Tagged Public Health

Viewpoints: Overlooking Screening For Cognitive Impairment Would Be A Mistake For Some Patients; McConnell Bills On Abortion Aren’t About Infanticide

State Highlights: Georgia Health Price Transparency Bill Breezes Through Senate; Texas Governor Explores Options For Expanding Medicaid

One Of Nation’s Largest PBMs Express Scripts May Be Hit With Subpoena Over Failing To Provide Insulin Price Info

Teaching Police About Autism: Advocacy Groups Hold Seminars In N.J. About Why Some Children Might Run From Law Enforcement

‘Unspeakable Tragedy’: Milwaukee Shooting At Molson Coors Plant Leaves 6 Dead Including Shooter Who Worked There

Biden Says Trump Wants To Fingerprint Food Stamp Recipients. Turns Out It Was Bloomberg Who Touted Such A Plan.

They Fell In Love Helping Drug Users. But Fear Kept Him From Helping Himself.

She was in medical school. He was just out of prison.

Sarah Ziegenhorn and Andy Beeler’s romance grew out of a shared passion to do more about the country’s drug overdose crisis.

Ziegenhorn moved back to her home state of Iowa when she was 26. She had been working in Washington, D.C., where she also volunteered at a needle exchange — where drug users can get clean needles. She was ambitious and driven to help those in her community who were overdosing and dying, including people she had grown up with.

“Many people were just missing because they were dead,” said Ziegenhorn, now 31. “I couldn’t believe more wasn’t being done.”

She started doing addiction advocacy in Iowa City while in medical school — lobbying local officials and others to support drug users with social services.

Beeler had the same conviction, born from his personal experience.

“He had been a drug user for about half of his life — primarily a longtime opiate user,” Ziegenhorn said.

Beeler spent years in and out of the criminal justice system for a variety of drug-related crimes, such as burglary and possession. In early 2018, he was released from prison. He was on parole and looking for ways to help drug users in his hometown.

He found his way to advocacy work and, through that work, found Ziegenhorn. Soon they were dating.

“He was just this really sweet, no-nonsense person who was committed to justice and equity,” she said. “Even though he was suffering in many ways, he had a very calming presence.”

People close to Beeler describe him as a “blue-collar guy” who liked motorcycles and home carpentry, someone who was gentle and endlessly curious. Those qualities could sometimes hide his struggle with anxiety and depression. Over the next year, Beeler’s other struggle, with opioid addiction, would flicker around the edges of their life together.

Eventually, it killed him.

People on parole and under supervision of the corrections system can face barriers to receiving appropriate treatment for opioid addiction. Ziegenhorn said she believes Beeler’s death is linked to the many obstacles to medical care he experienced while on parole.

About 4.5 million people are on parole or probation in the U.S., and research shows that those under community supervision are much more likely to have a history of substance use disorder than the general population. Yet rules and practices guiding these agencies can preclude parolees and people on probation from getting evidence-based treatment for their addiction.

A Shared Passion For Reducing Harm

From their first meeting, Ziegenhorn said, she and Beeler were in sync, partners and passionate about their work in harm reduction — public health strategies designed to reduce risky behaviors that can hurt health.

After she moved to Iowa, Ziegenhorn founded a small nonprofit called the Iowa Harm Reduction Coalition. The group distributes the opioid-overdose reversal drug naloxone and other free supplies to drug users, with the goal of keeping them safe from illness and overdose. The group also works to reduce the stigma that can dehumanize and isolate drug users. Beeler served as the group’s coordinator of harm reduction services.

“In Iowa, there was a feeling that this kind of work was really radical,” Ziegenhorn said. “Andy was just so excited to find out someone was doing it.”

Meanwhile, Ziegenhorn was busy with medical school. Beeler helped her study. She recalled how they used to take her practice tests together.

“Andy had a really sophisticated knowledge of science and medicine,” she said. “Most of the time he’d been in prison and jails, he’d spent his time reading and learning.”

Beeler was trying to stay away from opioids, but Ziegenhorn said he still used heroin sometimes. Twice she was there to save his life when he overdosed. During one episode, a bystander called the police, which led to his parole officer finding out.

“That was really a period of a lot of terror for him,” Ziegenhorn said.

Beeler was constantly afraid the next slip — another overdose or a failed drug test — would send him back to prison.

An Injury, A Search For Relief

A year into their relationship, a series of events suddenly brought Beeler’s history of opioid use into painful focus.

It began with a fall on the winter ice. Beeler dislocated his shoulder — the same one he’d had surgery on as a teenager.

“At the emergency room, they put his shoulder back into place for him,” Ziegenhorn said. “The next day it came out again.”

She said doctors wouldn’t prescribe him prescription opioids for the pain because Beeler had a history of illegal drug use. His shoulder would dislocate often, sometimes more than once a day.

“He was living with this daily, really severe constant pain — he started using heroin very regularly,” Ziegenhorn said.

Beeler knew what precautions to take when using opioids: Keep naloxone on hand, test the drugs first and never use alone. Still, his use was escalating quickly.

A Painful Dilemma 

The couple discussed the future and their hope of having a baby together, and eventually Ziegenhorn and Beeler agreed: He had to stop using heroin.

They thought his best chance was to start on a Food and Drug Administration-approved medication for opioid addiction, such as methadone or buprenorphine. Methadone is an opioid, and buprenorphine engages many of the same opioid receptors in the brain; both drugs can curb opioid cravings and stabilize patients. Studies show daily maintenance therapy with such treatment reduces the risks of overdose and improves health outcomes.

But Beeler was on parole, and his parole officer drug-tested him for opioids and buprenorphine specifically. Beeler worried that if a test came back positive, the officer might see that as a signal that Beeler had been using drugs illegally.

Ziegenhorn said Beeler felt trapped: “He could go back to prison or continue trying to obtain opioids off the street and slowly detox himself.”

He worried that a failed drug test — even if it was for a medication to treat his addiction — would land him in prison. Beeler decided against the medication.

A few days later, Ziegenhorn woke up early for school. Beeler had worked late and fallen asleep in the living room. Ziegenhorn gave him a kiss and headed out the door. Later that day, she texted him. No reply.

She started to worry and asked a friend to check on him. Not long afterward, Beeler was found dead, slumped in his chair at his desk. He’d overdosed.

“He was my partner in thought, and in life and in love,” Ziegenhorn said.

It’s hard for her not to rewind what happened that day and wonder how it could have been different. But mostly she’s angry that he didn’t have better choices.

“Andy died because he was too afraid to get treatment,” she said.

Beeler was services coordinator for the Iowa Harm Reduction Coalition, a group that works to help keep drug users safe. A tribute in Iowa City after his death began, “He died of an overdose, but he’ll be remembered for helping others avoid a similar fate.”(Courtesy of Sarah Ziegenhorn)

How Does Parole Handle Relapse? It Depends

It’s not clear that Beeler would have gone back to prison for admitting he’d relapsed and was taking treatment. His parole officer did not agree to an interview.

But Ken Kolthoff, who oversees the parole program that supervised Beeler in Iowa’s First Judicial District Department of Correctional Services, said generally he and his colleagues would not punish someone who sought out treatment because of a relapse.

“We would see that that would be an example of somebody actually taking an active role in their treatment and getting the help they needed,” said Kolthoff.

The department doesn’t have rules prohibiting any form of medication for opioid addiction, he said, as long as it’s prescribed by a doctor.

“We have people relapse every single day under our supervision. And are they being sent to prison? No. Are they being sent to jail? No,” Kolthoff said.

But Dr. Andrea Weber, an addiction psychiatrist with the University of Iowa, said Beeler’s reluctance to start treatment is not unusual.

“I think a majority of my patients would tell me they wouldn’t necessarily trust going to their [parole officer],” said Weber, assistant director of addiction medicine at the University of Iowa’s Carver College of Medicine. “The punishment is so high. The consequences can be so great.”

Weber finds probation and parole officers have “inconsistent” attitudes toward her patients who are on medication-assisted treatment.

“Treatment providers, especially in our area, are still very much ingrained in an abstinence-only, 12-step mentality, which traditionally has meant no medications,” Weber said. “That perception then invades the entire system.”

Attitudes And Policies Vary Widely

Experts say it’s difficult to draw any comprehensive picture about the availability of medication for opioid addiction in the parole and probation system. The limited amount of research suggests that medication-assisted treatment is significantly underused.

“It’s hard to quantify because there are such a large number of individuals under community supervision in different jurisdictions,” said Michael Gordon, a senior research scientist at the Friends Research Institute, based in Baltimore.

A national survey published in 2013 found that about half of drug courts did not allow methadone or other evidence-based medications used to treat opioid use disorder.

A more recent study of probation and parole agencies in Illinois reported that about a third had regulations preventing the use of medications for opioid use disorder. Researchers found the most common barrier for those on probation or parole “was lack of experience by medical personnel.”

Faye Taxman, a criminology professor at George Mason University, said decisions about how to handle a client’s treatment often boil down to the individual officer’s judgment.

“We have a long way to go,” she said. “Given that these agencies don’t typically have access to medical care for clients, they are often fumbling in terms of trying to think of the best policies and practices.”

Increasingly, there is a push to make opioid addiction treatment available within prisons and jails. In 2016, the Rhode Island Department of Corrections started allowing all three FDA-approved medications for opioid addiction. That led to a dramatic decrease in fatal opioid overdoses among those who had been recently incarcerated.

Massachusetts has taken similar steps. Such efforts have only indirectly affected parole and probation.

“When you are incarcerated in prison or jail, the institution has a constitutional responsibility to provide medical services,” Taxman said. “In community corrections, that same standard does not exist.”

Taxman said agencies may be reluctant to offer these medications because it’s one more thing to monitor. Those under supervision are often left to figure out on their own what’s allowed.

“They don’t want to raise too many issues because their freedom and liberties are attached to the response,” she said.

Richard Hahn, a researcher at New York University’s Marron Institute of Urban Management who consults on crime and drug policy, said some agencies are shifting their approach.

“There is a lot of pressure on probation and parole agencies not to violate people just on a dirty urine or for an overdose” said Hahn, who is executive director of the institute’s Crime & Justice Program.

The federal government’s Substance Abuse and Mental Health Services Administration calls medication-assisted treatment the “gold standard” for treating opioid addiction when used alongside “other psychosocial support.”

Addiction is considered a disability under the Americans with Disabilities Act, said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a nonprofit law firm based in New York City.

She said disability protections extend to the millions of people on parole or probation. But people under community supervision, Friedman said, often don’t have an attorney who can use this legal argument to advocate for them when they need treatment.

“Prohibiting people with that disability from taking medication that can keep them alive and well violates the ADA,” she said.

This story is part of a partnership between NPR and Kaiser Health News.

Related Topics

Mental Health Multimedia Public Health States

State Highlights: West Virginia Lawmakers Take Steps To Protect Health Law, Preexisting Conditions; Chicago Hospitals, AMA Invest $6M To Improve Health On West Side

Starting Exercise Programs Just Might Lead People To Run Away From Fatty, High Calorie Foods, Researchers Say

Border Patrol Sings Praise For New Migrant Detention Facility In Texas, Including Medical Screenings And Playgrounds

Coalition Of 39 States To Launch Investigation Into Juul’s Marketing Practices Amid Teenage Vaping Epidemic

Senate Dems Block 2 Abortion Measures, Accusing McConnell Of Playing Politics With Bills Destined To Fail

As The Coronavirus Spreads, Americans Lose Ground Against Other Health Threats

For much of the 20th century, medical progress seemed limitless.

Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.

Yet today, some of the greatest success stories in public health are unraveling.

Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such as halting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.

Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.

Although life expectancy inched up slightly in 2018, it hasn’t yet regained the lost ground, according to the Centers for Disease Control and Prevention.

“These trends show we’re going backwards,” said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.

While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.

“We’ve had an overwhelming investment in doctors and medicine,” said Dr. Sandro Galea, dean of the Boston University School of Public Health. “We need to invest in prevention — safe housing, good schools, living wages, clean air and water.”

The country has split into two states of health, often living side by side, but with vastly different life expectancies. Americans in the fittest neighborhoods are living longer and better — hoping to live to 100 and beyond — while residents of the sickest communities are dying from preventable causes decades earlier, which pulls down life expectancy overall.

Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.

With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a “post-antibiotic era.” Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic, and the CDC warns that “little now stands between us and untreatable gonorrhea.”

That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.

The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.

Those numbers illustrate the “failure of American public health,” said Dr. Cornelius “Neil” Clancy, a spokesperson for the Infectious Diseases Society of America. “It should be a global embarrassment.”

The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptions as well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. “The antibiotic market is on life support,” Clancy said. “That shows the real perversion in how the health care system is set up.”

A Slow Decline

A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.

By the 1990s, life expectancy in the United States was falling behind that of other developed countries.

The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, “the gains we’re making at the tail end of life cannot make up for what’s happening in midlife.”

Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.

“It’s not that we don’t have good blood pressure drugs,” Khan said. “But those drugs don’t do any good if people don’t have access to them.”

Addicting A New Generation

While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the “tobacco endgame.”

Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.

FDA officials say they’ve taken “vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren’t being marketed or sold to kids.” But Myers said FDA officials were slow to recognize the threat to children.

With more than 5 million teens using e-cigarettes, Myers said, “more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn’t reversed rapidly and dynamically, it threatens to undermine 40 years of progress.”

Ignoring Science

Where children live has long determined their risk of infectious disease. Around the world, children in the poorest countries often lack access to lifesaving vaccines.

Yet in the United States — where a federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents disregard the medical evidence that vaccinating kids is safe.

Studies show that vaccination rates are drastically lower in some private schools and “holistic kindergartens” than in public schools.

It could be argued that vaccines have been a victim of their own success.

Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.

By 2000, measles cases had fallen to 86, and the United States declared that year that it had eliminated the routine spread of measles.

“Now, mothers say, ‘I don’t see any measles. Why do we have to keep vaccinating?’” Schaffner said. “When you don’t fear the disease, it becomes very hard to value the vaccine.”

Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status. “Measles is still out there,” Schaffner said. “It is our obligation to understand how fragile our victory is.”

Health-Wealth Disparities

To be sure, some aspects of American health are getting better.

Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV can live into old age.

“It’s important to highlight the enormous successes,” Redfield said. “We’re on the verge of ending the HIV epidemic in the U.S. in the next 10 years.”

Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a 2016 study in JAMA.

The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.

“We’re not going to erase that difference by telling people to eat right and exercise,” said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. “Personal choices are part of it. But the choices people make depend on the choices they’re given. For far too many people, their choices are extremely limited.”

The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.

In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the poverty that erodes mental and physical health.

“So many of the changes in life expectancy are related to changes in opportunity,” Besser said. “Economic opportunity and health go hand in hand.”

Several policies have been shown to improve health.

Children who receive early childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.

And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.

Improving a person’s environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America’s Health.

“If we think we can treat our way out of this, we will never solve the problem,” Auerbach said. “We need to look upstream at the underlying causes of poor health.”

Related Topics

Pharmaceuticals Public Health

Trusting Injection Drug Users With IV Antibiotics At Home: It Can Work

Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He sets out a few rolls of tape and some gauze, then waits for a knock on his front door.

“This is Brenda’s desk,” Jackson said with a chuckle.

Brenda Mastricola is his visiting nurse. After she arrives at Jackson’s home in Boston, she joins him on the couch and starts by taking his blood pressure. Then she changes the bandages on Jackson’s right foot. His big toe was amputated at Brigham and Women’s Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.

Jackson is still taking intravenous penicillin to stop the infection. He came home from the hospital wearing a small medication pump that delivers a steady dose of penicillin via a PICC line. PICC stands for a “peripherally inserted” or “percutaneous indwelling” central catheter, and it resembles a flexible IV tube, inserted into Jackson’s chest.

“This all looks good,” Mastricola said, after making sure the line was clean and in place. “You don’t need me.”

When patients need weeks or months of IV antibiotic treatment but otherwise don’t need to be hospitalized, the standard protocol is to discharge them with a PICC line and allow them to finish the medication at home. It saves money and is much more convenient for patients.

But this arrangement is almost never offered to patients with a history of addiction. The fear is that such patients might be tempted to use the PICC line as a fast and easy way to inject drugs like heroin, cocaine or methamphetamine.

Jackson, 69, was addicted to heroin for 40 years. Although he’s been sober for years, most U.S. hospitals would force patients like Jackson to stay in the hospital, sometimes for eight weeks or more. But Brigham and Women’s in Boston, along with a few others in the U.S., is challenging that protocol, allowing some patients with a history of addiction to go home.

Supporters of the change argue that doing so boosts the chances these patients will stay on their antibiotics and beat the infection.

A Path To Safe At-Home Treatment

A small team of Brigham doctors and nurses started planning this unusual option shortly after opening the Bridge Clinic, a walk-in health center in Boston for patients seeking treatment for a substance use disorder. Dr. Christin Price, one of the clinic’s directors, said virtually every patient who injects drugs develops some kind of infection. It’s difficult to avoid injecting bacteria into the bloodstream when using drugs in an alley or a public bathroom. The national opioid epidemic has led, in many cases, to a parallel increase in diseases related to injection drug use, such as HIV, hepatitis C and bacterial infections of the heart and bones. A study of North Carolina hospitals found a twelvefold increase in cases of bacterial endocarditis, a heart infection, from 2010 to 2015.

“Every time someone uses injection drugs, they’re putting themselves at risk for a very complicated infection,” Price said.

Treatment options for endocarditis patients with a history of drug use are limited. Some skilled nursing facilities, home care agencies and antibiotic infusion companies decline to work with these patients once they’re released from a hospital. And, Price said, some of her patients aren’t willing to remain in a hospital for weeks on end just to finish a round of IV antibiotics.

“They kind of get stir crazy,” she said. “You can imagine it’s almost like being held captive for six weeks, especially when you’re feeling fine now because the infection is clearing. A huge problem is that some of them can’t last — and so they leave before the six weeks are over.”

Patients who don’t complete their course of antibiotics can end up with a recurring infection and a repeat trip to the hospital.

Doctors and nurses affiliated with the Bridge Clinic wondered if there was a way to send patients with a history of drug use home — safely. They mapped out three requirements: First, patients would have to be taking an addiction treatment medication such as buprenorphine, or be willing to start one. Second, patients would have to check in weekly at the Bridge Clinic. Third, patients would need to have stable housing, and live with a sober friend or loved one. Price and colleagues began months of discussions with specialists in heart, bone and joint conditions, seeking buy-in from surgeons and nurses, so their patients could participate.

“A lot of people did sort of look aghast,” Price said. “It was just their policy that people with a history of injection drug use would not go home.”

When Dr. Daniel Solomon, who is also with Brigham and Women’s, encountered those looks, he said, he’d remind colleagues that “the alternatives aren’t that good either.”

Holding patients for weeks in a hospital room is hard on both the patients and medical providers, he said. And if patients want to use drugs, they’ll find a way to do it, even in a hospital bed.

In spring 2018, Price, Solomon and others enrolled a few of the first qualified patients, then a few more — intentionally cherry-picking those who wanted to be in treatment and had a sober, stable home.

Brenda Mastricola checks on the PICC line through which Arthur Jackson, a former drug user, is receiving penicillin to treat a bone infection.(Jesse Costa/WBUR)

‘I’m Not Going Back’

Arthur Jackson met the requirement that at-home PICC line candidates take addiction treatment medication. He had been on methadone for 10 years, used heroin again, then switched to Suboxone, a combination medication containing buprenorphine and naloxone, which he has been taking for two years. And, in fact, Jackson said he was insulted when one of the doctors presented the home treatment option to him but said she was worried the PICC line might entice him to inject heroin.

“Stop right there,” Jackson recalled telling the nurse. “When it comes to my recovery, I’m serious because I’ve done so much to lick this — this thing.”

Although the possibility did cross Jackson’s mind.

“First thing I thought was, ‘Oh, I could inject heroin in here easily,’” Jackson said. “But I dismissed that thought because I’m not going back” — back to winters on the streets and living from one heroin fix to the next.

Other Bridge patients scoff at the concerns about PICC lines.

“Everyone makes such a big deal about this PICC line,” said Stephen Connolly, 36, who went home with the open port last year, while being treated for endocarditis. “If I want to get high, I know how to do it. I’m not going to mess around with a PICC.”

Connolly said that when he first came to Brigham and Women’s Hospital he was focused on his heart, ignoring his other disease: addiction. He said he was surprised when every doctor he saw, even his cardiologist, wanted to talk about addiction.

“I’m like, ‘Listen, dude. My heart’s falling apart here, so let’s hold up with the drug talk,’” Connolly recalled. He assured the cardiologist he had his addiction under control, even though he wasn’t so sure. “Obviously, I didn’t, but my mind tells me that. It’s just crazy.”

Connolly said he realizes now that the conversation around drug use was relevant and related to his heart infection.

Connolly finished his antibiotic treatment while staying with family members in Abington, Massachusetts. Brigham doctors say the housing requirement excludes otherwise eligible patients. Recent research shows homeless patients who have HIV or hep C do take their antiviral medicines; there are no equivalent robust studies on treating homeless patients who have bacterial infections.

Nevertheless, a few other hospitals are testing ways to continue outpatient treatment for patients who don’t have a stable home. In Portland, Oregon, a medical center tried providing IV antibiotics inside addiction treatment programs. A hospital in Kentucky combines addiction treatment, counseling and outpatient IV antibiotics. In Vancouver, British Columbia, the Canadian national health program pays for small apartments, staffed with a nurse 24 hours a day, where patients can stay while they complete antibiotic treatment.

“People who use drugs deserve the same standard of care,” said Dr. Christy Sutherland, medical director at the Portland Hotel Society in Vancouver. “We can’t change what we offer as clinicians — to give people subpar treatment with the excuse that they are IV drug users.”

Promising Early Signs

Arthur Jackson lives alone in his studio apartment (he does not live with a sober friend or loved one), but he convinced doctors he’d be better off there than in the hospital, so he could visit his 93-year-old mother daily, feed his tankful of tropical fish and his cat, and attend regular Narcotics Anonymous meetings.

“I guess the best way to put it is, I have a life and I need to get back to it,” he said.

Jackson is one of 40 patients with a history of drug use the Brigham team has discharged from the hospital to complete IV antibiotic treatment at home. The team is paying particular attention to 21 patients within that group who, unlike Jackson, are active drug users. So far, these men and women have finished their antibiotic treatment via a PICC line with no complications. One had to be readmitted because he had trouble administering the antibiotics. Price said three patients relapsed into drug use, but no one used the PICC line to inject illegal drugs.

“I think we’ve shown, through this pilot, that it is safe and feasible for certain patients,” Price said.

Brigham doctors have not yet published these initial results in a medical journal, though they plan to. But already, Price said, the pilot program is helping to cut health care costs.

Taken as a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home rather than in a hospital or rehab facility. Not including the cost of home care visits by a home nurse, the savings tally more than $850,000, based on estimates of $1,500 per hospital day.

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

Related Topics

Multimedia Public Health States

Democrats Sharpen Health Care Attacks As Primaries Heat Up

The ideal began to get real on Tuesday, as seven of the top contenders for the Democratic presidential nomination sparred over the price tag on health care reform and even revealed similarities on issues like marijuana legalization.

With Democrats in 15 states and American Samoa set to cast their primary votes in the next week, the candidates eagerly seized their chances on the debate stage in Charleston, S.C., to jab Sen. Bernie Sanders of Vermont, the current frontrunner, during the party’s tenth debate.

For all of their interruptions and talking over each other, though, the candidates offered a few thoughtful answers and, seemingly in spite of themselves, agreed on at least decriminalizing marijuana and expunging past, small-scale marijuana possession charges from Americans’ criminal records.

Sanders said he would remove marijuana from the list of controlled substances on the first day of his presidency and added that he would empower black, Latino, and Native American communities to start businesses selling the drug legally, rather than leave corporations to fill what is already a lucrative market.

Mike Bloomberg, the former mayor of New York City, expressed the most skepticism of full legalization because of his concerns about the drug’s effect on the brains of young people. Until we know the science, it’s just nonsensical to push ahead,” he said.

Rural health was also a topic, giving Sen. Amy Klobuchar of Minnesota the opportunity to tout her leadership on bipartisan legislation that would help rural hospitals as well as an immigration bill that would encourage foreign-born doctors trained in the United States to practice in rural areas.

And though the candidates were not asked about abortion rights, the subject came up, briefly and jarringly. Describing how she lost her job as a young teacher when she became pregnant and had no union or legal support to fight back, Sen. Elizabeth Warren of Massachusetts abruptly turned to the allegations of sexual harassment against Bloomberg.

“At least I didn’t have a boss who said to me, ‘Kill it,’ the way that Mayor Bloomberg is alleged to have said to one of his pregnant employees,” Warren said, eliciting gasps.

“I never said that,” Bloomberg said.

Let’s look at what else the candidates claimed.

‘The Incredible Shrinking Price Tag’

Pete Buttigieg, the former mayor of South Bend, Ind., took issue with Sanders’ changing cost estimates for his “Medicare for All” plan.

“Senator Sanders at one point said it was going to be $40 trillion, then 30, then 17. It’s an incredible shrinking price tag,” Buttigieg said. “At some point he said it is unknowable to see what the price tag will be.”

Sanders has indeed cited differing estimates of what Medicare for All would cost.

The $30 to $40 trillion figure alludes to work done by the Urban Institute, a Washington think-tank. It is the only analysis to factor in the price of long-term care — one of the most expensive components of Medicare for All — and finds the program would cost $34 trillion in new federal spending over 10 years. (In terms of national health spending — both public and private dollars, that is — it would result in an increase of just $7 trillion over a decade.) The research makes assumptions that Sanders’ bill leaves open-ended, for instance, estimating what Medicare for All would ultimately pay hospitals and health professionals. Experts note that this is a major hole in Sanders’ plan.

The $17 trillion comes from a paper released this month in the medical journal, The Lancet. The researchers say Medicare for All would save $450 billion annually. That would drop the cost significantly, to just about $17 trillion over 10 years.

This figure is what Sanders relies on in calculating his own plan to finance the single-payer plan. His proposed set of revenues would raise about $17.14 trillion in a decade. (For more information on the Lancet study — whose methodology prompted skepticism from many policy analysts — see our full fact-check.)

Sanders has also said in at least one interview that the price of Medicare for All is “impossible to predict.” This is perhaps the most correct. As analysts repeatedly have told us, the switch to single-payer would represent a shift of unprecedented magnitude in American history. And before you can predict what it would cost, you need to decide what you would pay hospitals and doctors.

Pandemic Specialists: Where Are You Now’?

When the debate turned to the global threat of the new coronavirus, COVID-19, Bloomberg, Klobuchar, and former Vice President Joe Biden used similar talking points: that President Donald Trump cut global health experts from his national security team, leaving the U.S. unprepared to face the virus outbreak either globally or domestically.

“The president fired the pandemic specialists in this country two years ago,” Bloomberg said.

It’s true that, in May 2018, the top White House official who was in charge of the U.S. response to pandemics left the administration. Rear Admiral Timothy Ziemer was the senior director of global health and biodefense on the National Security Council and oversaw global health security issues. That global health team was disbanded after Ziemer’s departure and reorganized as part of a streamlining effort headed by then-National Security Adviser John Bolton.

Ziemer’s position on the NSC has not been filled in the last two years. Tom Bossert, a homeland security adviser who recommended strong defenses against disease and biological warfare, also departed in 2018.  

Last month, Trump announced that Health and Human Services Secretary Alex Azar would be the chair of the coronavirus task force that’s in charge of the U.S. response to the disease. But many are still urging that this position be filled to coordinate the federal response. 

Last week a group of 27 senators sent a letter to current National Security Adviser Robert O’Brien to ask him to appoint a new global health security expert to the NSC.

Preparedness Funding For Global Infections 

Former Vice President Joe Biden said President Donald Trump “cut the funding for CDC.”

Trump has consistently proposed funding cuts to the Centers for Disease Control and Prevention. But Congress has consistently overruled him. 

Because the comment came during a discussion of the United States’ preparedness for emerging global infections like the coronavirus, we looked at the budgets for emerging and zoonotic infectious diseases at CDC, rather than for the CDC as a whole.

The Trump administration’s initial budget proposal has consistently been lower than what was spent the previous year. The administration proposed $61.7 million less in 2018 than 2017; $96.4 million less in 2019 than in 2018; $114.4 million less in 2020 than in 2019; and $85.3 million less in 2021 than 2020.

However, Congress usually treats any president’s budget proposal as an opening volley, with lawmakers reshaping the federal budget as they see fit when they craft final spending bills.

Every year since Trump has been president, lawmakers have passed bills — bills that were eventually signed by the president — that not only exceeded what Trump had asked for on emerging infections but also exceeded what had been spent the previous year.

The next debate, the eleventh of what the Democratic National Committee has said will be 12 presidential primary debates, is scheduled for Sunday, March 15.

PolitiFact’s Louis Jacobson contributed to this story.`

Related Topics

Elections Health Care Reform Insurance Medicare Public Health

Viewpoints: If Patient Voices Could Be As Loud As Lobbyists, Then Surprise Medical Bills Might End; How Is it That Greedy Corporations Get Rich On Insulin?

New Speedy Genomic Testing For Tough To Diagnose, Deadly Infections Could Revolutionize Care, Researchers Say

1,200 Plus Opioids Given To 3 Sisters: Appalachian Task Force Convicts Tennessee Psychiatrist

Google Researchers Candidly Lay Out Scope Of Difficulty When It Comes To Making Health Data Anonymous

Juul To Propose Selling E-Cigarette That Will Only Unlock For Users Who Are At Least 21 Years Old

Lawmakers Want IHS To Be Held Accountable For Its Role In Protecting Pediatrician Convicted Of Sexually Assaulting Boys

Immigration Advocates Braced As ‘Public Charge’ Rule Goes Into Effect

The Golden State’s Mixed Record On Lung Cancer

It was a bewildering moment for Zach Jump, the American Lung Association’s national director of epidemiology and statistics. The numbers leaped off the computer screen and prompted an immediate question:

How could California, a leader in reducing lung cancer cases, fall so short on early diagnosis and treatment of the disease?

“It’s like you’d found the needle in the haystack of results,” said Jump. “I don’t know if anyone knew this was going to show up.”

It was right there in the association’s annual “State of Lung Cancer” report, published in November: California had the third-lowest rate of new lung cancer cases in the country, a laudable achievement. But among state residents diagnosed with the disease, nearly a quarter received no treatment — a dismal showing that landed California near the bottom of the heap. Worse, California screened high-risk patients at a lower rate than every state but Nevada.

Nationally, the report showed a dramatic increase in the five-year survival rate of people diagnosed with the disease. That finding was reinforced by an American Cancer Society report released last month showing that from 2016 to 2017, the U.S. experienced the largest single-year drop in cancer mortality ever reported — driven by a decline in deaths from lung cancer.

California’s low rate of new lung cancer cases makes sense given its aggressive anti-tobacco laws and high taxes on tobacco products. Between 85% and 90% of people who die of lung cancer in the U.S. were smokers, and “California is the poster child for tobacco control,” said Jump.

But what explains the state’s dramatically weaker performance on early diagnosis and treatment?

The answer is complicated in a state as large as California, but lung cancer experts agree on the influence of several factors: the state’s large income inequality, broad cultural and linguistic diversity, inconsistency of health care access by region — and neighborhood — and a financial reluctance by many medical professionals to treat poor people, who smoke at higher rates than those of the general population.

“People aren’t getting screened in the places where the incidence of smoking is the highest,” said Dr. Jorge Nieva, an oncologist with Keck Medicine of the University of Southern California.

A low-dose CT scan, the only recommended screening exam for lung cancer, is highly effective, research shows. In one large clinical trial, it reduced lung cancer deaths by 20% among people at high risk, who were defined as those between ages 55 and 80 with a history of heavy smoking, even if they had quit within the previous 15 years.

The lung association study shows that just 4.2% of patients in the United States who are at high risk for lung cancer get screened for it — seen as an alarmingly low figure by those who work in the area of prevention. But compared with that low national figure, California’s screening rate is woefully inadequate: just 0.9%.

Performing the exam is profitable — but only if insurance payments are high enough. Medi-Cal, the government-funded insurance program for low-income people that covers about a third of all Californians, has long paid rates far below the national average.

Not surprisingly, scans are performed much more commonly in areas where people are likely to have good private insurance. “Unfortunately, it’s the population that doesn’t have great insurance that needs the screening the most,” said Nieva.

Medical experts say the state’s low screening numbers help explain why 24% of California’s diagnosed lung cancer patients receive no treatment at all, well above the national average of around 15%. Without adequate screening, lung cancer generally is discovered at later stages, when treatment is far less effective and many clinical trials aren’t offered.

Other factors weigh heavily on California’s ability to boost screening and treatment, according to people with deep experience in the field. Among them:

Cultural barriers. Especially among immigrant groups, “we need culturally sensitive approaches that include materials, educational tools, awareness campaigns and doctors who can speak to people in their native languages,” said Laurie Fenton Ambrose, president and CEO of the GO2 Foundation for Lung Cancer, a patient advocacy group.

Homelessness. As California’s unhoused population has swelled to over 150,000, health care providers have more difficulty reaching those in need of services. “Many of the 60,000 homeless in L.A. County would very likely be considered at risk for lung cancer, and they are not being screened,” said Dr. Steven Dubinett, a pulmonologist at UCLA.

Access to primary care. “California has some uniqueness in how hard it is to see a doctor in lots of parts of the state,” Nieva said. “That’s incredibly important when it comes to getting things early on, like that persistent cough you’ve had for a few months.”

Lack of statewide coordination. The state’s Comprehensive Cancer Control Plan hasn’t been updated in almost a decade. “It is inefficient and slow to improve. You don’t even have a plan that lays out its goals for fighting lung cancer,” Fenton Ambrose said.

Numerous personal factors can also influence whether patients get screening and treatment, experts say. Some people may be reluctant to be tested for fear of learning they have a terrible disease — including medical problems unrelated to lung cancer that the exam might uncover.

Nieva and Fenton Ambrose said the stigma attached to lung cancer — the notion that patients caused it themselves by smoking — can contribute to a sense of fatalism in both patients and their doctors.

Dubinett favors rolling out screening programs throughout the state, especially in areas where access to health care is spotty. Given the effectiveness of the exams and follow-up treatment if lung cancer is detected early, the state might well improve upon its five-year survival rate for lung cancer patients, which stands at 21.5% — roughly matching the national average of 21.7%, according to the lung association.

Such an initiative may fall to the state, with help from academic medical systems including USC and UCLA.

Nieva noted that USC has begun an outreach program in South Los Angeles offering high-risk patients free rides to Keck Hospital for screening.

“This should be getting done everywhere, and at a 100% rate,” Nieva said. The fact that it’s not is “a real indictment of our health care system.”

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

Related Topics

California Multimedia Public Health States

Viewpoints: Lessons On Physical, Mental Health Dangers Of ‘Stop And Frisk’ Policies; Why Hasn’t The U.S., Unlike Other Countries, Added Graphic Warnings To Cigarette Packs?

State Highlights: N.Y. Officials Urge Parents To Avoid Health Risks Of Circumcision Ritual; Maryland Lawmakers Consider Law Easing Restrictions On Medical Marijuana In Schools