It’s Not Just Heroin: Drug Cocktails Are Fueling The Overdose Crisis

Anthony, seen here in Chelsea, says he has overdosed 12 times. His really intense highs were produced by heroin, sometimes with an alcohol chaser, and pills. (Martha Bebinger/WBUR)

Anthony, seen here in Chelsea, says he has overdosed 12 times. (Martha Bebinger/WBUR)

A bald man in gray sweats bounds into the brick plaza next to City Hall.

“Hey,” someone calls out, “where you been?”

“At the hospital,” the man named Anthony says. “I OD’d.”

A half dozen people watching shake their heads. It’s a bad week in Chelsea, they say, with three overdose deaths.

“They’re dropping like flies,” says Theresa, a woman who manages a rooming house and does not want to share her last name.

Anthony, whose last name we’ve also agreed not to use, says he overdosed the night before on a particularly strong bag of heroin, laced with fentanyl, the dealer said, or something like it.

“[The dealer] told me how strong it was,” Anthony says, “but everyone says that to sell their dope.”

Fentanyl, an opiate that is many times more powerful than heroin, was present in about 37 percent of overdose deaths from January through June of last year, based on 502 cases analyzed by the Office of the Chief Medical Examiner in Massachusetts. Continue reading


CDC Report Tracks The IUD Renaissance

You might call it the “Comeback Contraception.” In any case, it seems, IUD use is on the upswing.

This week’s CDC National Health Statistic Report highlights the surge: The number of women using long-acting reversible contraception (LARC) has almost doubled in recent years, and most of the increase is due to the growing popularity of IUDs.

From the report:

Among women currently using contraception, use of LARC increased from 6.0% for 2006–2010 to 11.6% for 2011–2013. Use of IUDs makes up the bulk of this category, with 10.3% of current contraceptors using an IUD during 2011–2013.

The number of women using long-acting reversible contraception has increased from 6 percent in 2006 to 11.6 percent in recent years. (Source: Centers for Disease Control and Prevention)

The number of women using long-acting reversible contraception has increased from 6 percent in 2006 to 11.6 percent in recent years. (Source: Centers for Disease Control and Prevention)

Intrauterine devices remain less popular than other forms of contraception, according to the report. The pill ranks as the most widely used method (it’s taken by 25.9 percent of women who use contraception, or 9.7 million women), followed by female sterilization (25.1 percent, or 9.4 million women) and the male condom (used by just over 15 percent, or 5.8 million women).

Still, LARC devices, including IUDs and contraceptive implants, were used by 11.6 percent or 4.4 million women, according to the report: “While the most commonly used methods — female sterilization, the pill, and the male condom — appear to remain consistent over time, an increase has been noted in the use of LARC methods, primarily the IUD.”

A confluence of events have contributed to the IUD’s renaissance, experts say, including an improved product, a drop in price and more promotion by doctors, including the American Academy of Pediatrics, and backing by the family of Warren Buffett.



Darker Days: Talk Therapy May Be More Durable Than Light Treatment For Seasonal Affective Disorder

For me, it’s already started: As the darkness descends around 5 p.m., my mood starts to sink too. And it’s not even Thanksgiving.

Victims of SAD, or seasonal affective disorder, a form of depression marked by a dip in mood during the darker winter months, take note: Light therapy may help, but talk therapy may be more “durable” in the long-term.

Researchers at the University of Vermont report that light therapy (essentially, simulating sunrise by sitting in front of a device upon waking that emits high intensity artificial light, around 10,000 lux, for at least 30 minutes) was comparably effective as cognitive behavioral therapy for addressing acute episodes of SAD.

(Lloyd Morgan/Flickr)

(Lloyd Morgan/Flickr)

However, the researchers found that after two subsequent winters nearly half the subjects in the light therapy group reported a recurrence of depression, compared with just over one-fourth of those in the cognitive behavioral therapy (CBT) group.

Lead researcher Kelly Rohan, Ph.D. a professor in the Department of Psychological Sciences at the University of Vermont in Burlington, said in an interview that after two winters: “The CBT [patients] maintained their gains better, and we found a more enduring effect of the CBT treatment two years out. Fewer had recurrences of depression and, as a whole, their depressive symptoms were fewer and less intense than people with light therapy.”

Over 14 million Americans suffer from SAD, the researchers report, based on extrapolating a national number from a smaller U.S. sample; prevalence ranges from 1.5 percent of the population in southern states like Florida to over 9 percent in the northern regions of the country.

“There’s no argument that light therapy is a very effective treatment that can substantially improve winter depressive symptomsunder acute conditions, Rohan said in the interview. “But there’s an assumption that people stick to it, and interventions that require effort from people face compliance issues over time.”

The study’s bottom line, she said, is:

“I think the data show that consumers have choices — light therapy is very effective — the question is, ‘Am I willing to stick with it long term and then continue on through the whole winter and pick it up next fall through the winter?’…if so, more power to you. However, if you are willing to consider an alternative, that is CBT, it might be more durable  — you can carry it into the future like a toolbox, you’ve got coping techniques you can use over time.” 

(Full disclosure: Dr. Rohan receives book royalties from Oxford University Press for the treatment manual for the cognitive-behavioral therapy for SAD intervention.)

So how does CBT for SAD differ from therapy for general depression? Rohan says the approach is similar — with a bit of custom tailoring. For instance, the therapist might say something like: “‘We know the dark days are a big contributor to the onset of your symptoms and we can’t control that — we can’t control the sunrise and sunset. But we can control your reaction, and what you think and what you do in response to these light and temperature changes.’ ”

In general, CBT for this condition hinges on reframing the patient’s thinking about the approaching winter — away from a negative attitude about the shorter, darker, freezing, snowbound days, and toward a more positive approach, for instance: What kind of fun, frolicking things can I get out and do in the cold?

“Instead of hibernating and becoming more socially withdrawn,” Rohan said, “we try to get people more engaged in fun winter activities.”

And if you think escaping to the Caribbean will solve your problem, think again: “We don’t endorse jumping on a plane — that’s avoidance, that’s pretending it’s summer when it’s actually winter,” she said. “And dialing the heat up in your home or going to a tanning bed, we don’t advocate for that either — that’s denial, that’s never an adaptive coping strategy. We want people to take winter by the horns.”

Personally, sunshine-filled vacation therapy in winter has worked for me, but Rohan pushed me to rethink this strategy. “When you come back from a trip like that, re-entry can be really jarring,” she said. “Patients feel great when they’re there, when they come back to reality it can really bite.”

Here are some more specifics on the study, published online in the American Journal of Psychiatry, from the UVM news release:

In the study, 177 research subjects were treated with six weeks of either light therapy – timed, daily exposure to bright artificial light of specific wavelengths using a light box – or a special form of CBT that taught them to challenge negative thoughts about dark winter months and resist behaviors, like social isolation, that effect mood. Continue reading

Chest Pain Is Top Item On Nation’s $80 Billion ER Care Bill, Study Finds

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

(Courtesy Dr. J. Slutzman, presented to the American College of Emergency Physicians)

If you’re feeling chest pain that you think might be a heart attack, there’s only one thing to do, medical experts say: Seek emergency care. Do not pass go, do not collect $200. Or rather, do not think about the roughly $1,000 your care will cost the hospital. Your life may be at stake.

But at a calmer moment less fraught with risk, you might want to contemplate the bigger picture of chest pain and emergency care, as sketched out by Dr. Jonathan Slutzman of UMass Medical School and colleagues at a recent national conference on emergency medicine. To wit: Your costs are part of a national Emergency Department care bill that totals nearly $80 billion, including nearly $5 billion for chest pain alone.

Every year, Americans log a total of about 130 million visits to emergency rooms, Dr. Slutzman said. Among those visits, according to his team’s analysis of millions of records, patients who come in for chest pain are the single biggest line item on the bill.

“Chest pain is one of the two most common reasons somebody comes into the Emergency Department,” he said. “It’s somewhere on the order of 5 percent of all visits,” which may not seem like very much until you realize it’s 5 percent of 130 million, and each chest-pain visit costs about $1,000.

The grand total: $4.7 billion. It’s so high because chest pain is both a high-volume diagnosis and the treatment is high-intensity, Slutzman said, usually including blood tests, X-rays, sometimes CT scans and sometimes stress tests. They add up.

So now that we see that prodigious price tag, what is to be done?

Emergency medical specialists are working on that problem, he said, in part by figuring out what the “best practices” are for evaluating chest pain. “This is on people’s radar screens,” he said, “to try and ‘rightsize’ our care,” meaning that “we can safely treat many patients while doing less.”

To which I naturally responded: “Yikes. I don’t really want the system to be trying to save money when I might be having a heart attack.”

Slutzman calmed me down. His No. 1 takeaway from the findings, he said, is that more patients should probably be evaluated as to whether they’re having a heart attack without having to stay overnight in a hospital. Chest pain patients tend to be almost reflexively kept in the hospital for at least one night of testing, he said, “and a big subset of those people don’t really need it. One big key is more rapid access to outpatient providers. If someone can see their doctor in one to two days and maybe get some additional testing then, they can be safely discharged.”

That calmed me down a bit. I do believe in staying out of the hospital whenever possible.

He calmed me still further with a story:

Historically, back in the late ’80s and early ’90s, if you walked into an Emergency Department with chest pain, you got admitted to a cardiac Intensive Care Unit, pretty much no matter what, because there was so much concern that they could be missing heart attack. There was a lot of fear of that.

And then, over time, we learned more and more. We could read our electrocardiograms — our EKGs — a little better, we could learn a little bit more about what the squiggles meant, and which ones were dangerous and which ones weren’t.

And then we got more blood tests that were a little bit more sensitive and a little bit more specific, and a little bit better at figuring out who was having a heart attack and who wasn’t. Continue reading

Opinion: Doctors Aren’t The Only Problem When It Comes To Opioid Abuse

By Anne-Marie Williams

I applaud the work of Gov. Charlie Baker and his Opioid Working Group in making bold moves to address the worsening epidemic, but I was alarmed by how physicians were portrayed during a recent panel on the crisis, in which Baker participated.

During the panel, physicians were portrayed both as over-prescribers of pain medications and defensive opponents to the governor’s efforts to address the opioid crisis.

Baker has talked in the past about doctors and hospitals as partners in this fight while saying he’s surprised by the cavalier attitude he hears from many physicians about their pain prescribing practices.

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

However, at this forum physicians were repeatedly cited for frivolous dispensing of pain medication, with no attention paid to the difficulties of balancing adequate pain control with the risk of addiction, and physicians groups were raised as some of the predominant opponents to the governor’s legislation.

As a medical student, I beg to disagree.

Doctors are critical allies in halting the opioid epidemic. I would caution the governor to avoid dismissing physicians’ objections to his proposals as defensive attempts to resist oversight. I work with many doctors and medical students who feel hampered by systemic barriers to better addressing substance use disorders in our practice. Instead of calling them out, I urge the governor to call physicians groups in to the fight.

The opioid epidemic is rooted in more than overzealous prescribers. Profiteering by pharmaceutical companies, systematic failures of the FDA, widespread barriers to medical and mental health care and the poverty that so many in our population face all have important roles in the story.

And providers have a unique perspective on ways that new policies such as 72-hour limits on opioid prescriptions or involuntary commitment for people with addiction might actually challenge their ability to provide effective care to patients with addiction. Here’s the president of the Massachusetts Medical Society, Dr. Dennis Dimitri, detailing that perspective. Continue reading

Fentanyl-Related Deaths Up Sharply In Mass.

The number of fentanyl-related overdose deaths is up sharply in Massachusetts.

State police, which conducts toxicology tests for the state medical examiner, say that fentanyl was present in 336 people who died of overdoses in a 12-month period that ended on Oct. 6.

That’s up more than 50 percent from the previous 12-month period.

Fentanyl is a synthetic opioid that is much more potent than morphine and is often mixed with another substance such as heroin.

A report last month from the Centers for Disease Control and Prevention found Massachusetts had the second-highest number of fentanyl confiscations in 2014, with 630 seizures by U.S. law enforcement.

Massachusetts Attorney General Maura Healey has proposed a bill that would make trafficking in fentanyl a crime.

State officials have said there were more than 1,200 overdose-related deaths in Massachusetts last year.


Fatal Fat Shaming? How Weight Discrimination May Lead To Premature Death

Jeff Newell, left, in November 2014, and then on Oct. 18 of this year, after finishing his first road race (Courtesy)

Jeff Newell, left, in November 2014, and then on Oct. 18 of this year, after finishing his first road race (Courtesy)

As soon as the chair broke under the weight of his 533 pounds, Jeff Newell knew he wouldn’t get the job.

With a background in customer service and a culinary arts degree, Newell, of Taunton, Massachusetts, had been searching fruitlessly for work for several years. Finally, a great job near his home opened up that seemed a perfect fit with his credentials. But then came the chair-breaking incident. Humiliating, yes, but even more infuriating because the interviewer, offering neither help nor an apology, simply shook her head and made a face.

“I knew what she was thinking: ‘This person is overweight and he’s going to be lazy and why should I hire him?’ ” Newell said. The situation was mortifying emotionally, but also took a physical toll. Newell broke out in a sweat, his heart racing.

The sort of weight-based discrimination that he says he experienced is not just unpleasant and stressful; it may actually lead to premature death, a recent study finds.

While earlier research has shown that weight discrimination is associated with poor health outcomes for a variety of reasons, the new study, led by researchers at Florida State University, concludes that in addition, “weight discrimination may shorten life expectancy.”

The new analysis found an association only, and no causal link between discrimination and life expectancy. Still, researchers in the field say the paper, published in the journal Psychological Science, adds to a growing body of literature pointing to the deep, long-term impact of weight bias and discrimination.

“I think this is one of the most important papers to come out in the research of weight stigma,” said A. Janet Tomiyama, Ph.D., assistant professor in the Psychology Department at the University of California, Los Angeles, where she studies weight stigma and directs UCLA’s Dieting, Stress, and Health Laboratory. “The finding itself is astonishing, but even more significant is that they were able to replicate the finding across two very high quality cohort studies. The crucial implication here is that the stigma alone of being heavy can be harmful to health — and we know that weight stigma is rampant in this country.”

The findings emerged after researchers analyzed data from two separate national studies: the Health and Retirement Study (HRS), with more than 13,000 participants, and the Midlife in the United States Study (MIDUS), with more than 5,000 participants. The two studies (conducted about 10 years apart) both included reports on perceived discrimination, including weight discrimination.

The new analysis found that weight discrimination was associated with an increase in mortality risk of nearly 60 percent among both HRS and MIDUS participants and also that the increased risk “was not accounted for by common physical and psychological risk factors.” In other words, the health effects of the discrimination were teased out from the health effects of the weight itself.

In an interview, Angelina Sutin, the study’s lead researcher and an assistant professor in the Department of Behavioral Sciences and Social Medicine at Florida State University College of Medicine in Tallahassee, said the big surprise was that even after statistically controlling for other factors such as body-mass index, level of disease, depression and smoking, among others, the experience of weight discrimination was linked with people dying earlier than expected.

“What was really surprising was that the association was there not just in one sample but in two, and the associations were almost identical,” Sutin said.

Weight discrimination and bias are widespread, according to an overview on the stigma of obesity, and that translates into inequities in employment, health care and education

And that stigma appears to contribute to a “vicious cycle,” according to Tomiyama, of UCLA, who writes about “a positive feedback loop wherein weight stigma begets weight gain.”

Indeed, in an earlier study, Tomiyama found that children labeled as “too fat” had an increased risk of having an obese body mass index nearly a decade later.

So why might stigma be causing such problems, and possibly contributing to premature death?

That question wasn’t addressed in the recent study, but Sutin offered some informed speculation.

“Part of it might be stress that people are carrying around with them,” she said. But sometimes it’s where the discrimination comes from that’s meaningful. For instance, she said: “Families are often the source of weight discrimination,” and that can be particularly painful, since “families are supposed to be a support.”

Also, several studies find that weight bias is rampant among medical students and other health care providers. Even eating disorder specialists are not immune to negative stereotypes about obese patients, according to a 2014 study. This attitude among health care professionals can lead to delays in care and treatment, and also misdiagnoses, experts say.

Much of the research on weight stigma and discrimination is led by Rebecca Puhl, Ph.D., deputy director of the Rudd Center for Food Policy & Obesity and a professor in the Department of Human Development & Family Studies at the University of Connecticut. She said there are several possible mechanisms at work that could contribute to premature mortality for people subject to weight discrimination.

“Other studies have found that when people are exposed to weight stigma or discrimination, that they actually experience elevated physiological stress responses (e.g., cortisol reactivity, blood pressure) which could contribute to poor health outcomes,” Puhl wrote in an email. “In addition, studies show that exposure to weight stigma can also lead to increased calorie intake, food consumption, and binge eating, which could play roles as well. The idea here is that weight stigma can induce emotional distress, which in turn becomes a trigger for turning to some of these maladaptive eating patterns as temporary coping strategies to alleviate those negative feelings.”

Sarah Bramblette, who has a master’s degree in health law, says even though she suffers from a medical condition called Lipedema that contributed to her current weight of over 400 pounds, she has been subjected to weight discrimination throughout her life. While she says some of the nasty comments hurt her feelings, it’s the bias from health professionals that has the greatest impact.

Here’s how Bramblette opened her recent TedxNSU talk at Nova Southeastern University in Fort Lauderdale:

When I first appeared on stage, what was your perception of me? Lazy, disgusting, perhaps depressed, unmotivated, unhealthy? Based on my appearance it’s usually assumed… that my weight and my condition in life are self-induced. That’s not true, but often I don’t get a second chance to make a first impression….Weight bias that I’ve experienced in health care has hurt me physically. When doctors and nurses have the perception that I’m lazy and unmotivated and noncompliant, that influences the care they provide and it has a negative impact on my health.

Continue reading

Cambridge ‘Safety Net’ Program Seeks To Catch Troubled Kids

After some behavioral issues, Deven is now a client of the Cambridge Safety Net Collaborative. This summer, he was kept busy, including joining a Pop Warner football team. (Robin Lubbock/WBUR)

After some behavioral issues, Deven is now a client of the Cambridge Safety Net Collaborative. This summer, he was kept busy, including joining a Pop Warner football team. (Robin Lubbock/WBUR)

It started with one of those “you’re so ugly” insults kids throw around when they’re feeling mean. Deven, then a fifth-grader in the Cambridge Public Schools, blew up.

“I threw my lunch tray at a kid,” Deven says in a quiet voice, nestled into his living room couch and remembering one of the most difficult days of his life. “The principal wrapped me up and put me in the office.”

This was at least the second time last spring that the school worried Deven — whose last name we’re withholding to protect his privacy — would hurt himself or others.

“One day, I put a kid in a chokehold. And then, another day, my teacher said she was going to call security on me,” Deven says. “I’m not a bad kid, it’s just when some kids get on my nerves I can get anxious to hurt ’em.”

Deven remembers feeling sad and angry often last spring. His grandfather had just died. And his dad, who he doesn’t live with, had had a stroke and lapsed into a coma. Deven says his dad later showed him pictures from his hospital stay. Deven would stop talking and shut down emotionally when he thought about the pictures. He was running away from conversations he couldn’t handle, disappearing from home or school.

When he started flipping chairs in the cafeteria, school officials called an ambulance, and Deven was strapped to a stretcher, he says. Two members of the Cambridge Police Department met Deven at Cambridge Hospital for a psych evaluation. One of them, Officer Pam Morris, was already tracking Deven’s case, but not the way you might expect a police officer would. Continue reading

Exploring The Link Between Chronic Pain And Suicide

By Judy Foreman

This week’s grim report about rising suicide and overall death rates among white, middle-aged Americans contains a slim silver lining. Here it is:

The new analysis by two Princeton economists, Anne Case and Angus Deaton, suggests that chronic pain — and the opioids used to treat it — may be a key driver of the rising deaths. While the “noisy” opioid epidemic has garnered near-daily headlines across the country for several years now, the equally horrible but silent epidemic of chronic pain has not yet broken through into the nation’s consciousness. Maybe things are beginning to change.

Many people still don’t realize it, but 100 million American adults live with chronic pain, many of them with pain so bad it wrecks their work, their families, their mental health and their lives.

There are no hard data on how many people with chronic pain die by suicide every year. But there are inferences. The suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain.

(jennifer durban/Flickr)

(jennifer durban/Flickr)

Since there are 41,149 suicides every year in the U.S., according to the National Center for Health Statistics,  it’s possible that roughly half of these suicides are driven by pain. Not proven fact, but plausible hypothesis. This would suggest that perhaps up to 20,000 Americans a year with chronic pain kill themselves, which would be more than the government’s tally of 16,235 deaths from prescription opioids every year.  According to a CDC spokeswoman:

In 2013, there were 8,257 deaths that involved heroin and 16,235 deaths that involved prescription opioids. These categories are not mutually exclusive: if a decedent had both a prescription opioid as well as heroin listed on their death certificate, their death is counted in both the heroin as well as the prescription opioid death categories.

The truth, of course, is devilishly difficult to figure out with any certainty. Many people in severe, chronic pain have, and should have, opioids available. But unless they leave a suicide note it’s virtually impossible to tell if they overdose on purpose or accidentally. That’s in stark contrast to a pain patient who ends his or her life using a gun. That’s clearly a suicide, with or without a note.

In the course of researching my 2014 book on chronic pain, I heard many grisly stories. One Salt Lake City truck driver I interviewed would be dead today if his wife hadn’t walked in on him with a gun in his mouth. He had been in severe headache pain and after many visits to the ER, was repeatedly dismissed as a drug seeker, even without a medical workup. (Eventually, he was diagnosed with two brain aneurysms, bulging weak spots in a blood vessel). Continue reading