Tagged Mental Health

Concentrated, Intensive Programs Offer Short-Term Alternative To Traditional Weekly Therapy Sessions

Some patients can finish therapy in just a few weeks. The model is gaining popularity because it is proving to be as effective as long-term weekly treatments. In other public health news: vaping, med students, Lyme disease, autism, HPV, toxins in water, work wellness programs and more.

Technology To ‘Turn Off’ Genes Responsible For Trans Fats Exists. But Is It Ready For Prime-Time?

When it comes to altering genes in the food we eat, some experts want to tread carefully while others want to embrace the healthier food. In other public health news: glaucoma, the human cell atlas, c-sections, empathy, family planning apps, growth hormones, depression, online dating and more.

‘End Family Fire’: Advocates Want To Curb Children’s Deaths From Accidental Shootings By Giving The Problem A Name

“Just like the term ‘designated driver’ changed perceptions about drinking and driving, the term ‘Family Fire’ will help create public awareness to change attitudes and actions around this important matter,” said Kris Brown, co-president of the Brady Campaign to Prevent Gun Violence. In other public health news: online dating, dementia, sperm count, suicide, and heart health.

‘End Family Fire’: Advocates Want To Curb Children’s Deaths From Accidental Shootings By Giving The Problem A Name

“Just like the term ‘designated driver’ changed perceptions about drinking and driving, the term ‘Family Fire’ will help create public awareness to change attitudes and actions around this important matter,” said Kris Brown, co-president of the Brady Campaign to Prevent Gun Violence. In other public health news: online dating, dementia, sperm count, suicide, and heart health.

Beyoncé, Serena Williams’ Traumatic Birth Experiences Highlight Ongoing Need For Improved Maternal Care In U.S.

“People tend to think about pregnancy as a universally happy experience,” said Daniel Grossman, of the University of California at San Francisco. “But the reality is that pregnancy is inherently risky. … Black women face significantly higher risks during pregnancy, and Beyoncé and Serena Williams help to put a very well-known face to these risks.” In other public health news: the need for men to be tested for BRCA2 gene; the psychological harms of technology on children; drinking water during hot weather; and more.

As Opioid Crisis Rages, Some Trade ‘Tough Love’ For Empathy

It was Bea Duncan who answered the phone at 2 a.m. on a January morning. Her son Jeff had been caught using drugs in a New Hampshire sober home and was being kicked out.

Bea and her husband, Doug, drove north that night nine years ago to pick him up. On the ride back home, to Natick, Mass., the parents delivered an ultimatum: Jeff had to go back to rehab, or leave home.

Jeff chose the latter, Bea said. She remembers a lot of yelling, cursing and tears as they stopped the car, in the dead of night, a few miles from the house.

“It was really, really difficult to actually just drop him off in a parking lot on our way home and say, you made the decision — no rehab — so we made the decision, no home,” Bea said. “It was exquisitely difficult.”

But it was not unexpected. Doug Duncan said many parents had told him to expect this moment. Your son, he remembered them saying, will have to “hit rock bottom; you’re going to have to kick him out of the house.”

Two torturous days later, Jeff Duncan came home. While he returned to rehab, the Duncans decided their approach wasn’t working. They sought help, eventually connecting with a program that stresses empathy: CRAFT or Community Reinforcement and Family Training.

“There was more compassion and ‘Wow, this is really difficult for you,’ more open questions to him instead of dictating what he should and should not behave like,” said Bea.

The Duncans said the training helped them shift from chaos to calm.

“I started to feel an immense sense of relief,” Bea said. “I stopped feeling like I had to be a private investigator and controlling mom. I could kind of walk side to side with him on this journey, instead of feeling like I had to take charge of it.”

For the Duncans, the approach meant they could switch from enforcing family consequences, like kicking Jeff out of the house, to supporting him as he faced others, like losing a job due to drug use. It worked well: Bea and Doug helped Jeff stick to his recovery. He’s 28 now and has been sober for nine years.

Many drug users say, in hindsight, they appreciated being forced into treatment. But studies show that a compassionate approach and voluntary treatment are the more effective ways to engage drug users in recovery and keep them alive. That’s a critical consideration for families in this era of fentanyl, which can shut down breathing in seconds.

“The concept of letting their children hit bottom is not the best strategy because in hitting bottom they may die,” said Nora Volkow, director of the National Institute on Drug Abuse.

But desperate parents often don’t know how to avoid hitting bottom with their children as the Duncans did on that dark, frigid January morning. They have found ways to help: Doug is a parent coach through the Partnership for Drug-Free Kids, which is now collaborating with the Grayken Center for Addiction at Boston Medical Center.

The collaboration will close a gap in services for families caught up in the opioid epidemic, said Grayken Center’s director, Michael Botticelli, who served as drug czar in the Obama administration.

“They don’t call this a family disease for no good reason,” Botticelli said. “The whole design of these services [is] to promote tools and information for families so they know how to approach a situation and can heal.”

There is no uniform path to healing for the drug user or parents, and no widespread agreement on the best approach for families.

Joanne Peterson, who founded the parent support network Learn to Cope, said there are reasons why some parents ask older children to leave the house — if there are younger children at home or if the parents don’t feel safe.

“So it depends on what tough love means; it can mean many different things,” Peterson said.

She applauds the Grayken Center for expanding access to parent coaches, but “we also need more professional help.” Peterson said she routinely hears from parents who can’t find counselors and doctors who understand their daily traumas.

Some critics suggest the CRAFT model is too soft, that it enables drug use.

“That’s a misconception,” said Fred Muench, president of the Partnership for Drug-Free Kids. “CRAFT is authoritative parenting, creating a sense of responsibility in the child and at the same time saying ‘I am here for you, I love you, I’m going to help you, but I can’t help you avoid negative consequences if you’re not looking to do that on your own.’”

The parent coaching extends beyond periods of crisis.

On a recent afternoon, Doug Duncan was on the phone with Doreen, a mom whose daughter is in recovery. (We’re using only Doreen’s first name to protect her daughter’s identity.) Doreen was upset about an angry text from her daughter that sounded like when the young woman was using drugs.

“It brings me back there. In two seconds, I am back on that scene thinking she’s on the heroin, she’s not going to live,” Doreen told Duncan, expressing a very common fear of relapse.

In a panic — her daughter had overdosed twice and been rescued — Doreen wanted to ask if she was using heroin again. But she ran it by Duncan first. He encouraged her to talk it through.

Doreen paused, then said she could ask her daughter about work, whether it’s been stressful, or about her grief after a friend’s recent death. There are many reasons, Doreen realized, that her daughter might be angry. Her tone doesn’t have to signal a relapse.

“You talk yourself off the cliff,” Duncan said.

“Oh yes, I know all about that cliff, I’ve visited a few times before,” Doreen laughed. “You know, that ties in with what you said before about focusing less on what your feelings are and the terror or fear that you’re going through and more on what they’re feeling and what they’re going through — turn the tables a bit. That’s an excellent point.”

“That’s true compassion,” said Duncan, “and oddly enough it’s very therapeutic for you, too.”

More compassion in the home fits the shift away from criminalizing addiction — toward accepting and treating it as a chronic medical condition.

If a child had cancer, parents “wouldn’t disengage with them or be angry with them,” said Botticelli. “So I do think it aligns our scientific understanding that addiction is a disease and not a moral failure.”

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

Privacy Guidelines For Genetic-Testing Sites Touted As ‘Step Forward,’ But They Don’t Address De-Identified DNA

Samples that are stripped of any identifying details are extremely lucrative to pharmaceutical companies and other medical organizations, but the consumers have no way of knowing when their data is used. In other public health news: birth defects, Ebola, scooter injuries, brain surgery, and more.

Doctors Reckon With High Rate Of Suicide In Their Ranks

Alarms go off so frequently in emergency rooms, doctors barely notice. And then a colleague is wheeled in on a gurney, clinging to life, and that alarm becomes a deafening wake-up call.

“It’s devastating,” said Dr. Kip Wenger, recalling a 33-year-old physician and friend who died by suicide in 2015. “This is a young, healthy person who has everything in the world ahead of them.”

The medical profession is built on the myth that its workers are all highly conditioned athletes — clocking long hours while somehow staying immune to fatigue and the emotional toll of their jobs.

But there’s a dark side to the profession that has been largely veiled — even from doctors themselves: They are far more likely than the general population to take their own lives.

Wenger said his colleague was a confident doctor who worked with him in emergency rooms all over Knoxville, Tenn., and died in one of those same ERs. Wenger is regional medical director for TeamHealth, one of the country’s largest emergency room staffing companies, based in Knoxville.

One of the unavoidable dangers of being a doctor is knowing exactly how to kill yourself and having easy access to the tools to do it. There are stories of anesthesiologists found in a hospital, hooked up to an IV. Wenger said his colleague used numbing agents in order to die more painlessly.

“She wrapped herself in a blanket, and she got a Bible,” Wenger said. “She wrote a note on the door to her best friend. ‘If you come here, don’t come in the door. Call Kip or call Peter and they’ll know what to do.’ And that’s how she checked out.”

This young doctor had confided in a few co-workers about recent relationship struggles, but nothing that affected her work. And then she became part of the grim statistics.

“She was very strong-willed, strong-minded, an independent, young female physician,” said emergency doctor Betsy Hull, a close friend. “I don’t think any of us had any idea that she was struggling as much personally as she was for those several months.”

Addressing An Uncomfortable Reality

An estimated 300 to 400 doctors kill themselves each year, and the suicide rate is more than double that of the general population, according to a review of 10 years of literature on the subject presented at the American Psychiatry Association annual meeting in May.

For TeamHealth, the young woman’s death in 2015 sparked some deep soul-searching.

“A few of these things happened that were just so sobering,” said TeamHealth co-founder Dr. Lynn Massingale. “People don’t stab themselves to death. Young people don’t stab themselves to death.”

It’s been an uncomfortable topic to address. A 2018 study from Mayo Clinic finds disenchanted doctors are more likely to make mistakes.

But TeamHealth held listening sessions and realized that burnout was rampant. To start, they began encouraging doctors to work less. Massingale said the company average is now close to 40 hours a week — though there’s no avoiding nights and weekends in the ER.

The company also started a new protocol for one of the most stressful times in a physician’s career: when doctors are sued. The company then pairs them with someone who has been there.

“We can’t change the facts. We’re not coaching you to change your memory,” Massingale said. “But we can help you deal with the stress of that.”

And TeamHealth is trying to reduce some bureaucratic headaches. A significant portion of the required corporate training has been deemed optional. And the company began spending millions of dollars a year to hire scribes — staff members who follow around ER physicians and enter information into sometimes finicky electronic health records.

Technology has become a real source of stress in a career that comes with lots to worry about, even beyond dealing with patients.

Dr. Jeffrey Zurosky, who is an ER director at Parkwest Medical Center in Knoxville, said he’s concerned for his youngest doctors who start out with a mountain of med school debt, eager to pick up as many shifts as possible.

“I tell them: Be balanced. Don’t overwork yourself. Spend time with your family. Stay married, if you can,” Zurosky said.

Dr. Jeff Zurosky (left) calls to order a test for a patient as his scribe, Brandon, fills out the patient’s electronic health record.(BLAKE FARMER/WPLN)

Yet to some in the medical community, the problem is far more fundamental than “burnout.” Pam Wible doesn’t even like the term, since it puts the burden on physicians, as if they just have to find a way to cope. The family practitioner from Eugene, Ore., sees it all starting in medical schools. Entrenched ideals, like muscling through long hours on little sleep, are hard to break. Wible calls it abuse.

“These people who have been previously abused are now the teachers,” she said. “They’re teaching the next generation of doctors.”

Too Close To Call For Help

And when physicians do want help, the industry makes it especially difficult. Wible said they can’t go see a psychiatrist without jeopardizing their medical license.

“I know a lot of them,” Wible said. “They’re having to sneak out of town, pay cash and use a fake name to do it. Why are we putting these people in such a situation?”

Wible has collected more than 900 stories of doctor suicides and set up an anonymous help line. She has inspired more physicians to share their experiences, such as an emergency doctor licensed in Ohio.

“You don’t focus on the 99 you save,” that ER doctor said. “You end up focusing on the one that you lose.”

The one he lost was 19 years old and came in with the flu, but tests didn’t show anything unusual. He sent her home. She returned in cardiac arrest. When he found out she died, he went to a dark place — despite no history of depression.

“Like all doctors, you put that Superman cape on and you think you can get through it,” he said.

The family filed a complaint. And being told he might lose his job pushed him over the edge. He swallowed a lethal overdose. But the police found him, and got him to a hospital where he had to be revived.

This ER doc had treated untold numbers of suicidal patients but never saw himself in their place.

“I didn’t know I was at higher risk of suicide than the average person,” he said.

Kaiser Health News and NPR are not naming this doctor because his story could affect his future career. But he said he wishes he could speak more freely, thinking it might encourage physicians to seek help sooner than he did.

This story is part of a partnership that includes Nashville Public RadioNPR and Kaiser Health News.

LISTEN: Inexpensive Nerve Drug Often Abused As Opioid Epidemic Grows

Kaiser Health News reporter Carmen Heredia Rodriguez joins the host of “On Point,” Anthony Brooks, to discuss public health officials’ concerns about the increasing use of the drug gabapentin by people addicted to opioids. Gabapentin is not an opioid, and it is approved to treat patients with nerve pain or epilepsy. However, some people are illicitly buying the drug and abusing it to enhance their opioid highs or stave off withdrawal from other drugs.

Heredia Rodriguez wrote about the problem in an earlier story on KHN.

The “On Point” discussion about the drug (cue it up at 39:22) follows a discussion on the show about proposals for a single-payer health system.

“On Point” is produced by WBUR in Boston and distributed by NPR.

Patients With Chronic Pain Feel Caught In An Opioid-Prescribing Debate

It started with a rolled ankle during a routine Army training exercise. Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called ­­­­­­­complex regional pain syndrome.

The condition causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.

For Hubbard, it manifested years ago following surgery on her foot — a common way for it to take hold.

“My leg feels like it’s on fire pretty much all the time. It spreads to different parts of your body,” the 47-year-old veteran said.

Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It’s red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.

“That started as a little blister and four days later it was like the size of a baseball,” she said. “They had to cut it open and then it got infected, and because I have blood flow issues, it doesn’t heal.”

She knows it’s likely to happen again.

“Over the past three years, I’ve been prescribed over 60 different medications and combinations; none have even touched the pain,” she said.

Hubbard said she’s had injections and even traveled across the country for infusions of ketamine, an anesthetic that can be used for pain in extreme cases. Her doctors have discussed amputating her leg because of the frequency of the infections.

“All I can do is manage the pain,” she said. “Opioids have become the best solution.”

For about nine months, Hubbard was on a combination of short- and long-acting opioids. She said it gave her enough relief to start leaving the house again and do physical therapy.

But in April that changed. At her monthly appointment, her pain doctor informed her the dose was being lowered. “They had to take one of the pills away,” she said.

Hubbard knew the rules were part of Arizona’s new opioid law, which places restrictions on prescribing and limits the maximum dose for most patients. She also knew the law wasn’t supposed to affect her — an existing patient with chronic pain.

Hubbard argued with the doctor, without success. “They didn’t indicate there was any medical reason for cutting me back. It was simply because of the pressure of the opioid rules.”

Her dose was lowered from 100 morphine milligram equivalents daily (MME) to 90, the highest dose allowed for many new patients in Arizona. She said her pain has been “terrible” ever since.

“It just hurts,” she said. “I don’t want to walk, I pretty much don’t want to do anything.”

Hubbard’s condition may be extreme, but her situation isn’t unique. Faced with skyrocketing drug overdoses, states are cracking down on opioid prescribing. Increasingly, some patients with chronic pain like Hubbard say they are becoming collateral damage.

New Limits On Prescribing

More than two dozen states have implemented laws or policies limiting opioid prescriptions in some way. The most common is to restrict a patient’s first prescription to a number of pills that should last a week or less. But some states like Arizona have gone further by placing a ceiling on the maximum dose for most patients.

The Arizona Opioid Epidemic Act, the culmination of months of outreach and planning by state health officials, was passed earlier this year with unanimous support.

It started in June 2017, when Arizona Gov. Doug Ducey, a Republican, declared a public health emergency, citing new data, showing that two people were dying every day in the state from opioid overdoses.

He has pledged to come after those responsible for the rising death toll.

Arizona Gov. Doug Ducey’s moves against opioid over-prescribing initially faced resistance from the state’s medical associations.(Will Stone/KJZZ)

“All bad actors will be held accountable — whether they are doctors, manufacturers or just plain drug dealers,” Ducey said in his annual State of the State address, in January 2018.

The governor cited statistics from one rural county where four doctors prescribed 6 million pills in a single year, concluding “something has gone terribly, terribly wrong.”

Later in January, Ducey called a special session of the Arizona legislature and in less than a week he signed the Arizona Opioid Epidemic Act into law. He called it the “most comprehensive and thoughtful package any state has passed to address this issue and crisis to date.”

The law expands access to addiction treatment, ramps up oversight of prescribing and protects drug users who call 911 to report an overdose from prosecution, among other things.

Initially, Arizona’s major medical associations cautioned against what they saw as too much interference in clinical practice, especially since opioid prescriptions were already on the decline.

Gov. Ducey’s administration offered assurances that the law would “maintain access for chronic pain sufferers and others who rely on these drugs.” Restrictions would apply only to new patients. Cancer, trauma, end-of-life and other serious cases were exempt. Ultimately, the medical establishment came out in favor of the law.

Pressure On Doctors

Since the law’s passage, some doctors in Arizona report feeling pressure to lower patient doses, even for patients who have been on stable regimens of opioids for years without trouble.

Dr. Julian Grove knows the nuances of Arizona’s new law better than most physicians. A pain doctor, Grove worked with the state on the prescribing rules.

“We moved the needle to a degree so that many patients wouldn’t be as severely affected,” said Grove, president of the Arizona Pain Society. “But I’ll be the first to say this has certainly caused a lot of patients problems [and] anxiety.”

“Many people who are prescribing medications have moved to a much more conservative stance and, unfortunately, pain patients are being negatively affected.”

Dr. Julian Grove, a pain specialist, says that doctors were already facing pressure on many fronts to reduce treatment by opioids in Arizona.(Will Stone/KJZZ)

Like many states, Arizona has looked to its prescription-monitoring program as a key tool for tracking overprescribing. State law requires prescribers to check the online database. Report cards are sent out comparing each prescriber to the rest of their cohort. Clinicians consider their scores when deciding how to manage patients’ care, Grove said.

“A lot of practitioners are reducing opioid medications, not from a clinical perspective, but more from a legal and regulatory perspective for fear of investigation,” Grove said. “No practitioner wants to be the highest prescriber.”

Arizona’s new prescribing rules don’t apply to board-certified pain specialists like Grove, who are trained to care for patients with complex chronic pain. But, said Grove, the reality is that doctors — even pain specialists — were already facing pressure on many fronts to curtail opioids — from the Drug Enforcement Agency to health insurers down to state medical boards.

The new state law has only made the reduction of opioids “more fast and furious,” he said.

Grove traces the hypervigilance back to guidelines put out by the Centers for Disease Control and Prevention in 2016. The CDC spelled out the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage.

Psychiatrist Sally Satel, a fellow at the American Enterprise Institute, said those guidelines stipulated the decision to lower a patient’s dose should be decided on a case-by-case basis, not by means of a blanket policy.

“[The guidelines] have been grossly misinterpreted,” Satel said.

The guidelines were not intended for pain specialists, but rather for primary care physicians, a group that accounted for nearly half of all opioids dispensed from 2007 to 2012.

“There is no mandate to reduce doses on people who have been doing well,” Satel said.

In the rush to address the nation’s opioid overdose crisis, she said, the CDC’s guidelines have become the model for many regulators and state legislatures. “It’s a very, very unhealthy, deeply chilled environment in which doctors and patients who have chronic pain can no longer work together,” she said.

Satel called the notion that new prescribing laws will reverse the tide of drug overdose deaths “misguided.”

The rate of opioid prescribing nationally has declined in recent years, though it still soars above the levels of the 1990s. Meanwhile, more people are dying from illicit drugs like heroin and fentanyl than prescription opioids.

In Arizona, more than 1,300 people have died from opioid-related overdoses since June 2017, according to preliminary state numbers. Only a third of those deaths involved just a prescription painkiller.

Heroin is now almost as common as oxycodone in overdose cases in Arizona.

A Range Of Views

Some physicians support the new rules, said Pete Wertheim, executive director of the Arizona Osteopathic Medical Association.

“For some, it has been a welcome relief,” he said. “They feel like it has given them an avenue, a means to confront patients.” Some doctors tell him it’s an opportunity to have a tough conversation with patients they believe to be at risk for addiction or overdose because of the medication.

The organization is striving to educate its members about Arizona’s prescribing rules and the exemptions. But, he said, most doctors now feel the message is clear: “We don’t want you prescribing opioids.”

Long before the law passed, Wertheim said, physicians were already telling him that they had stopped prescribing, because they “didn’t want the liability.”

He worries the current climate around prescribing will drive doctors out of pain management, especially in rural areas. There’s also a fear that some patients who can’t get prescription pills will try stronger street drugs, said Dr. Gerald Harris II, an addiction treatment specialist in Glendale, Ariz.

Harris said he has seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids. He receives new patients — almost daily, he said — whose doctors have stopped prescribing altogether.

Dr. Gerald Harris II, an osteopathic physician, specializes in treating addiction in Glendale, Ariz. He says he’s seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids.(Will Stone/KJZZ)

“Their doctor is afraid and he’s cut them off,” Harris said. “Unfortunately, a great many patients turn to street heroin and other drugs to self-medicate because they couldn’t get the medications they need.”

Arizona’s Department of Health Services is working to reassure providers and dispel the myths, said Dr. Cara Christ, who heads the agency and helped design the state’s opioid response. She pointed to the recently launched Opioid Assistance and Referral Line, created to help health care providers with complex cases. The state has also released a set of detailed prescribing guidelines for doctors.

Christ characterizes this as an “adjustment period” while doctors learn the new rules.

“The intent was never to stop prescribers from utilizing opioids,” she said. “It’s really meant to prevent a future generation from developing opioid use disorder, while not impacting current chronic pain patients.”

Christ said she just hasn’t heard of many patients losing access to medicine.

It’s still too early to gauge the law’s success, she said, but opioid prescriptions continue to decline in Arizona.

Arizona saw a 33 percent reduction in the number of opioid prescriptions in April, compared with the same period last year, state data show. Christ’s agency reports that more people are getting help for addiction: There has been about a 40 percent increase in hospitals referring patients for behavioral health treatment following an overdose.

Shannon Hubbard, the woman living with complex regional pain syndrome, considers herself fortunate that her doctors didn’t cut back her painkiller dose even more.

“I’m actually kind of lucky that I have such a severe case because at least they can’t say I’m crazy or it’s in my head,” she said.

Hubbard is well aware that people are dying every day from opioids. One of her family members struggles with heroin addiction and she’s helping raise his daughter. But she’s adamant that there’s a better way to address the crisis.

“What they are doing is not working. They are having no effect on the guy who is on the street shooting heroin and is really in danger of overdosing.” she said. “Instead they are hurting people that are actually helped by the drugs.”

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