to go to an “underground practice” to get lethal medication, said Dr. Timothy Quill, a palliative care physician at the University of Rochester School of Medicine. Quill became famous in the 1990s for publicly admitting that he gave a 45-year-old patient with leukemia sleeping pills so she could end her life. He said he has done so with only one other patient.

Quill said he considers suicide one option he may choose as he ages. “I would probably be a classic [case] — I’m used to being in charge of my life.” He said he might be able to adapt to a situation in which he became entirely dependent on the care of others, “but I’d like to be able to make that be a choice as opposed to a necessity.”

Suicide could be as rational a choice as a patient’s decision to end dialysis, after which the patient typically dies within two weeks, he said. But when patients bring up suicide, he said, it should launch a serious conversation about what would make their life feel meaningful and their preferences for medical care at the end of life.

Clinicians have little training on how to handle conversations about rational suicide, said Dr. Meera Balasubramaniam, a geriatric psychiatrist at the New York University School of Medicine who has written about the topic. She said her views are “evolving” on whether suicide by older adults who are not terminally ill can be a rational choice.

“One school of thought is that even mentioning the idea that this could be rational is an ageist concept,” she said. “It’s an important point to consider. But ignoring it and not talking about it also does not do our patients a favor, who are already talking about this or discussing this among themselves.”

In her discussions with patients, she said, she explores their fears about aging and dying and tries to offer hope and affirm the value of their lives.

These conversations matter because “the balance between the wish to die and the wish to live is a dynamic one that shifts frequently, moment to moment, week to week,” said Conwell, the suicide prevention expert.

Carolyn, who has three children and four grandchildren, said conversations about suicide are often kept quiet for fear that involving a family member would implicate them in a crime. The seniors also don’t want to get their retirement community in trouble.

In some of the cases KHN reviewed, nursing homes have faced federal fines of up to tens of thousands of dollars for failing to prevent suicides on-site.

There’s “also just this hush-hush atmosphere of our culture,” said Carolyn. “Not wanting to deal with judgment — of others, or offend someone because they have different beliefs. It makes it hard to have open conversations.”

Carolyn said when she and her neighbors met at the cafe, she felt comforted by breaking the taboo.

“The most wonderful thing about it was being around a table with people that I knew where we could talk about it, and realize that we’re not alone,” Carolyn said. “To share our fears — like if we choose to use something, and it doesn’t quite do the job, and you’re comatose or impaired.”

People who attempt suicide and survive may end up in a psychiatric hospital “with people watching you all the time — the complete opposite of what you’re trying to achieve,” Quill noted.

At the meeting, many questions were practical, Lois said.

“We only get one crack at it,” Lois said. “Everyone wants to know what to do.”

Davis said she did not have practical answers. Her expertise lies in ethics, not the means.

Public opinion research has shown shifting opinions among doctors and the general public about hastening death. Nationally, 72% of Americans believe doctors should be allowed by law to end a terminally ill patient’s life if the patient and his or her family request it, according to a 2018 Gallup poll.

Lois said she’s seeing societal attitudes begin to shift about rational suicide, which she sees as the outgrowth of a movement toward patient autonomy. Davis said she’d like to see polling on how many people share that opinion nationwide.

“It seems to me that there must be an awful lot of people in America who think the way I do,” Davis said. “Our beliefs are not respected. Nobody says, ‘OK, how do we respect and facilitate the beliefs of somebody who wants to commit suicide rather than having dementia?’”

If you or someone you know has talked about contemplating suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.

People 60 and older can call the Institute on Aging’s 24-hour, toll-free Friendship Line at 800-971-0016. IOA also makes ongoing outreach calls to lonely older adults.

 

Oregon Has Botched Efforts To Move Patients Out Of Restrictive Psychiatric Facilities, Investigation Finds

The Oregonian/OregonLive launched an investigation into the Oregon Health Authority’s management of moving patients out of specialized care. Chris Bouneff, director of Oregon’s branch of the National Alliance on Mental Illness, said the newsroom’s findings are “disturbing.” “We don’t have many others who look after us,” Bouneff said of people with severe mental illness. “And if that state agency can’t do it, and it didn’t do it in this instance, who can we trust?”

Many Of The Worst Mass Shootings In Recent Memory All Have Something In Common: AR-15 Style Rifles. Why?

The rounds from that style of weapon are three times faster and strike with more than twice the force of other bullets. “Organs aren’t just going to tear or have bruises on them, they’re going to be, parts of them are going to be destroyed,” says Cynthia Bir. In other public health news: gene-edited babies, alcohol, vitiligo, the cautious generation, cancer, CBD, and more.

Meth In The Morning, Heroin At Night: Inside The Seesaw Struggle of Dual Addiction

In the 25 years since she snorted her first line of meth at a club in San Francisco, Kim has redefined “normal” so many times. At first, she said, it seemed like meth brought her back to her true self — the person she was before her parents divorced, and before her stepfather moved in.

“I felt normal when I first did it, like, ‘Oh! There I am,’” she said.

Kim is 47 now, and she has been chasing normal her entire adult life. That chase has brought her to some dark places, so she asked us not to use her last name. For a long time, meth, also known as speed, was Kim’s drug of choice.

Then she added heroin to the mix. She tried it for the first time while she was in treatment for meth.

“That put me on a nine-year run of using heroin. And I thought, ‘Oh, heroin’s great. I don’t do speed anymore.’ To me, it saved me from the tweaker-ness,” Kim said, referring to the agitation and paranoia many meth users experience, and how heroin, an opiate, calmed that.

Now, Kim has finished treatment for both drugs.

Kim was part of the previous meth wave, in the ’90s, and now she’s part of a new meth epidemic that has been sweeping through parts of the United States, especially the West. Deaths involving methamphetamine are up. Hospitalizations are up.

After struggling with addiction to both heroin and meth for decades, Kim got care at a residential treatment program for women — Epiphany Center, in San Francisco. She’s now working and plans to go back to college in the fall.(April Dembosky/KQED)

Seeking A ‘Synergistic High’

Researchers who have tracked drug use for decades believe the new meth crisis got a kick-start from the opioid epidemic.

“There is absolutely an association,” said Dr. Phillip Coffin, director of substance use research at the San Francisco Department of Public Health.

Across the country, more and more opioid users say they now use meth as well, up from 19% in 2011 to 34% in 2017, according to a study published last year in the journal Drug and Alcohol Dependence. The greatest increases were in the western United States.

That research suggests efforts to get doctors to cut down on writing opioid prescriptions may have driven some users to buy meth on the street instead.

“Methamphetamine served as an opioid substitute, provided a synergistic high, and balanced out the effects of opioids so one could function ‘normally,’” the researchers wrote.

It’s kind of like having a cup of coffee in the morning to wake up, and a glass of wine in the evening to wind down: meth on Monday to get to work, heroin on Friday to ease into the weekend.

Amelia said that’s how her drug use evolved to include meth — she also asked that we use only her first name because she has used illegal substances.

At first, drugs were just a fun thing to do on weekends — ecstasy and cocaine with her friends. Then, on Monday, Amelia went about her workweek.

“I’m a horse trainer, so I worked really hard, but I also partied really hard,” she said.

Then one weekend, when Amelia was feeling kind of hung over from the night before, a friend passed her a pipe. She said it was opium.

“I thought it was like smoking weed or hash, you know? I just thought it was like that,” Amelia said.

She grew to like the opium stuff. Eventually, Amelia met up with her friend’s dealer.

“The woman said, ‘How long have you been doing heroin for?’ and my jaw nearly hit the ground,” Amelia said. “I was just really, honestly shocked. I was like, ‘What? I’ve been doing heroin this whole time?’ I felt really naive, really stupid for not even putting the two together.”

Pretty soon, Amelia started feeling sick around the same time every day. It was withdrawal symptoms, a clear sign she was becoming dependent on the drug. Her weekend smoke became her daily morning smoke. Then it was part of her lunch-break routine.

“I just kind of surrendered to that and decided, ‘Screw it,’” she said. “‘I’ll just keep doing it. I’m obviously still working; I’m fine.’”

A heroin habit is expensive. Amelia was working six days a week to pay for it. Any horses that needed to be ridden, any lessons that needed to be taught, she said ‘yes,’ because she wanted the money.

But bankrolling her heroin habit was exhausting. One day, one of the women she worked with at the horse barn offered her some meth as a pick-me-up.

Meth is comparatively cheap. It became the thing that kept Amelia going so she could earn enough money to buy heroin.

“The heroin was the most expensive part,” she said. “That was $200 a day at one point. And the meth was $150 a week.”

This pattern lasted for three years, until Amelia discovered she was pregnant. As soon as her daughter was born, she entered a residential treatment program in San Francisco, called the Epiphany Center, that would accept her and her baby.

“I was OK with being a drug addict. I was OK with that being my life,” she said. “But I wasn’t OK with having kids and letting that be part of my life.”

Rehab Admissions On The Rise For Users Who Mix Meth, Heroin

Admissions to drug rehabilitation for heroin have remained steady in recent years in San Francisco. But the number of heroin addicts reporting methamphetamine as a secondary substance problem has been rising. In 2014, 14% of heroin users said meth was also a problem. Three years later, 22% said so.

“That is very high,” said Dr. Dan Ciccarone, a physician and professor at the University of California-San Francisco who has been studying heroin for almost 20 years. “That’s alarming and new and intriguing and needs to be explored.”

The speedball — heroin and cocaine — is a classic combination, he said.

“It’s like peanut butter cups, right? Chocolate and peanut butter together,” he said. “Methamphetamine and heroin are an unusual combination.”

The meth-and-heroin combo is referred to as a goofball, Ciccarone added, because it makes the user feel “a little bit silly and a little bit blissful.”

For Kim, adding heroin to her methamphetamine habit compounded her use. “I ended up doing both, at the same time, every day, both of them,” she said.

It was all about finding the recipe to what felt normal. Start with meth. Add some heroin. Touch up the speed.

“You’re like a chemist with your own body,” she said. “You’re balancing, trying to figure out your own prescription to how to make you feel good.”

Now Kim is trying to find balance without drugs. She’s been sober for a year. So has Amelia, the horse trainer. Her sobriety anniversary is her daughter’s birthday.

This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

Despite International Kerfuffle Over Chinese Scientist’s Decision To Gene-Edit Human Embryos, Others Want To Follow In His Path

Denis Rebrikov, a Russian scientist, claims he has developed a safe way to gene-edit babies. “How it can be unethical if we will make [a] healthy baby instead of diseased?” Rebrikov told NPR during his first broadcast interview. “Why? Why [is it] unethical?” The issue has gained international attention as of late, with most experts in the field recommending caution. In other public health news: robotic ducks to help kids with cancer, a look at federally funded research, the flu, parenting, herbs and modern medicine, skeletal changes from phone use, and more.

Suicide Rates For Teens Reaches High-Water Mark Driven In Part By Sharp Uptick Among Older Teenage Boys

For girls and young women, suicide rates have mostly followed a steady upward trajectory since 2000, but for boys it turned up sharply starting three to four years ago. Not since 1980 — when the HIV/AIDS epidemic touched off widespread despair among young gay males across the United States — has the suicide rate for this group been so high.

You Can Still Be Healthy With A High BMI Yet Many Fertility Clinics Close Door To Obese Women

Does it make sense, medically or ethically, when fertility clinics refuse to treat prospective mothers they consider too large? One woman was treated coldly at a clinic and told she was too fat to get pregnant. “Have more sex and lose the weight,” the technician said to her. In other public health news: murders of black transgender women, sleeping without drugs, eating expired foods, shortage of geriatricians, lessons on modern technology, living after cardiac arrest and obesity’s ties to prostate cancer.

Looking For New Answers To Aging Well: What Bats In Belfries, Marmosets In Mountains Might Tell

While animals have long been studied in medical research, a new wave of researchers is looking for different answers. “The goal isn’t to increase the number of 120-year-olds who are living in nursing homes. We want more 80- and 90-year-olds who are living independently,” says Corinna Ross, a primatologist at the Texas Biomedical Research Institute. More aging news reports on grip strength, defining “old” and the power of laughter.

Federal Grants ‘A Lifesaver’ In Opioid Fight, But States Still Struggle To Curb Meth

In his 40 years of working with people struggling with addiction, David Crowe has seen various drugs fade in and out of popularity in Pennsylvania’s Crawford County.

Methamphetamine use and distribution is a major challenge for the rural area, said Crowe, the executive director of Crawford County Drug and Alcohol Executive Commission. But opioid-related overdoses have killed at least 83 people in the county since 2015, he said.

Crowe said his organization has received just over $327,300 from key federal grants designed to curb the opioid epidemic. While the money was a godsend for the county — south of Lake Erie on the Ohio state line — he said, methamphetamine is still a major problem.

But he can’t use the federal opioid grants to treat meth addiction.

“Now I’m looking for something different,” he said. “I don’t need more opiate money. I need money that will not be used exclusively for opioids.”

The federal government has doled out at least $2.4 billion in state grants since 2017 to address the opioid epidemic, which killed 47,600 people in the U.S. that year alone. But state officials noted that drug abuse problems seldom involve only one substance. And while local officials are grateful for the funding, the grants can be spent only on creating solutions to combat opioids, such as prescription OxyContin, heroin and fentanyl.

According to the most recent data from the Centers for Disease Control and Prevention, 11 states have reported that opioids were involved in fewer than half of their total drug overdose deaths in 2017, including California, Pennsylvania and Texas.

The money is also guaranteed for only a few years, which throws the sustainability of the states’ efforts into question. Drug policy experts said the money may not be adequate to improve the mental health care system. And more focus is needed on answering the underlying question of why so many Americans struggle with drug addiction, they said.

“Even just the moniker, like ‘the opioid epidemic,’ out of the gate, is problematic and incorrect,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University in Boston. “This was never just about opioids.”

(Story continues below.)

States received federal funds for opioids primarily through two grants: State Targeted Response and State Opioid Response. The first grant, authorized by the 21st Century Cures Act, totaled $1 billion. The second pot of money, $1.4 billion — approved as part of last year’s omnibus spending bill — sets aside a portion of the funding for states with the most drug poisoning deaths.

For states like Ohio and Pennsylvania, the need was great. Nearly 4,300 and 2,550 residents, respectively, died from opioid-related overdoses in 2017. State officials say the money enabled them to invest significantly in programs like training medical providers on addiction, more access points to treatment and interventions for special populations, like pregnant women. Ohio was awarded $137 million in grants; Pennsylvania, $138.1 million.

The grants also stipulate a minimum amount of money for every state, so even areas with reportedly low opioid-related overdose death rates now have considerable funds to combat the crisis. Arkansas, for example, reported 188 opioid-related deaths in 2017 and received $15.7 million from the federal government.

While 2,199 people in California died from opioid-related causes in 2017, its opioid death rate was one of the 10 lowest in the country. The Golden State received $195.8 million in funding, more than any other state.

“This funding is dedicated to opioids,” said Marlies Perez, a division chief at the California Department of Health Care Services, “but we’re not blindly just building a system dedicated just to opioids.”

Mounting evidence points to a worrisome rise in methamphetamine use nationally. The presence of cheap, purer forms of meth in the drug market coupled with a decline in opioid availability has fueled the stimulant’s popularity. The number of drug overdose deaths involving the meth tripled from 2011 to 2016, the CDC reported. Hospitalizations involving amphetamines — the class of stimulants that includes methamphetamine — are spiking. And it is harder to address. Treatment options for this addiction are narrower than the array available for opioids. In light of the increase in deaths related to other substances, are these grants the best way to fund states’ response to opioids?

Bertha Madras, a professor of psychobiology at Harvard Medical School and a former member of the federal Opioid and Drug Abuse Commission, said the federal government has responded well by tailoring the response to opioids because those drugs continue to kill tens of thousands of Americans per year. But, she said, as more people living with addiction are identified and other drugs rise in popularity, the nation’s focus will need to change.

Beletsky emphasized that the grants are insufficient to support fixes to the mental health care system, which must respond to patients living with an addiction of any kind.

People addicted to a particular substance typically use other drugs as well. Controlling addiction throughout a person’s life can be akin to “whack-a-mole,” said Dr. Paul Earley, president of the American Society of Addiction Medicine, because they may stop using one substance only to abuse another. But specific addictions may also require specific treatments that cannot be addressed with tools molded for opioids, and the appropriate treatment may not be as available.

“I think we have to really begin to self-examine why this country has so much substance use to begin with,” Madras said.

Readers And Tweeters: No Rush To Judge Patients Who Leave The ER Without OK

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


At The ER, It’s Hurry Up And Wait

At least the patients mentioned in “As ER Wait Times Grow, More Patients Leave Against Medical Advice” (May 17) were allowed to leave. An emergency room may not be a safe place for people and they may wish to go. It is not always the patient who is being irresponsible; it is sometimes those who work in the hospital.

My significant other and I ended up in a situation at the University of New Mexico Hospital. We were there for an appointment with a doctor associated with the hospital, but while she was getting checked in, she fainted. She was out for a short time. They sent over a paramedic to take her to the ER. She did not wish to go to the ER but was not immediately able to get up and leave, even by wheelchair.

The paramedic and his assistant took elaborate measures to separate me from my significant other, for whom I am a caregiver, and they interrogated her. It seemed they wanted her to admit to drug usage. She was very frightened. Eventually, I was allowed to enter the ER, and when the paramedic saw me, he scattered like a roach.

Five hours is a long time to wait. That makes no sense. If people have to wait for five hours it means you really do not have enough staff to handle them all. In most cases, an ER is useless, anyway. They work for people who suffer a car accident, gunshot wound, broken leg or heart attack. For other things, they generally are not much help and often do not even have essential services manned, like ultrasound, MRI, etc. So, in most cases, it is basically a waste of time.

Look inward to figure out why people bolt.

— Sigmund Silber, Santa Fe, N.M.


— Dr. Ali Khan, Omaha, Neb.


There is a lot of discussion over the cost of health care, but people don’t realize how inefficient our system is. I have an 18-year-old son who was born with spina bifida and has had many other health issues. In mid-May, he had a pain in the left side of his back. Not common, and he does not complain about pain. The nurse at his school was concerned; my son looked pale, he came to her wanting to lie down — not typical. So I called his urologist’s office asking how to recognize kidney stones, which he has never experienced. The front desk personnel told me to take him to the ER.

We traveled almost an hour to Children’s Healthcare of Atlanta at Scottish Rite, where he has specialty docs. After running many tests, they told us he had a stomach virus, and we were sent home. On May 30, my son got his annual renal bladder ultrasound done in preparation for a mid-June spina bifida clinic appointment. Turns out, he had a kidney stone! It showed up on the ultrasound.

I am extremely frustrated since it is not the first time I have been told to take my son to ER only to be told “nothing is wrong” or “we can’t help him” even though there later proved to be a problem. What a BIG waste of time and money on our health care system. But you can’t get in to see doctors when you have a problem, so you almost always have to go to the ER. In my opinion, that is a waste of ER services, which I do not hear talked about in the news.

— Rebecca Joiner, Fayetteville, Ga.


— Michael Bertaut, Baton Rouge, La.


Give Midwives And Birth Centers A Chance

In your “Bill of the Month” piece about laughing gas, “Not Funny: Midwife Slapped With $4,836 Bill For Laughing Gas During Her Labor” (May 29), I wish your recommendations would have included seeking out birth centers as an alternative to hospital births. Given the embarrassing state of maternity care in the United States, it’s time to focus on the advantages of midwives and birth centers. They have proven statistically better outcomes at half the cost. As a former consultant to the American Association of Birth Centers, I was impressed when I learned that the AABC built a registry of data to track, measure and improve quality over 13 years ago. They recognized the need for a separate credentialing association, the Commission for Accreditation of Birth Centers, or CABC, and supported the development of its standards. Women need an alternative to our current standard options for low-risk maternity care.

— Linda Davis, Minneapolis


Editor’s note: This is a teachable moment. The following tweeter might have confused Kaiser Health News for Kaiser Permanente. KHN, the health care policy news source you’re currently reading, is not affiliated with the managed-care consortium, although both were named for innovative American industrialist Henry J. Kaiser. Any confusion shouldn’t diminish the strength of her argument, however.

— Allie Keeley, Richmond, Va.


— Dr. Tom Pink, Geneva, Switzerland


In fact, there are positive developments in prenatal care. Several readers weighed in on our article about what to expect when you go through pregnancy with a group of other expectant parents.

— Lauren Lee White, Los Angeles


At The Center Of Group Maternity Care

It was great to see your story on the centering model of maternity care (“The Unexpected Perk Of My Group Pregnancy Care: New Friends,” May 30), but how about some credit to Sharon Rising, the nurse who founded, tested and promotes this health-expanding approach? Nurses are rarely credited. She is an astonishing clinician-scientist who deserves being named in such stories. Thank you.

— Debbie Ward, Sacramento, Calif.


A tweeter in Portugal called her role in a group prenatal program a career highlight:

— Justine Strand de Oliveira, Algarve, Portugal


Missing Tool In The Toolbox For Treating PTSD

I was grateful to see the recent story by Caroline Covington about treatment for PTSD (“For Civilians, Finding A Therapist Skilled In PTSD Treatments Is A Tough Task,” May 22). Unfortunately, she missed a huge piece of the puzzle. A therapy called Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for post-traumatic stress disorder, having been validated by more than 36 randomized controlled studies. Endorsed by the American Psychological Association, the Substance Abuse and Mental Health Services Administration, and the Departments of Defense and Veterans Affairs, it is used throughout the world to heal PTSD efficiently. It was developed in 1987 by Francine Shapiro. Please check out EMDRIA.org for research documentation. As a licensed psychotherapist and certified EMDR therapist, I have witnessed the dramatic healing effect of EMDR with my clients suffering from PTSD for many years. I appeal to Ms. Covington to look into this area and complete the story.

—Stephen Weathersbee, a licensed marriage and family therapist, Tyler, Texas


— Harry Stark, Woodland Hills, Calif.


As a short-term veteran (1988-90) diagnosed in 2016 with complex post-traumatic stress disorder, I wanted to add a couple of thoughts. As much as my story was influenced by having been in the military, I constantly found myself comparing my experiences with other veterans. I was always giving deference to the fact that my story wasn’t theirs, and that theirs was usually far more of a “good excuse” to have the condition. In treatment, that logic extended to my individual circumstances. I was constantly comparing my experiences, minimizing at every turn.

I’ve been through both Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), about two years apart; the PE was used more recently and, in my opinion, was more effective. I wanted to mention another therapy your missed, though: Eye Movement Desensitization and Reprocessing (EMDR). I am on a waiting list with Virginia’s Salem VA Medical Center to try this cutting-edge, light-based therapeutic tool. I even wrote to Samsung and Oculus corporations to suggest they work on making EMDR programs for their VR headsets, in conjunction with VA clinicians.

As you suggested in the article, the industry is catching up to both new methodologies as well as a new client base for PTSD that includes the civilian community. The influx of money and research capacity that comes with this new client base could be well used in advancing this method, and/or combining it for use with current methods.

I know your article concentrated on PTSD experienced by civilians and overcoming the stigma that this disease is somehow reserved for veterans. People need to understand that because we’re all different in our brains that this condition is never the same exact thing … even in two veterans who served side by side. Sure, someone always has it worse than you, but that doesn’t mean your symptoms don’t deserve help.

— Neil Marsh, Moneta, Va.


Spreading The Word (Correctly) About Measles

The United States did not declare measles “eradicated” (“How Measles Detectives Work To Contain An Outbreak,” June 10). It declared the disease “eliminated.” Big difference. In medical terms, “eradicated” means gone forever, as in smallpox. “Eliminated” means no sustained transmission over the period of a year.

— Linda Hultman, Louisville, Colo.

Editor’s note: Another teachable moment. We stand corrected. Thank you!


Dignity At The End Of Life

Something useful to add to Jenny Gold’s article “Will Ties To A Catholic Hospital System Tie Doctors’ Hands?” (April 29): I believe Catholic hospitals ignore patients’ end-of-life wishes. No advance medical directives. So, if I want a do-not-resuscitate (DNR) order, they can override that and insist I live my final days in agony or zoned out.

I always learn something in your newsletters. Keep up your good work!

— Gail Jackson, Waikoloa, Hawaii


Readers everywhere rejoiced over good news, for a change.

— Oral Hazell, St. Thomas, U.S. Virgin Islands


Good Work Restoring Faith In Humanity

The article “Churches Wipe Out Millions In Medical Debt For Others” (June 3) was one of the most uplifting and inspirational stories I have read in such a long time. Kudos to the author and your publication. This is a creative solution that not only stretches donation dollars but sets an example that other religious organizations could easily follow. Thank you.

Philip Heigl, New Cumberland, Pa.


— Chase McGee, Durham, N.C.


— Don Purser, Marietta, Ga.


Helping Those With Developmental Disabilities Navigate Health Care

I have a 17-year-old son with cerebral palsy, so the article “For Those With Developmental Disabilities, Dental Needs Are Great, Good Care Elusive” (May 3) hits home. I would like to see more stories that shed light on the challenges of navigating the health care system for individuals with developmental disabilities. Along with a small share of the U.S. population, my son receives long-term services and supports (LTSS) through Arizona’s Medicaid program. According to a report from Truven Health Analytics, “The Growth of Managed Care Long-Term Services and Supports Program: 2017 Update,” approximately 1.78 million individuals are enrolled in the MLTSS program. Our health care system should do a better job easing the burden in navigating the system for this vulnerable population. I hope that by bringing more attention to these issues will result in policy changes.

— Son Yong Pak, Tempe, Ariz.


In response to the article by David Tuller on dental care for the disabled: I wanted him to know that Special Olympics Virginia provides free dental care (including treatment and procedures) for hundreds of special needs athletes at their Summer Games. Dozens of dentists donate their time for this free clinic. Special Olympics Virginia is able to do this with the support from the Virginia Dental Foundation, Virginia Commonwealth University and Missions of Mercy (MOM Project).

— Donnie Knowlson, Special Olympics Virginia board member, Chesterfield, Va.


The Other Side Of The Opioid Story

Your article “Opioid Prescriptions Drop Sharply Among State Workers” (May 20) draws from biased and highly inaccurate opinion. Here’s a contradicting view.

Massive reductions in opioid prescribing are not a measure of success but instead signal failures of pain medicine under a draconian and unjustified program of persecution of doctors by Drug Enforcement Administration and state regulatory agencies. Tens of thousands of patients have been deserted by physicians afraid of losing their licenses if they treat pain with the only therapies that work for the majority of those with severe pain.

In the article, Beth McGinty is quoted as follows: “These reductions … signal a reduction in the overprescribing practices that have driven the opioid epidemic in the U.S.” This assertion is false. Overprescribing has never substantially “driven” the opioid crisis in the U.S. Statistics on opioid deaths are grossly inflated, representing deaths where a prescription-type opioid is among several factors detected in postmortem “tox screens.” No less a figure than Dr. Nora Volkow, director of the National Institute on Drug Abuse, informs us that addiction is not a predictable outcome of prescribing, and is rare even in at-risk patients.

The article states “One major factor is that many health insurers have imposed limits on prescriptions, as recommended by the CDC in 2016.” The Centers for Disease Control and Prevention recently issued a clarification that the guideline was never intended to justify mandatory tapering of legacy patients. The American Medical Association also repudiated the fundamental logic of the guidelines in Resolution 235 of the November 2018 House of Delegates meeting. Practicing physicians do not consider the equivalent of 50 morphine milligrams (MME) a high dose. Minimum effective dosages can range from ~20 MME to over 1000 MME, depending on metabolism.

Kathy Donneson, chief of CalPERS’ Health Plan Administration Division, says the surest sign of success will be when patients with chronic pain are “kept pain-free in other ways.” However, the literature for such therapies is abysmal, offering weak evidence and no direct comparisons of “alternatives” to properly titrated opioids.

CalPERS is on a course of action that is deeply damaging to patients. The agenda is cost control, not patient care. The other side of the story involves deserted patients who are committing suicide every day.

— Richard Lawhern, Fort Mill, S.C.


— Ben Miller, Denver


Not News To Me

As someone who has worked as a health actuary and executive for major insurers, I am surprised that Rand Corp. or anyone else thought a study needed to be done on what private insurers pay compared with Medicare (“Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers,” May 9). This is OLD, OLD news. Hospitals and other health providers have been demanding more from private payers for the past 30 years! No study needed to be done. Just ask any actuary or health executive who works on contracting with providers. Despite the protestations of health economists who don’t work for insurers, providers demand more from private payers to make up for insufficient payments from Medicare and Medicaid. I can’t believe that this is a surprise to KHN or anyone who is knowledgeable about how medical insurance works in this country.

— Roy Goldman, Jacksonville Beach, Fla.

One Of The Biggest Myths About The AIDS Epidemic Is That It’s Over

Dr. Demetre Daskalakis, deputy commissioner for the Division of Disease Control of the New York City Department of Health and Mental Hygiene, talks with The New York Times about his philosophy in addressing the AIDS epidemic. In other public health news: breast milk, blood donations, gene tests, protecting your DNA, spousal abuse, and more.

Drug Users Armed With Naloxone Double As Medics On Streets Of San Francisco

The man was out of his wheelchair and lay flat on his back just off San Francisco’s Market Street, waiting for the hypodermic needle to pierce his skin and that familiar euphoric feeling to wash over him.

The old-timer, who appeared to be in his 60s, could not find a viable vein, so a 38-year-old man named Daniel Hogan helped him. Hogan, a longtime drug user originally from St. Louis, leaned over the older man, eyeing his neck as he readied a syringe loaded with the powerful synthetic opioid fentanyl.

Hogan called the man a “jellyfish” because most of his veins had collapsed from years of intravenous drug use and he rarely bled when pricked. But the older guy still had his jugular vein, and for Hogan that would work just fine.

Hogan’s hands were pink and swollen, bearing scars and scabs from years of daily drug use and the harshness of life on the streets. But those hands were skilled in the art of street phlebotomy. He slid the needle into the man’s neck and pushed the plunger.

Hogan, who said he had taken fentanyl every day for the past two months, explained that he’d developed a tolerance for the drug, and the dose he gave himself would kill a less experienced user. So, he gave the older man only a fraction of that amount.

In case it was too much, Hogan was ready with a vial of naloxone, the overdose-reversal drug.

Grim drug scenes like this play out every day on the streets surrounding San Francisco’s Civic Center — an area that spans the hard-luck sidewalks of the Tenderloin district and the transitional Mid-Market neighborhood, home to tech titans Twitter and Uber.

The area has become a beachhead for fentanyl, which has killed tens of thousands across the United States and is beginning to make itself felt in California.

The drug, which can shut down breathing in less than a minute, became the leading cause of opioid deaths in the United States in 2016. It is increasingly sought out by drug users, who crave its powerful high.

Carus displays a bag of fentanyl.(Brian Rinker for KHN)

Carus mixes fentanyl with water in a “cooker” — equipment often distributed at needle exchanges. (Brian Rinker for KHN)

They feel a measure of security because many of their peers carry naloxone, which can quickly restore their breathing if they overdose.

Data suggests that in San Francisco the users may be reversing as many overdoses as paramedics — or more. In both cases, numbers have risen sharply in recent years.

In 2018, San Francisco paramedics administered naloxone to 1,647 people, up from 980 two years earlier, according to numbers from the city’s emergency response system.

That compares with 1,658 naloxone-induced overdose reversals last year by laypeople, most of them drug users, according to self-reported data from the DOPE Project, a Bay Area overdose prevention program run by the publicly funded Harm Reduction Coalition. That’s nearly double the 2016 figure.

“People who use drugs are the primary witnesses to overdose,” said Eliza Wheeler, the national overdose response strategist for the coalition. “So it would make sense that when they are equipped with naloxone, they are much more likely to reverse an overdose.”

The widespread availability of naloxone has radically changed the culture of opioid use on the streets, Hogan said. “In the past, if you OD’d, man, it was like you were really rolling the dice.” Now, he said, people take naloxone for granted.

Carus prepares fentanyl shots for himself and his friend Bud. (Brian Rinker for KHN)

“I feel like as long as there is Narcan around, the opiates can’t kill you,” said Nick Orlick, 26, referring to one of the brand names for the overdose reversal drug.

As he huddled in the recess of a building along Mission Street, around the corner from high-rise luxury apartments, Orlick explained that he’d been revived with naloxone 15 times in recent years.

Despite fentanyl’s growing presence in San Francisco and other parts of California, it has not hit the Golden State nearly as hard as the rest of the country.

In 2017, 28,466 people across the U.S. died from overdoses involving synthetic opioids, which include fentanyl and related compounds, according to data from the Kaiser Family Foundation. California, which represents 12% of the country’s population, had 536 of those deaths — fewer than 2% of the total. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

However, use of fentanyl is likely to grow in San Francisco and Los Angeles, as people get accustomed to it and begin to prefer its more intense high, said Ricky Bluthenthal, professor of preventive medicine at the Keck School of Medicine of the University of Southern California, who researches injection drug use.

In California, as in many other states west of the Mississippi, heroin is smuggled in the form of a gooey or hard black tar. This “black tar” heroin, “a well-known garbage drug,” is diluted with fillers, which induces some users to seek out the much more powerful effects of fentanyl, said Kristen Marshall, manager of the DOPE Project.

Fentanyl is dangerous not only because it is up to 50 times more potent than heroin, but also because people often take it unknowingly when their dealers mix it in with street drugs such as heroin. However, the black tar is difficult to mix with fentanyl, and that may help protect drug users who might otherwise ingest it unwittingly, experts say.

But even if they overdose on fentanyl, it’s not necessarily a death sentence. The widespread practice by community organizations in San Francisco and Los Angeles of distributing naloxone to the drug-using population also helps explain California’s lower rate of deaths from fentanyl and other opioids, harm reduction workers and researchers say.

On the streets around San Francisco’s Civic Center, homeless drug users often duck into alcoves, alleys or tents for a moment of privacy amid the bustle of government employees, tourists and tech workers. (Brian Rinker for KHN)

On the streets around San Francisco’s Civic Center, homeless drug users gather on sidewalks with their dogs, some huddling under blankets to smoke their white, powdered fentanyl through hollowed-out pens. Others inject it, often ducking into alcoves, alleys or tents for a fleeting moment of privacy amid the bustle of government employees, tourists and tech workers. Some of them overdose in plain sight.

They employ various methods to reduce the overdose risk. Some, like Daniel Hogan, take methamphetamine or smoke crack between injections to keep themselves alert. Another technique is to delay the full dose by pushing the plunger only partway down.

If gathered as a group, they often stagger their fentanyl use so one of them will be physically able to administer naloxone.

One recent May afternoon near Market Street, a thin man in his early 40s who called himself Bud slid a needle into his arm and slowly pushed the plunger down, stopping every so often to gauge the effects of the fentanyl.

“Hey, stop there. Pull it out,” said his friend Seth Carus, 55. Bud’s eyes were vacant and his mouth drooped — telltale signs the fentanyl had taken hold.

Carus is ready with naloxone for Bud, who has just overdosed, but Bud comes to before he needs the medication.(Brian Rinker for KHN)

As the police arrive, Carus comforts Bud after his overdose.(Brian Rinker for KHN)

Bud, wearing tight clothing and a blue beret, didn’t listen. He pushed the plunger all the way. Five minutes later, the color drained from his face, his eyes opened wide, his jaw locked and his entire body went stiff as he lay on the sidewalk.

Carus, living on the streets and a fentanyl user himself, sprang into action. He prepared a shot of naloxone and told a bystander to call 911.

But before Carus could administer the overdose reversal drug, Bud began to stir. Carus cradled him in his arms as the police arrived, followed quickly by the paramedics, who put Bud in an ambulance.

Carus blamed himself as he bent over and cried. The fentanyl was his, and he had been trying to do Bud a favor by getting him high.

A while later, Bud emerged from the ambulance and embraced his friend. “You did the right thing, man,” he told Carus. “I did the shitty drug addict thing. You said to stop, and I didn’t listen.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.