The Medical News Report, #47

December 2015

www.themedicalnewsreport.com

Merry Christmas to you and your family!

Get your Flu Shot!

I want to thank Brenda Korte for all of her great website work to manage my website and publish my reports every month. Thank you Brenda!! If anyone wants help with website creation and management, she is a clear choice.

Subjects for December:

1.The Obesity Series-Part 5----the link to cancer

2. Gastrointestinal Series---Part 8- Upper GI Bleeding and Peptic Ulcer Disease

3. Anticoagulants---Blood Thinners

4. STDs---Part 2—viral causes—Hepatitis B and C, Molluscum Contagiosum

5. Answers to the high cost of healthcare---from the editors of the Harvard Business Review and the New England Journal of Medicine; personal comments

6. Opioid (narcotic) Addiction—what you need to know

1. The Obesity Series—Part 5-The link to Cancer!

This series began in August, so if you have not read the series from the beginning, I suggest you consider it in Medical News Report #41

A.Obesity is the no. 2 cause of cancer(after smoking tobacco). Why? Recent research points the finger at the effect of obesity on 3 factors:

1)Fat cellsthat secrete adipokines, a group of inflammatory markers.

2) Sex hormones and their effect on fat dysfunction.

3) Endocrine hormones (leptin and ghrelin)secreted by the fat cells-the fat cells in our body are considered an endocrine organ.

Explanation:

Fat cells are influenced though a variety ofadipokines (interleukins, leptins, adiponectin, tumor necrosis factor, etc.) produced in these cells, which are inflammatory markers. These pro-inflammatory markers influence the creation of cancer (tumorgenesis) cell by stimulating cancer stem cells and many other pathways thus creating a rich environment for cancerogenesis and growth. In fact, there is a known mechanism for most specific cancers including breast and colon.

Sex hormones are well known to influence the growth of breast and prostate cancer and are more influential in overweight people.  I have discussed this at length under these 2 cancer topics.

  Additional Factors—Chemicals cause cancer--There are thousands of endocrine disruptors (chemicals) that we are all exposed to daily. These chemicals have been linked to obesity, diabetes, and heart disease to mention a few. It is theorized that since obese people have so many more fat cells and these carcinogens are stored in fat cells, that it is not surprising that cancer is increased in these patients.

  Cancer is therefore a concern for people who are overweight.Some of the best known chemicals include bisphenol(BPA) found in plastics, in the plastic interiors of metal cans, and cash register receipts; phthalates used to soften plastic, also used in perfumes, soaps, shampoos, and cosmetics; pesticides;triclosanused in antibacterial soaps. These chemicals need to be avoided as they increase the risk of cancer. 

Target Storeshave told their suppliers to remove some 800 chemicals out of the products they sell. It is now recommended by many experts not to microwave food in plastic containers.

B.Obesity and Cancer Risk--Studies report that there is 6-59% increased risk for esophago-gastric carcinoma, leukemia, non-Hodgkins lymphoma, colon, thyroid, and kidney cancer. Rectal carcinoma and melanoma are increased in obese men, and survival in prostate cancer is reduced;in women--gall bladder, endometrial, pancreatic, and post-menopausal breast cancer.

C.Mortality increased in obesity--Another recent study reported 14% increase in mortality in men and 20% in women in the U.S with increases in all populations (race, color, etc.).

D. The effect of weight loss and cancer risk--Until recently has it been known that weight loss in the obese will reduce their cancer risk by decreasing these inflammatory markers. What better reason for losing those pounds. Perfect timing for discussing treatment options for losing weightin my January, 2016 report.

E.Another Factor--A new study reported that the long term use of aspirin decreases an overweight person’s risk of colorectal cancer back to the level of the population.

Reference--Journal of the American Society of Clinical Oncology; Journal of Endocrinology, 2015

2. Gastrointestinal Series—Part 7-Upper Gastrointestinal (UGI) Bleeding; Peptic Ulcer Disease

Bleeding from the esophagus, stomach and duodenum defines UGI (upper gastrointestinal) bleeding and tends to be a complication of acid induced disease—ulcers and gastritis. In alcoholics, bleeding from enlarged veins (esophageal varices) at the gastro-esophageal junction is a real medical emergency.  These veins enlarge from back pressure in the veins of the liver caused by cirrhosis (portal hypertension).

The majority of bleeding cases from ulcers and gastritis haveoccult bleeding. That means it is silent and is only apparent as dark or tarry stools. The blood turns dark because acid makes red blood dark from a process called reduction. Being aware of the color of the stool is important, as it will alert your doctor to silent bleeding. This type of silent bleeding is more common because so many patients are on acid blockers (H-2 inhibitors and PPIs).

These acid inhibitors may help ulcers but may not heal them. This endoscopic photo above shows an ulcer with active bleeding.

Acute bleeding can fill the stomach and cause nausea and may induce vomiting, which will be bright red. This can drop the blood count dramatically and should be considered an emergency. This can cause dizziness or fainting (syncope) with paleness from the blood loss. 

Intractable vomiting can cause a tear in the distal esophagus (Boerhaave Syndrome) and cause acute bleeding. This accounts for 10% of bleeding from the esophagus.

Gastric cancer must be ruled out with an endoscopic evaluation as well as other more common causes.

 Regardless of the cause of an ulcer, patients may not be aware of an ulcer until it bleeds. Being aware of your body is critical to prevent such potential emergencies.

Diagnosis can be confirmed with a nasogastric tube placed into the stomach to aspirate the contents. Endoscopic evaluation is the most common method unless the patient is bleeding rapidly.

If an ulcer is bleeding severely, a hemoclip can be place over the ulcer to stop the bleeding. 

Example: 

Treatment in the emergency department: IV fluids, blood work including type and cross match for potential blood transfusions, cardiac monitor, and establishing an airway if necessary. Once stabilized, acid blockers (PPIs) should be given, and replacement of blood loss with plasma expanders.

Drawing of an ulcer in the stomach and duodenum (the first part of the small intestine)

For acute bleeding from a duodenal ulcer will usually require one of three procedures: 1) vagotomy and pyloroplasty (cut the vagus nerve to reduce acid production and repair of the perforation and or ligation of the arterial bleeder, 2) vagotomy and resection of part of the area bleeding and/ or suture ligation of the bleeding ulcer, 3) vagotomy and duodenostomy (place a tube from the duodenum and pull through the abdominal wall).

Many ulcers are caused by medication (aspirin, anti-coagulants, NSAIDs –non steroidals such as ibuprofen, aleve, etc.). The diagnosis of the bacterium H.pylori is very important as that is the primary reason for peptic ulcers. A recent study determined that ulcersnot associated with H. pyloriare more likely to rebleed.

 If a patient is having typical symptoms of gastritis or an ulcer (heartburn, pain, bloating, belching, etc.) and does not respond within 2-3 weeks of acid blockers (PPIs-proton pump inhbitors), seeking consultation with a gastroenterologist is indicated. As usual, prevention of bleeding is the key to success.

Free Cancer Survivorship Magazines

There are 2 magazines that are free to cancer survivors, caregivers, and families that are a must.
Cure Magazine is a top notch magazine written at the laymen’s level and is very helpful.

To subscribe, Click on: www.curetoday.com

Another very valuable patient resource comes from the Academy of Oncology Nurse and Patient Navigators. This is a free bimonthly subscription includes personal stories from patients, caregivers, and healthcare professionals, advice on preparing for and managing costs related to cancer treatment, the latest prevention strategies, articles about nutrition, stress management, and survivorship.

Click on:   www.conquer-magazine.com

3. Anticoagulants—all the blood thinners

The categories of blood thinners based on action:

a) Thrombin Inhibitors--Heparin, Low molecular weight heparins

b) Enzymes-pTA-the clot buster

c) Anti-platelet drugs-Aspirin, Plavix

d) Vitamin K inhibitors-Warfarin (Coumadin)

e) Factor Xa-inhibitors-New generation anticoagulants-Xarelto, Pradaxa, Eliquis, Savaysa

Below is a review of the way blood clots. This cascade of factors is a complex pathway and clotting is interfered with at various points by anticoagulants.The new generation anticoagulants interfere with Factor Xa (ten) except Pradaxa, which interferes with thrombin.

Removing a clot versus dissolving it

Having discussed the normal way the body clots to save us from bleeding due to injury, surgery, etc., when a clot forms in a vessel, it may occlude (block) the vessel as is the case of arteries (coronaries, carotids, intra-cerebral  arteries) and veins. Normal blood clotting requires several factors to come together to form a clot with the aid of platelets. If clot blocks a vessel, a heart attack or stroke will likely occur. In certain circumstances the clot must beretrieved manually usingan instrumentusually introduced through a groin vessel.

The alternative is the use of an enzyme is used to dissolve the clot (known as tissue plasminogen activator--t-PA). This needs to be used within the first few hours after the event occurs, especially strokes. I have discussed this in report #38:

After these events occur, anticoagulants are used to keep the blood “thin” and prevent future clots or to protect stents that are placed in vessels to keep them open. Just for the record, anticoagulants do not thin the blood; they just keep the blood from clotting. Doctors use this “model” to explain what anticoagulants do to patients.

In the case of clots in veins (especially lower leg veins) that clot that can potentially dislodge (creating emboli), and anticoagulants are also used. I just discussed the issue of pulmonary emboli in the November report.

a)Thrombin Inhibitors--Heparin and Low Molecular Weight Heparins

These drugs are usually administered intravenously in the hospital in acute care.Heparin is used to treat or prevent blood clots, especially immediately after surgery, during dialysis, when giving blood transfusions, and it is used in tubes when blood is drawn so the blood won’t clot. 

Heparin is used in acute cases of pulmonary emboli, and can be used to treat certain blood clotting disorders. It can be administered under the skin (subcutaneous). Today, it is reserved mostly for in-hospital treatment.

Heparin is produced normally by certain white blood cells (basophils and mast cells), and it assists in keeping the blood from clotting while it travels in the vessels normally.

Heparin is used in coronary artery syndromes, deep vein thrombosis, pulmonary embolism, atrial fibrillation, during cardiopulmonary bypass, dialysis, and in IVs when they are not being used (heparin lock). It is also used postop after serious surgery, such as joint replacement, to prevent blood clots in the legs.

How it works--It inhibits the clotting factor- Factor Xa and thrombin to create anticoagulation. There is an antidote to reverse the drug-protamine sulfate.

Low molecular weight heparins(Fragmin, Lovenox, Innohep)are also in this category and are an alternative. 

b) Thrombolytics-(clot busters)-Tissue Plasminogen Activator—tPA(Alteplase, Reteplase, Tenectiplase)

I have discussed clot busters before when I reported on the treatment of strokesand last month pulmonary embolism. This is a very common treatment in appropriate cases with an acute stroke. tPA must be given within the first 4 hours (some give it up to 6 hours) after an ischemicstroke occurs, however, many patients delay calling 911, and miss an obvious opportunity to increase the likelihood of recovery from a stroke.

This medication is an enzyme that activates plasminogen which converts to plasmin, the active chemical that dissolves clots. It can be used in embolism orthromboses. Thrombolytics can be reversed with aminocaproic acid.

c) Antiplatelet medications—Aspirin,Plavix, and Kengrel

There are categories of blood thinners, although none of them actually thin the blood. These medications inhibit coagulation by inhibiting platelet function and are frequently used in combination with other anticoagulants. The most well-known medication is aspirin.

Aspirin-acetylsalicylic acid has been around for centuries. Hippocrates prescribed the extract of the willow tree bark 2400 years ago and has been used to treat pain,headaches, fever, arthritis, inflammation, and as an anticoagulant. It is one of a group of drugs called NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and Aleve. It directly inhibits the stickiness of platelets, preventing them to form a firm clot along with the clotting factors. It is the main ingredient in Alka Seltzer, Goody powders, and Excedrin. 

It has been determined that aspirin could help prevent stroke and heart attacks, and colon cancer by 7% in women and 9% in men after 10 years of continuous use.

It is recommended to chew an adult aspirin (325 mg.), if you think you are having a heart attack or stroke and dial 911.

Aspirin affects platelets by interfering 2 chemicals in the blood-prostaglandins and thromboxane. Thromboxane is necessary for platelets to help form a clot. It blocks the stickiness of platelets so they can’t clump and stick to a clot making it stable. Taken with an enteric coating, it is well tolerated by most patients, but certainly can cause gastric irritation and bleeding especially when combined with other anticoagulants. Do not take aspirin without your doctor’s approval, especially if you have gastric reflux or any gastrointestinal disease.

Interaction with some NSAIDs—Some NSAIDs such as ibuprofen and naproxen (Aleve) can decrease the anti-platelet effect of aspirin by as much as 50%, therefore, taking both is not recommended if the reason a person is taking aspirin is to prevent heart attacks and strokes.  Talk to your doctor about this. There are a few NSAIDs that can be taken without affecting the antiplatelet effect of aspirin—diclofenac (Volteran), sulindac (Clinoril), and meloxicam (Mobic). Reference- Medscape Pharmacies

The antiplatelet effect of aspirin is not reversible since the effect on platelets is permanent and to rid its effect, new platelets have to be formed and replace older platelets. The normal turnover for platelets is 7-8 days. If you are having certain surgeries, you will be asked to stop aspirin a week before the procedure, however, some surgeries can still be performed safely stopping the drug just 3 days.

Aspirin resistance does exist. There are individuals who have the gene CYP2C19, which is also an issue with the antiplatelet drug Plavix. Testing for this gene will give your doctor the information they need to decide if you need to adjust the dosage.

Aspirin and anticoagulants such as Plavix are combined when a vascular stent is placed. This combination may be recommended for 1-3 months, to prevent clotting in the stent. After that either drug can be chosen and will need to be taken indefinitely.

(Plavix) clopidogrel is the other drug that inhibits platelet function. It was FDA approved in 2002. This drug acts similar to aspirin and is commonly used in combination with it. It is approved for mild heart attacks, unstable angina, embolic stroke prevention, vascular stents, and peripheral arterial disease. It is not recommended for pulmonary embolism or DVT (deep vein thrombosis).

There is a long list of meds that interact with Plavix including many supplements. Be sure you tell your doctor every medication and supplement you are taking!!Your doctor will be able to access that list and decide whether Plavix is the drug for you.

The gene (CYP2C19) testingI mentioned under aspirin therapy is used primarily in the management of the dosage with Plavix. There is no drug to reverse this drug, but it clears in a few days.

Testing for blood levels of Plavix can tell the doctor whether they are adequate.

If you would like to read all the drug interactions, side effects,and warnings, click on: http://www.webmd.com/drugs/2/drug-5190/clopidogrel-oral/details

(Kengreal) cangrelor has just been FDA approved to use intravenously when coronary arteries are being stented for a few days. This medication is specifically used to prevent clotting after a stent is placed in a coronary artery. This medication tested better than Plavix in preventing clotting when a stent is placed, but much more expensive. When stable, the patient can be switched to an oral anticoagulant such as Plavix.

d)Vitamin K inhibitor--Warfarin (Coumadin)

This oral anticoagulant has been around since 1948.  You may be started on heparin and then switched to Coumadin before discharge and maintained on it indefinitely depending on the circumstances (heart valve, atrial fibrillation, vascular stent, etc. It is still the most widely prescribed anticoagulant in the U.S. After being started, it still takes 2-3 days to effectively work.

Coumadin can be reversed with Vitamin K within 3-4 days. It can be stopped and have surgery within 5 days. 

The drug inhibits Vitamin K, which is involved with the function of Factor VII and prothrombin, 2 critical blood factors in clotting.

To maintain an adequate blood level, a blood test (INR-International Normalized Ratio) must be performed regularly, and some patients are not very compliant, thus running an increased risk of serious bleeding or inadequate anticoagulation. A new self INR test (using a finger stick) can be used to monitor levels. It will be up to your doctor to recommend this.

Drug, supplement, and food interactions with Coumadin--

Certain foods can increase bleeding in the face of Coumadin—green leafy vegetables (spinach, kale, greens, parsley,and cilantro) and cruciferous vegetables (broccoli, cabbage) must not be consumed regularly.

There are many medications that can increase the risk of bleeding, such as aspirin, NSAIDS (ibuprofen, Aleve, etc.), simvastatin (lipid med), certain broad spectrum antibiotics, supplements (St. John’s Wort, Vitamin E, fish oil, ginger, garlic), and excessive alcohol consumption.

Bleeding is a significant complication of Coumadin. The bleeding can be serious (stomach) and even fatal (usually intracranial hemorrhage). Easy bruising is common.

The new generation anticoagulants may eventually replace Coumadin, because it does not require regular testing for levels of the drug and it is safer. However, for heart valve patients, Coumadin will remain the drug of choice, as the new generation drugs are not used in cases of heart valve replacement.

Many cardiologists are switching to the new generation non-Vitamin K anticoagulants, but it should be a decision between the patient and their doctor.

e) New Generation oral anticoagulants

The new generation oral anticoagulants are a big advance in the field of blood thinners. They are FDA approved for the prevention of stroke from dangerous clots due to non-valvular atrial fibrillation (5.8 million Americans), deep vein thrombosis, and pulmonary embolism. Even though, the newer anticoagulants cause less bleeding than Coumadin(intracranial hemorrhage severity), there is still a risk of dangerous bleeding.

These new generation drugs do not require blood test monitoring, which is a distinct advantage.

These new drugs have an advantage over Plavix and Coumadin in that there is little fluctuation of the blood levels of these drugs and fewer drug interactions. Just in the last few months, some of these have antidotes available, which takes away one of the problems these drugs had.

Kidney function is an important issue with thesenew  anticoagulants. Although the BUN and creatinine are the major tests ordered, if a person’s kidney function is borderline or abnormal, a creatinine clearance study is indicated. These drugs are excreted by the kidneys and will affect the blood concentration and the potential for excessive bleeding if elevated.

These new drugs affect clotting in 2 ways….either direct thrombin inhibition (Pradaxa) or inhibiting the Factor Xa(all of the rest). 

Check the FDA website for each drug for more information.

List of Current New Generation Anticoagulants

1. Dabigatran (Pradaxa)-released 2010

This drug binds to the site of thrombin, a necessary chemical in the cascade of clotting. It is eliminated by the kidneys unchanged, and therefore, if there is decreased function of the kidneys, it can increase in the blood to higher levels and cause bleeding.Eliquis is a better choice if the kidney function is impaired.There are certain drugs that will also require adjustments in Pradaxa (amiodarone, verapamil). There is a reversal drug just FDA approved-Praxbind. Other side effects of dabigatran can include heart attack, bleeding, liver failure, and death. It is FDA approved to prevent stroke, pulmonary emboli, deep vein thrombosis due to non-valvular atrial fibrillation, recurrent emboli or DVT, and recently after hip replacement surgery.

2. Rivaroxaban (Xarelto)

This drug inhibits the blood clotting factor Xa. This drug should be taken with food as it is better absorbed. Only one third of the drug is eliminated by the kidneys, therefore, may be a better choice for those with impaired kidney function. They are potent inhibitors of certain antifungals, antibiotics (clarithromycin), amidarone, verapamil), and therefore another choice needs to be made. An antidote has just been released-Kcentra-a human prothrombin complex that reverses Xarelto. This drug is once daily.

3. Apixaban (Eliquis)

This is another one that inhibits Xa (ten-a) clotting factor.  This must be taken twice daily, which might be a disadvantage. This drug also should not be taken with certain drugs (same as Xarelto) plus, certain sedatives (phenobarbital, Dilantin, Tegretol, Rifampin). Kcentra can reverse this drug too. It is least affected by decreased renal function, which is a big advantage if the function of kidney is impaired. This is the most common new generation anticoagulant prescribed today.

4. Edoxaban (Savaysa), another FDA approved Xa inhibitor. It has the same concerns all of these drugs have in kidney impaired patients. It has an advantage of 2 doses available (30 and 60mg) so that it can be taken with the smaller dose if kidney impairment is present. If the creatinine clearance (the test for renal function) is high, there is a higher risk of stroke. Kidney function studies are mandatory before choosing an anticoagulant.

5. Betrixaban (yet to be FDA approved)

Another Xa inhibitor, which just released this year, and it is the newest one in this group. It is currently in phase 3 trials, yet to be FDA approved.

Universal antidote--Andexanate alpha, a drug that can potentially reverse any anticoagulant inhibiting Xa Factor in minutes is currently being considered for fast track approval by the FDA. We still await the actual clinical value in a bleeding patient from a Xa-factor inhibitor anticoagulant.

The most common reason for anticoagulants is atrial fibrillation today. It is stated that as many as 40% more patients should possibly be on these drugs. The new oral meds have made it much more acceptable, but the long term effects of these new drugs has not been determined.

Cost Alert!! These newer drugs are coming out every year, because they are making Big Pharma rich. Coumadin costs between $1-2 per tablet and these new generation drugs cost $8-10 per pill.

The British Medical Journal (BMJ), reported found out that the drug company withheld information about the need for at least some of the patients to be monitored.

Aspirin is very good at affecting the function of platelets (interferes with thromboxane) by makng them less sticky and therefore less effective for clotting.  Most everyone takes 81 mg. a day to prevent heart attacks these days. Under the circumstances of an acute event or placement of a vascular stent, 325mg of aspirin may be recommended in addition to the anticoagulant. 

4.STDS—Sexually Transmitted Disease—part 1—viral infections continued –Hepatitis B and C, andMolluscun Contagiosum

Follow up from last month--I am currently on a committee for the American Cancer Society updating the recommendations for HPV (Human Papilloma Virus) vaccination.Currently, the CDC recommends that females be vaccinated by 11 or 12 up to age 26 and males 11 or 12 up to 21 (males who have sex with males, those with HIV, or are immunocompromised by any disease) up to age 26.

A. MolluscumContagiosum-This is a skin infection caused by the pox virus, which is sexually transmitted. The lesions are usually in the genital area and are very different from any of the other STD lesions. They are pink raised lesions with a small dent in the middle. They can be removed with liquid nitrogen, trichloracetic acid, or manual removal.

A photo of molluscumcontagiosum below!

B. Hepatitis B and C

I have discussed both hepatitis B and C previously in Medical Report #6.

1)Hepatitis B-HBV

One third of patients do not know they are infected, and for that reason any higher risk group needs to be routinely checked for HBV. Certainly the LGBT community, drug users, healthcare professionals, those with HIV,patients going to third world countries, and those immunosuppressed should be tested. They should be vaccinated against HBV. It may take as many as 20 years for this disease to manifest itself with cirrhosis.

Acute hepatitis B will cause a patient to have gastrointestinal symptoms, yellow jaundice, fatigue, osisand fever. 20-30% will eventually be diagnosed with cirrhosisand ultimately be a candidate for a liver transplant.

Risky behavior can cost so much and this is just another disease that can infect people and cause serious illness decades later.

2) Hepatitis C-HCV

  This disease is not uncommonly being diagnosed in the 50 years of age or older group. All Americans born from 1945 to 1965 should be tested once, and high risk groups frequently based on risk.

Currently, there are 3.2 million Americans with Hep C.  This is another STD that can be picked up without knowledge and a large percentage will not know they have been infected until they start having symptoms of liver failure from cirrhosis. Acute hepatitis is much less frequent, so they proceed from an undetectable acute disease to the more common chronic form. Approximately 75% will develop chronic hepatitis. The same risk group for Hep B is at risk for HCV. There is one big difference—there is no vaccine for HCV.

This is the most common reason for liver transplants today, although with the new FDA approved medical treatments, this may change the outcome of this disease over time.

GREAT NEWS---HUGE PROGRESS—A NEW DRUG REGIMEN--There are 4 genotypes of HCV and require different regimens, and those with type 2 and 3 respond better. Interferon and ribavirin have been the standard drugs for most HCV. A recent study with 700 patientsdemonstrated better results with sofosbufir/velpatasavir for all genotypes, a once a day oral therapy showing a 90% cure rate. If this study holds up, theoretically the need for genotyping may not be necessary and the numbers developing cirrhosis and/or liver cancer will be dramatically reduced.

The cost for treatment is over $94,000 for a 12 week course of treatment and is rationalized by the savings in future healthcare costs.

Other successful drugs are Harvoni, Viekira Pak, Sovaldi, Olysia, and Vietrelis.

Recently there are blood tests that can monitor the status of the liver saving the necessity for repeat liver biopsies.

1 in 30 baby boomers have been infected and are facing serious consequences without these treatments.

Another consequence of HCV--4% develop liver cancer. 

Transplants are being used to cure not only end stage cirrhosis from HCV but also for liver cancer (if it is limited to the organ). I have a friend who just successfully had a transplant because of liver cancer from Hep C at Vanderbilt Medical Center, one of the premier liver transplantation centers in the country. He is doing great!

HIV-AIDS will be discussed next month.

5. Answers to the rising healthcare costs from the editors of The Harvard Business Review and the New England Journal of Medicine, and my comments!

Before I explore some of the potential answers to the healthcare cost crisis, I feel the privateinsurance industry and Obamacare policies are destroying the quality of our healthcare. About 10 million more are insured but at a high price in quality. No longer will you be able to find many plans that cross state lines, because most of the marketplace plans are HMOs with narrowing networks, higher deductibles and co-pays. PPOs are becoming a thing of the past. Private insurance is impossible to navigate without spending hours on the internet or settling for an inferior plan.

The private insurance industry is currently coming up with alternatives, because healthcare is switching to a value-based system (fee for service is going).This will require better outcomes or the providers of healthcare will be penalized. This paradigm shift will be discussed in another report.

Physicians are once again being penalized by not receiving their promised 0.5% increase in reimbursement from Medicare. Instead, they will receive a 0.3% decrease. How long will doctors put up with this?The feds can’t keep biting the hand that feeds us!

Here are some key points on this subject brought up in the online course presented by the Harvard Business School.

1) Attacking wasteful spending in healthcare is the primary target to resolve some of the ways we can rein in rising healthcare costs. This is defined as “spending without improving quality of care”. Estimates are 25% of healthcare costs.

2) Develop consumer- directed health plan optionssuch as alternative ways to pay for provider (doctors) services eliminating the waste in the healthcare system.

3) There are 4 basic healthcare systems being proposed by the presidential candidates.

1---the current trajectory with little changes

2---Comprehensive demand-side reform (makes patients more consumer savy making wiser choices and cost conscious through incentives and better information for their healthcare based on the individual needs of the patients)

3---Aggressive supply-side reform (payment to doctors and hospitals based on outcomes and efficiency rather than volume of services)

4---A combination of demand and supply- side reform.

The above system changes do not address 40% of the $1 trillion dollars of wasteful spending.

  There are 4 categories of how to reduce wasteful healthcare spending cited below:

My opinion!

Since 2009-2013, there was a lower rise in costs, in part due to economic downturn, fewer people in the workplace, and before Obamacare began. In 2014, there is already a trend going upward in costs because of expansion of Medicaid via Obamacare (ACA) rules.

We will see shifting of costs to the states in 2016 when they will begin taking on more cost-sharing for Medicaid (Feds will pay 95% in 2016 and drop from there each year). The cost shifting to the patient in the ACA (Obamacare) healthcare exchanges will save federal money, but force patients into limiting going to the doctor or paying up to 30% of the costs as is the case in the Silver Plan of the ACA.

Encouraging patients to make wiser choices is admirable, but will they just wait til they are sicker before going to the doctor? Ultimately this will lead to costlier services because of that delay.

By 2018, there will be a major shift of payment to doctors and hospitals to models that shift more costs to the patient.

You may notice there is no mention of legal reform, containment of immigration into this country increasing the numbers to care for. How do we sustain healthcare costs without some rational approach to the exploding population? When has administrative costs ever gone down? How much does it cost to fight fraud?  If the economy does not return, how are all those people going to pay a bigger piece of the pie without jobs?

Obamacare has done nothing but pad the numbers of those insured without maintaining quality, choice of doctor or even access to care. And millions can’t even afford to pay their premiums. Unless, we come up with a reasonable solution, expect a federal one-payer socialized answer.

6. Opioid (Narcotic) Addiction (overprescribing; diagnosis and treatment of narcotic addiction)

This is a crisis that is ugly throughout. Opioid addiction, suicide, and liver disease are the reasons the death rate in middle aged white people have risen every year since 1998. How do we assure adequate pain management for deserving patients and yet prevent an ever expanding country abusing and becoming addicted to prescription medications. There is no easy answer. Although, it might be appropriate to discuss alcohol addiction here, I have chosen to discuss that huge topic at a later date.

What is known?

1. Drug addiction is a treatable progressive brain disease, not a weakness.

2. This is a relapsing disease characterized by compulsive behavior seeking out and using drugs regardless of the consequences.

3. 9.4% of the population either abuses or is addicted to opioids (24.6 million). 1.9 million Americans are addicted and 517,000 are addicted to heroin. Drug abuse occurs in 9 million Americans—includes all forms of illegal and prescription drugs)

4. Over 100 Americans died from drug overdose every day in 2013.

5. Drug overdose is the number one cause of injury in the U.S. (more than accidents or homicides).

6. 75% of opioid addicts switch to heroin because it is cheaper and easier to obtain.

7. In 2012, there were 259 million opioid prescriptions written.

8. 1 in 30 highschool seniors have taken Vicodin, and 1 in 20 abuse oxycodone. Click on an article on heroin in the schools:

www.teenvogue.com/story/teen-heroin

9. 40-60% of drug addicts relapse.

10. Only 1% out of the 9.4% of the population addicted in the U.S. seek treatment. If an addict can stay sober for 5 years, the relapse rate is only 15%.

Reference--The American Society of Addiction Medicine

Opioids include heroin, hydrocodone, oxycodone, Vicodin, Demerol, Dilaudid, codeine, and others. They are derived from the poppy plant, which comes primarily from Afghanistan. This plant has financed Islamist terriorism and is the main source of income for this country. Because heroin is so plentiful, it has become cheap, and is the number one narcotic used illicitly in the world.

The Pharmacy Industry should monitor prescribing trends of each doctor and have a data base for controlled substances for each patient. We need to know who is prescribing too any opioids!

Barriers--Mental health and substance abuse treatment in this country have taken a back seat in modern medicine. One reason for this is the rate of relapsewhich is very frustrating to medical professionals, patients, and families. Statistics make it easy for insurance companies to put a maximum on treatment,and therefore, if a relapse occurs, it is frequently not covered. Also, deductibles and co-pays have become a barrier to continued treatment.

Many more Americans with legitimate chronic pain become addicted innocently than those who chose to abuse. Pain management as a specialty has become big business, and if a patient has chronic pain, referral is most appropriate. Alternative medicine should be used as non-drug alternatives more aggressively.

The youngsters find their opioids very close to home, by stealing them from their own parent’s medicine cabinet. Don’t be naive about this. Keep your pain meds locked up and out of the reach of your kids.

The neurobiology of drug addiction is complex. Genetics play a huge role, as we all see this problem run in families, whether it is drug or alcohol abuse.

Brain abnormalities result for chronic abuse, which create craving and a need to prevent withdrawal. Detoxification will resolve these issues if properly managed by a qualified facility. It takes friends and family to organize an intervention with a qualified counselor to pull it off successfully.

Other factors include the social context for the initial opiate exposure, stress of the situation, psychological conditioning, and environmental factors. The genetic predisposition on the brain pathways that may be abnormal even before exposure, have influence on the outcome for abuse. The pleasure centers in the brain are the root of the problem. They create the desire for habituation, abuse, and addiction…even relapse after months or years of abstinence.

The Midbrain and the Limbic System

Mechanism of Addiction--The Mesolimbic Reward System--The mechanism for narcotic influence occurs in the midbrain (ventral tegmental area) that when stimulated release dopamine (and other areas including the nucleus accumbiens). Dopamine gives the pleasurable effects. Other areas of the brain create memories called conditioned associations which lead to cravings. This leads to compulsion, tolerance (need more and more to satisfy) of the drug, and dependence.

Withdrawal---With tolerance and dependence, withdrawal will occur if the drugs are stopped. Addicts will act normally while on a maintenance dose, but that dose continues to increase over time leading to dangerous levels.Withdrawalsymptoms of jitters, anxiety, muscle cramps, and diarrhea occur through a mechanism of stimulation of noradrenaline in another area of the brain. There is a great drive to keep stimulating the pleasure centers, but it takes more of the narcotic. Without increasing the dose there will be no pleasure. Drug addicts know that “chasing the dragon” ultimately is futile, leading to dangerous and even lethal levels of drug. That occurs all too often.

Preventing stress, not associating with situations or individuals will help prevent relapse, but it is a life-long struggle. It is complex and expensive to treat. With relapse as the norm, it has become a low priority for insurance companies to favorably cover the expense.

It will take legislative and perhaps presidential influence to address this major healthcare crisis. President Obama has included this in one of his initiatives on mental health.

The combination of alcohol and drug addiction creates an environment for potential overdose.

TREATMENT

For those who can’t understand what it is like to be addicted, realize the craving for a particular drug is just as powerful as hunger for food. Consider what you would do if you were starving and knew there was food out there to satisfy your craving and override higher reasoning.

Unfortunately, only 13.5% of drug abusers seek treatment. This is a shameful percentage.

Prescribing drugs that can relieve pain and not stimulate the complex pleasure centers is at the center of pharmacologic management, but if it was only that simple. Blocking chemicals in the brain like dopamine creates problems as well.

Methadone, LLAM (levoalpha-acetylmethadol), buprenorphine-naloxone (Suboxone) have been the mainstay of treatment, as these meds can act very similar to the narcotics but differ in that they have certain protective and normalizing effects. Suboxone treats addiction in 2 ways: satisfies craving and prevents withdrawal symptoms. These meds can still be abused, and that is why treatment must include behavioral therapy to maintain abstinence and careful monitoring.

Detoxification requires hospitalization because of the risk of death. Withdrawal symptoms include anxiety, jitters, sweating, muscle and gut cramps (from noradrenaline). Later symptoms include gastrointestinal issues (diarrhea, nausea, vomiting, etc.). Clonidine will help these symptoms by blocking the noradrenaline effects. Buprenorphine medications have proven very valuable in treating withdrawal.

Naltrexone (Vivitrol)-injectible- has been used to rapidly detoxify in certain cases. It blocks the euphoric effects of opioids, however, compliance with taking a maintenance dose of naltrexone is a problem, being only successful in about 15%.

If you want to read about this injection, click on:

www.drugs.com/vivitrol.html

Support Groups

AA and other organizations have tremendous benefit as support groups. Religion plays a role for many. Having a higher power for many is the extra key to success.

Another year has come to a close. I hope you enjoy these reports and they continue to empower you to read more and become more proactive with your own healthcare. We are in for hard times in this country and no one is going to look out for you better than you and your doctors.

  Subjects for January, 2016

1. The Obesity Series ends with a profile of treatments.

2. What are GMOs?

3. STDs-Part 3-viral causes-HIV-AIDS

4. Gastrointestinal Series-pancreatitis, diagnosis and

    Treatment

5. Dental Series—causes of bad breath

6. Why do so many women have to have their breast

    cancer surgeries reoperated?

7. New treatment for chronic sinus disease.

Stay healthy and well, my friends, Dr. Sam

Merry Christmas, Happy Hanukkah!!