The Medical News Report, #58

November, 2016

Samuel J. LaMonte,MD,FACS

www.themedicalnewsreport.com

samlamonte@yahoo.com

Subjects for November:

1. Comparing Clinton and Trump’s Healthcare plans

2 ADHD-Attention Deficit Hyperactivity Disorder

3. Substance Abuse Series—Part 2-Opioid/Heroin (Narcotic) Addiction Epidemic

4. The Genitourinary System-Part 2- Infections

5. The Gastrointestinal Series-Part 14-Colorectal Cancer

 

Reminder!! Breast Cancer Awareness Month was October. Get your mammogram! Support breast cancer research!

IMPORTANT REMINDER!!!! PLEASE READ!!!

  I remind you that any medical information provided in these reports is just that…information only!! Not medical advice!! I am not your doctor, and decisions about your health require consultation with your trusted personal physicians and consultants.

  The information I provide you is to empower you with knowledge, and I have repeatedly asked you to be the team leader for your OWN healthcare concerns.  You should never act on anything you read in these reports. I have encouraged you to seek the advice of your physicians regarding health issues. Feel free to share this information with family and friends, but remind them about this being informational only. You must be proactive in our current medical environment.

   Don’t settle for a visit to your doctor without them giving you complete information about your illness, the options for treatment, instructions for care, possible side effects to look from medications, and plans for follow up. Be sure the prescriptions you take are accurate (pharmacies make mistakes) and always take your meds as prescribed. The more you know, the better your care will be, because your doctor will sense you are informed and expect more out of them. Always write down your questions before going for a visit.

  Now, on with the information!! Thanks!! Dr. Sam

 

1.Last minute Update on Healthcare plans from Clinton and Trump

News Flash!

The average increase of premiums for Obamacare next year will be 25%. That means subsidies to these recipients will skyrocket as well . Obama expected the healthy to pay for the sickest Americans, and it has blown up in his face. His mandates were too little. Even now it cannot exceed $700.  Many states are down to one carrier for insurance, and it is a travesty. Consider this latest information when you vote for the candidate of your choice.

The American Hospital Association has just announced that from 2013-2015,inpatient costs have risen 23.4%. With this rise and continued escalation of cost, there is little chance of sustaining our current healthcare system without getting the cost of medicines under control, as they are the offending culprit. There is a real question which candidate (or neither) can get these costs under some kind of control, but negotiation of drug prices with Big Pharma for Medicare is a great start. I am afraid whoever does win the presidential election may decrease the quality of healthcare in an attempt to cut costs. Think very hard about this when you vote.

  Consider all the faults and unintended consequences of the ACA plan (Obamacare). With Secretary Clinton trying to get expand the number people on Obamacare (illegals and refugees), the cost will necessarily spread to all of us forcing an accelerated route a single payer system, which is of course her plan. Clinton plans on continuing Obamacare no matter the consequences to our citizens. Trump wants to repeal Obamacare and place the sickest people in state governmental grants for insurance. Separating the sickest from the healthiest is a clear path to getting healthcare under control.

RAND Corp. announced its analysis of both plans and stated that Clinton’s plan would decrease the number of uninsured by 40% at an estimated increased cost of $90 million in 2018 alone. Trump’s plan will theoretically increase the number of uninsured by 25 million. They do not explain how that was calculated. Because those people would lose Obamacare, the U.S. Treasury could lose up to $41 billion, assuming those people were actually paying their monthly premiums. Currently 1.4 million are already losing their Obamacare because the providers (insurance) are bailing out. This was just announced.

  Remember healthcare plans are passed by the Congress (not the president), and who controls the Senate and the House, will determine whether either candidate can effectively change the current program.

  The bottom line for Clinton is to push a federal one payer system(Medicare for all over 49) in addition to continuing Obamacare. This will put a tremendous strain on the Medicare fund already running out of money in the next decade or two. Getting this program off the ground will take a few years to have enough physicians and networks to handle the number of patients that would flood the program, and that assumes doctors will sign up for expanded Medicare. I anticipate serious curtailment of the current Medicare system, diminishing the current quality.

 RAND is assuming that the government will reimburse doctors and hospitals at the Medicare rate.  Of course, her program will increase taxes to all taxpayers (everyone making over $200,000). That will include a lot of people in the middle class. 40% of all taxes are paid for by the upper 5% of Americans. If you are in favor of more taxes, this is the plan for you.

According to Clinton, drug costs for Obamacare patients would be capped at $250 per month, and allow Congress to negotiate Medicare drug prices with Big Pharma. Medicaid drug prices are already negotiated. The deficit for their savings will be paid for by additional taxes to over half of all tax paying Americans.

  Trump would repeal and replace Obamacare providing governmental block grants for high risk groups (Medicaid) of patients, paying insurance premiums with pretax dollars, and allowing Americans to purchase insurance across state lines (which assumes competition will quickly drive down the cost of premiums). He will also reduce taxes and assumes stimulation of the economy to pay for these additional tax burdens.

  Both candidates proposed getting rid of the Cadillac tax on expensive medical insurance plans.

  RAND analysis does point out the increase in numbers of uninsured people in the country, however, if Trump were to win the election, the borders would be tightened, and illegals would not be eligible for insurance since they would be deported. Tightening the borders will also reduce the drug trafficking which is costing billions of dollars in healthcare costs including death and devastation to families.

  Remember, any plan proposed must be passed by the Congress. It is up to you to vote for your candidate. No matter who is president, the quality and cost of care is at stake. Increasing the cost for any healthcare program is highly likely. There is no way to simplify the issue of healthcare. It is hard to carve out healthcare without looking at each candidate’s entire plan. The differences are striking. We are looking at two very different  Americas!!

Reference-Medscape Medical News, September, 2016

 

2. ADHD-Attention Deficit Hyperactivity Disorder in Adults

A. Introduction

Although the cause of ADHD is not known, it is an authentic medical disorder with genetic and brain chemistry abnormalities. Boys age 4-17 are twice as likely to be diagnosed with ADHD (13.2% boys and 5.6% girls) in the general population. 12% of the population (39 million) has ADHD.

ADHD usually begins before the age of 6. It should be noted that girls may not be diagnosed as easily as boys, and therefore, it may not be true that this disorder is necessarily 3 times as common in boys. Many are not diagnosed at all and may present as adults with obsessive compulsive disorder, anxiety, or depression. As high as 30-70% of children with the disorder continue symptoms into adulthood (they don’t “grow out” of it).

B. Types of ADHD

   Not all children with this disorder are hyperactive. There are 3 types of ADHD:

1) Predominantly inattentive-- girls and boys are equal in frequency, lack focus and have trouble paying attention. They may be careless and don’t follow through with tasks. Girls tend to be more daydreamers and have trouble socializing. Depression, bulimia, and anorexia are more common ADHD girls.

2) Predominately hyperactive/impulsive

3) Combined

C. Identifying ADHD

a) A recent study pointed out that in adolescents who commit suicide, ADHD is more common than depression.

b) Trouble in school is common to all kids with this disorder.Behavior issues are most common.

c) Many patients are never diagnosed and find themselves having trouble with relationships and their professions, may be frequently tardy, andhave difficultykeeping the task at hand.

D. The dynamics of ADHD:

   --Teens and young adults have more traffic accidents, speeding, and lose their license more frequently. People with ADHD have trouble multitasking, and are greater offenders of texting while driving. Cellphones and emails tend to be great distractions.

--Starting and finishing jobs is difficult. Sitting still watching a TV program may be a challenge. Some are poor readers because they can’t concentrate for long.

   --Having trouble with finances and caring for children is not uncommon in women. 

   --Lack of self-control leads to losing their temper easily (more common in boys and men), and they tend to verbalize their frustration easily. They tend to have impulsive behavior

   --It should be noted that if the person is extremely interested in a task, they may be very effective while demonstrating poor abilities to deal with less interesting tasks. Putting off tasks is common. 

   --These patients are commonly the kids described as hyperactive, into “everything”, do not do well in school because of the lack of paying attention in class. Daydreamers might be included in this group.

   --2/3rds of these patients have depression and or anxiety, obsessive-compulsive behavior, learning disabilities, disruptive or defiant behavior, drug and or alcohol abuse (including more likely to smoke) as other associated psychological disorders.  These patients tend to self-medicate themselves with substances that calm them down.

e) Brain abnormalities/familial tendency

Certain neurotransmitters are less active in the part of the brain that deals with attention. It runs in families and is more common if a mother used tobacco and drank alcohol during her pregnancy.

E. Associations with other disorders

  There are many other disorders these patients are prone to:

   Learning disabilities (30%), Tourette’s syndrome, conduct disorders (20%), defiant disorders (50%), mood

disorders (depression, anxiety, and bipolar disorders), insomnia, restless leg syndrome, and substance abuse.

  There are specific differences in brain activity in patients with ADHD.

Note above the difference in activity in the yellow portions of the brain between controls and patients with ADHD

F. Treatmentof ADHD

According to the CDC, only half of the children with ADHD receive psychological services. In addition to counseling, medicaltreatment for this disorder isa stimulant medication, whichparadoxically sharpens concentration and curbs distractibility in about 70-80% of the patients. Methylphenidate is the classic treatment. Brand names areRitalin, Quillivant-XR, and Concerta.

This medication works by slowly increasing the brain chemical dopamine. Abuse of this medication is a problem as are the amphetamines, which is similar.

  There are side effects of Ritalin including an increased risk of heart attacks and arrhythmias in young patients, especially in those with congenital heart disease. The risk/ benefit must always be considered. It is recommended that both prescription therapy and psychological counselling be utilized.

If these stimulants don’t work,SSRIs (antidepressants) may help, and if impulsive behavior is an issue, the nor-epinephrine reuptake inhibitor, atomoxetine (Strattera), may be recommended.

G. Adjustment of diet

Avoiding high fats, additives in foods, sugar, and processed foods has shown some value as a supplement to actual therapy. There is no proof this would be successful in treating ADHD as a sole treatment.

H. Contradictory study results

  A recent large study at Duke University Medical Center cited about a 69% success rate with methylphenidate (Ritalin). Adding behavioral therapy did not improve the results. This goes against standard recommendations.

Acceptance and staying on medication was more successful (78%) than behavioral therapy (63%).

  A limiting factor is the availability of pediatric therapists. The findings of the this study might allow doctors to at least try prescription treatment alone.

Reference--Archives of General Psychiatry

 

3. Substance Abuse-Part 2—Opioid and Heroin Addiction Crisis in the U.S.;

Overdose is common!

A. Scope of the problem of pain

One out of three Americans (over 100 million) have experienced some form of pain in the past 6 months. Half (50 million) of those people had pain daily, and a third (over 16 million) of them rated it as severe. 20% of them will receive a prescription for an opioid. The most common pain treated is low back pain. Not seeking non-opioid alternative treatments is a mistake, because the answer to chronic pain is not continuous narcotic useage. Other therapies include physical therapy, acupuncture, massage therapy, yoga, improving the patient’s mattress, using NSAIDs (Aleve, etc.), and topical pain remedies.

  It has been reported in studies that very few of these patients are really helped by opioids. This is new information that has the medical profession rethinking all those narcotic prescriptions. Recently, thankfully, rates of opioid prescription writing have leveled off because of the recognition of the hazards of narcotics and the rates of abuse and addiction. However, that has opened the door for “street drug” abuse.

B. Pain relief in postoperative patients

  A recent report from MD magazine cited 1 in 10 surgical patients become dependent on opioids to some degree. This is astounding!

  The medical profession is requesting that surgeons have a discussion about pain meds before surgery and get a feel for their patient’s expectation for pain control. They feel this will create an open dialog after surgery about how much pain medication is really needed after 3 or 4 days. Writing a pain prescription for a large quantity should not be done routinely. Rather re-evaluation of a patient’s pain level in a few days is more appropriate and a milder pain prescription is frequently adequate. Expecting to be pain free after surgery is just unrealistic. Using non-narcotic medications (NSAIDs) as a substitute or supplement to the narcotic can lead to less dependency on the narcotic.

  The risk factors for abuse include being male, over 50 years of age, having a history of taking antidepressants and antianxiety (benzodiazepines) meds, history of alcohol or drug abuse, and a history of depression.

  A new anti-pain medication campaign called Choices Matter Campaign, a program to utilize non-narcotic methods after surgery is being promoted. IV Tylenol and IV anti-inflammatories are now available along with other methods to ease pain. For more information, click on www.planagainstpain.com

Gabrielle Reece, a professional athlete has championed this cause.

C. Causes of the Epidemic—how did we get to an opioid and heroin epidemic? Surgical Patients

5 million Americans are addicted to opioids, and17,000 die of an opioid overdose in our country each year according to the CDC.

What are the factors that have created the current environment that has created a crisis? I recommend you read this popular medical blog:

http://www.kevinmd.com/blog/2016/06/opioid-disaster-stop-criminalizing-doctors.html

Here are some of the factors leading to the current opioid crisis:

1-Back in the 70s there were no limits on visits for physical therapy, psychotherapy, and chiropractic as long as your physician felt it was medically necessary for pain control. Now insurance pays for very few sessions.(Medicare only pays for 12 sessions of physical therapy in 12 months)

2-There were over a thousand legitimate interdisciplinary pain clinics in the country that treated pain using a multitude of modalities that were quite successful.However, “pill mills” spoiled the attempts of legitimate doctors trying to have holistic approach to pain management.

3- In 1996, a pharmaceutical company (Purdue Pharma) provided false information to the FDA about the safety of Oxycontin, the first long acting opioid, and the FDA approved it. Insurers decided that these long acting opioids were a cheaper way to treat pain, so they stopped paying for pain clinics. 90% of those clinics closed. The abuse of Oxycontin started this crisis! Insurers increased restrictions on chiropractic, physical therapy, and doctors who treated pain and pain clinics.

4- The feds put restrictions on doctors prescribing pain meds, most of whom were following proper guidelines for prescribing pain meds.

5-Doctors used to be able to bill on time spent with patients, so if more time was necessary, individual patients with difficult pain managementissues could have more time. Now, with all the Medicare regulations and drop in pay for physicians, doctors can’t spend enough time with these types of patients. This led to ignoring difficult issues like addressing pain medication abuse and addiction. Doctors just stopped writing pain prescriptions for fear of repercussions. Certain pain meds now require special certification to even prescribe.

5- When doctors began to refuse refilling pain meds, patients turned to street supply of drugs. Oxycontin cost $20 plus a pill on the street, but a bag of heroin cost as little as $10-20. Heroin is easily available. What followed is what we are seeing today, and it is coming right through our borders.

5-Governmental regulations did not interfere with patient care back in the day, but current ones have trampled the doctor-patient relationship and the patient is losing.

6-Criminalizing physicians for treating painhas led them to turn their backs on treating chronic pain all together. Certified pain management doctors are scarce and are expensive. They have even more restrictions and rules.

7-The liberalization for prosecution of drug abusers, legalization of marijuana, and the continued flow of illegal drugs across our borders (and in cargo from ships and airplanes) all adds up to a opioid and heroin crisis.

8-The lack of not destroying the poppy fields (source of opioids and heroin) in Afghanistan continues to baffle me. It is the main source of income for Afghanies, and so our government chose to turn their backs on the main source. Today, heroin and oil finance ISIS and radical Islam.

9-The lack of responsible parents leaving narcotics in their medicine cabinets for the young to steal is a huge problem for youth. It is as dangerous as leaving a gun out for children to get their hands on.

10- Our government has not given this major American problem the attention it deserves. There are few families in the U.S. who have not had exposure to someone who has become addicted to narcotics.

11- Acceptance of drug use and Abuse in Celebrities

  It is amazing how the media glamorizes the death of celebritiespushing the “accidental overdose” concept, and expressing the loss of another false idol dope addict and not addressing their addiction. The media is responsible for making too little of this epidemic. They do not expose the fact that these “entertainers” are frequently hooked on narcotics to withstand their rigorous lifestyle. They add sleeping pills and alcohol to get sleep and then take their narcotic to get up for their “show” and their horrendous pace. They easily get addicted. Prince had plenty of doctors around him that did nothing….same for Michael Jackson, and both of them died of a fentanyl and propofol overdose. These drugs are many more times potent than morphine. These drugs are used for anesthesia and are extremely powerful and should never be prescribed for chronic pain patients. Their physicians need to be disciplined and lose their licenses.

Heath Ledger, Whitney Houston, and Philip Seymour Hoffman died of a combination of drugs including heroin, cocaine, benzodiazepines, and amphetamines. And the public mourns their loss, but overlooks their horrible addiction and the effect on their family and friends. 

  These are all factors in the country’s attitude toward substance abuse.

  The medical profession has defined substance abuse as an illness with an uncontrollable desire to get high on drugs, but it usually starts with legitimate physical pain. 

  The JAMA (Journal of the American Medical Association) (2016) reported a 72% increase risk of death from causes other than accidental overdose with a 65% increase risk of a cardiovascular death reported in the JAMA, 2016.

Drug addiction is pretty, isn’t it?

D. Chronic Pain and Addiction; Scope

The June, 2016, JAMA reported that of those addicted to opioids, 75% of patients reported chronic back pain and 65% of other musculoskeletal pain that required pain management. The feds (USPSTF) have decided that regulations for pain management should be based on sound research. How can you disagree with that? There is only one problem……guidelines become rules, and insurers reimburse on the basis of following those guidelines even when they don’t apply to individual patients.

We must address this epidemic with a multifaceted approach which includes prevention, recognition of the early signs of abuse, and confront patients with proper referral to experts in the field. There are, however, many barriers to access to care including over an overwhelming 25 million Americans that are addicted to drugs and alcohol. Only 11% seek treatment!!

This crisis has overwhelmed our country. Federal programs, including Medicaid and Medicare, pay for 77% of the costs incurred with drug rehabilitation while only 10% is paid for by private insurance (private insurance pays 37% for other types of medical costs).

Sadly, only 7% of patients are referred for treatment by a physician. Most come from self-referral and the police. This has put a huge burden on our government and it is ineffective. And yet, our government has declared mental health and substance abuse addiction treatment as an essential part of health care reform and a top priority.

E. New Regulations from the Federal Government

Mental health and substance abuse has been the step-child in medicine. There has also been a sense that doctors overprescribe opiates. Clearly there are those that abuse this, but it is not the norm. Funding has been sparse. Now with the overwhelming crisis, there is a rush for new legislation(Comprehensive Addiction and Recovery Act, 2016), but most of its funds are going toward the study of the issue, a typical academician’s answer to everything. Currently, there are 18 bills being introduced and if you are interested, please click on:

www.medpagetoday.com/publichealthpolicy/publichealth/57980

Grants for education, prevention, treatment, and recovery are overdue, and researching innovation in treatment with currently available medication is a must.

 Emphasis on curtailing doctors from prescribing opioids and making it more difficult for addiction doctors to use innovative medications to treat these addictions is not the answer. As usual, academicians muddy the water with layers of red tape and unnecessary cost. There is no evidence that these measures will be effective. Doctors have been begging them for reform for the last 8 years. Even though we are far behind, at least, it is under way.

F. Heroin mixed with new synthetic drug killing users

  Addiction is now more prominent because of the access to street drugs. Believe me, they are everywhere.

  As stated earlier, because the feds gave physicians more regulations for prescribing narcotics and frequently refuse to OK refills, many turn to heroin. The prescription drugs on the street are so much more expensive, that heroin has become the go-to drug in many cases.

  Now, China has made a synthetic fentanyl called Carfentanil, a sedative used in animals like elephants. The high is similar to Oxycontin.  Drug dealers are mixing it with heroin to make it more potent. It is sent to Mexico and comes across the border to feed the U.S. frenzy for illicit drugs.  It is a killer. Time magazine just did a story on it, reporting on this new trend, and it is happening from Ohio to Florida.

  The DEA says Carfentanil is 100 times more potent than fentanyl, used in anesthesia. Over 300 deaths have been reported recently with the mixture of Carfentanil and heroin.

G. Anatomy of Addiction—how the brain creates addiction

Addiction is a complex neurochemical disease. It involves many centers including a reward center, inhibition of natural controls, memory of the drug high, and motivation to control the cravings.

Serotonin and dopamine are the two neurotransmitters responsible for the complex interaction of multiple brain sites in providing pleasure and reward. Dopamine is responsible for motivating us to do what is necessary to meet our needs. Serotonin competes with dopamine to provide happiness, satisfaction, and contentment. Low levels of serotonin created by such things as stress will increase cravings, depression, and anxiety lowering the threshold and increasing vulnerability to abuse with alcohol and or drugs. This is exaggerated by low self-esteem and neglect by loved ones. Stimulating these centers with addictive substances creates an imbalance between these two chemicals creating the addictive environment.

Below are the responses creating addiction:

H. The menu of opiates

  

        Poppy plant

Naturally occurring opiates (narcotics) that are similar in action are opium, codeine, morphine, and heroin. These are produced by the poppy plant. Opium is the primary chemical produced by the poppy plant. Certain brain cells produce a natural opioid, endorphins, that are extremely powerful. These cells have opiate receptors, and when a person is given an opiate or an opioid, it binds these receptor sites stimulating endorphins.

Synthetic opiates(opioids) include hydrocodone, dilaudid,demoral, Percodan, Percocet,Vicodan,  oxycodone (Oxycontin), fentanyl, and methadone.

  The term “narcotic” comes from the word narcosis, implying depression of the brain, the main function of opiates. Euphoria is a secondary effect and decreasing pain occurs because the brain is interpreting pain less vigorously.

  There are chemicals that are antagonistic to opiates, and are used to reverse the effects of these opiates—naloxone and naltrexone, and are playing a larger role in the treatment of addiction to be discussed below.

  Prescribing less potent meds over time should be considered, and substituting NSAIDs when possible is recommended. Reference:Medpage, 2016

I. Medical Detox Rehabilitation Centers

  Every city has licensed rehab centers to treat drug and alcohol addiction. To remove the drugs from the blood stream requires detoxification and treatment of withdrawal symptoms without complications including death.

  Although detox can be supervised as an outpatient, inpatient detox is preferred to safely withdraw a substance from the blood stream. But this is very expensive and reimbursement does not cover the massive costs.

   The decision regarding inpatient vs. outpatient must come from the experts based on many factors from co-existing medical and psychiatric conditions, age, length of addiction, and psychosocial issues, including financial capability.

There is an online guide to drug and alcohol recovery including centers in local areas. Click on:

www.addictionrecoveryguide.org/treatment/detoxification/

To find a licensed center click on the Substance Abuse and Mental Health Administration’s website:

https://www.findtreatment.samhsa.gov/

 

J. Drug Assisted Treatment--Naloxone (Narcan), Buprenorphine (Suboxone)

Using medications that are, in fact, narcotics to treat narcotic addiction has always been controversial, but they have proven to be effective, when no other traditional treatment has worked. AA, psychotherapy, religion, family support, work for some, but recidivism (falling off the wagon) is high, and that is why insurers have limited reimbursement. Much of the cost must come from individuals.

Physicians must turn to non-pharmaceutical management of pain. The use of ancillary methods must be reimbursed chiropractic, physical therapy (Medicare only allows 12 visits per year), acupuncture, massage therapy, referral to board certified pain management physicians are all needed.

  Treatment for addiction does not come from primary care physicians. They are not equipped to handle this terribly difficult process.

  There is a medical specialty of addiction medicine, but there are far too few of these providers.

  There are medications to assist in the treatment of addiction.

1-Naloxone(generic name is Narcan) reverses the effects of opioids. Studies, however, support the co-prescribing of naloxone with opioids to prevent the “high” part of narcotics and misuse while still allowing for the benefit of pain relief.At one year, those who were taking both prescriptions had 63% less opioid-related emergencies. (Annals of Internal Medicine, June 28, 2016).Narcan is used to reverse the respiratory depression of an overdose. Given IV, it can reverse the effects of the narcotic in 2 minutes. Police and emergency personel routinely carry Narcan and administer it right on-site.

2-Buprenorphine (Suboxone) is the most successfuldrug-assisted treatment for opioid addiction. The Substance Abuse and Mental Health Services Administration finalized a rule to increase access to buprenorphine in the care of addicted individuals. Addiction specialists have been hampered because of the limited availability of this drug. This is being recommended as an alternative to methadone. Although both these drugs are narcotics, they are much safer to take when other pain management alternatives have not worked.

  The Drug Addiction Act of 2000 passed by our government was intended to curb prescribing abuse of these drugs. Addiction medicine doctors are the only ones who can prescribe this drug. The feds have recently relaxed the number of patients that can be treated per year to a maximum of 275 (from 30) by pain management doctorsbut requires extra training and membership in addiction medicine organizations.Many doctors are not willing to go through these extra hoops.

In 2014, of the 1 million addicts with a medication-assisted treatment, 600,000 plus addicts were treated with buprenorphine. By no means is buprenorphine the answer to the current crisis, but it is another step in the right direction.

  Further legislation has been recommended to increase the number of patients per year and expand prescribing capabilities to certified nurse practitioners and PAs. We are still waiting on Congress to appropriate the proposed $1.1 billion to help with this crisis by the Department of Health and Human Services.

The buprenorphineimplant(subdermal-under the skin) was approved by the FDA this May. 85% of addicts stayed off opioids compared to 72% who took sublingual medication.  This willlimit the abuse oral meds potentially has. Medscape, 2016

 

3--Methadone clinics 

The FDA no longer regulates methadoneaddiction treatment and in 2001 transferred oversight to the Center for Substance Abuse, an agency of the Substance Abuse and Mental Health Administration.

  Methadone is a synthetic opiate substitute, which can be taken orally (preventing shooting up heroin), and is long acting, acts slowly without the rush of heroin, helps craving, prevents withdrawal, and still provides pain relief.

  The federal agency has hampered the use of methadone to the detriment of many patients. Illegal diversion (black marketing) and methadone deaths (from unsupervised use) are cited as the cause of diminished use of the drug. We want regulation, but it can get in the way of the doctors to treat their patients.

For an in-depth look at the policies and various aspects of methadone treatment, click on:

www.adsyes.org/methadone-program-handbook/

4--Experimental techniques

A new experimental technique is finding success in decreasing the cravings of heroin (average length of addiction=17 years) using transcranial electrical stimulation. This is a non-invasive procedure involved placing electrodes on the scalp for 20 minutes. This controlled study reported less craving when shown a video on heroin.

  An herb from a tropical tree leaf in Southeast Asia called Kratom has been used for hundreds of years as a pain reliever. It does have potent pain relieving capability, but has not been well studied and at higher doses causes hallucinations and psychological addiction. The DEA last month placed it on the Schedule 1 list, which includes marijuana, LSD, heroin, and ectasy. It apparently does not cause respiratory depression, which is the main cause of death in overdoses of narcotics. This herb needs to be fast- tracked and considered for usage for pain. However, since it is in plentiful supply, it can’t be patented by a drug company, so where will the funds come for research?? A conundrum!Congress is currently asking the DEA to hold off on placing it on the schedule 1 list. We will see how it turns out soon.

  It is very important for patients and physicians to distinguish between acute and chronic pain. Acute pain can be treated successfully with a short course of opioids, but not chronic pain. Chronic pain demands a careful assessment with referral to specialists trained to deal with it.Having patients sign a contract not to abuse opioids is working with some, and the new prescription monitoring program is also helping.

 When will our country get a handle on this? It must come from the will of the country and our U.S. government. Controllinggovernmental corruption, abuse of funds, lack of border control, not destroying the poppy fields, not preventing influx of drugs from other sources all must be addressed. Financing further preventative measures is needed, because we as a country can’t treat our way out of this crisis.

  In the future, I will report on the guidelines imposed on physicians to curb misuse of opioids, so you will see it from the doctor’s side. They are well-intentioned but have placed more control on prescribing and indirectly pushed patients to use street drugs. There is a balance, but currently still in the phase of the pendulum swinging too far to the right. Reference-Medpage, 2016

K. The recommended approach for physicians to take with pain patients

Although each patient must be handled differently, it is generally recommended to prescribe short acting opioids, avoiding the more addictive long acting types such as Oxycontin. It should be prescribed for no more than 7 days without re-evaluation of the patient’s condition and pain level. Caregivers need to know that respiratory depression is a sign of overdose. The level of consciousness must be assessed, as this is also a sign of opioid excess. An injection of naloxone will reverse the effects of opioids. It is available as a nasal spray or an auto-injector to be used in case of overdose.

  Pain management must be handled carefully. Consultations with expert pain management physicians are highly recommended to add other forms of treatment in addition to narcotic medications.

 

4. Genitourinary System Series-Part 2-Infections of the Bladder and Kidneys

Infections of the urinary tract (UTIs) can be very severe. It is important to differentiate the difference between infections of the upper (kidneys) and the lower urinary (bladder) tract, since upper tract infections are more serious. Since these infections are usually separate, I will discuss them one at a time.

A. Kidney Infections—commonly called Pyelonephritis

Kidney infections are very common especially in younger females. They are usually bacterial in cause.

1-Risks for developing a urinary tract infection

These include sexual intercourse, pregnancy, a history of previous urinary tract infections, spermicide use, a history of kidney stones, use of urinary catheters, diabetes, and a history of surgical instrumentation of the urinary tract. Dehydration and frequent baths (bathtubs) also can increase the risk.

  Congenital deformities of the urinary tract can predispose the patient to UTIs.

  Kidney infections gain entrance from the vagina and the anus. Infections (prostatitis) or an enlarged prostate can also create kidney infections. 

2-Symptoms of a kidney infection

  These include chills, fever, abdominal and or flank pain, fever, nausea, and vomiting. Pain on urination and frequency of urination can occur, but can occur with a bladder infection as well. Pyelonephritis can cause infection to spread into the blood (septicemia).

Infections of the kidney can destroy kidney tissue and cause permanent damage especially with recurrent infections. Congenital abnormalities have been mentioned and kidney stones can form with repeated infections, which block the kidney’s ability to filter the fluid through the kidneys, creating ultimate scarring and reduction of the size of the kidney. Bladder infections can spread to the kidneys, as urine can reflux back up into the kidneys through the ureters.

  Urine is normally sterile, therefore, bacteria have to enter the system, and the entry occurs from below from the vagina and anus. The bacteria normally live in the genital and intestinal tracts, which contaminate the system.

3-Diagnosis of Kidney Infections

IVP-intravenous pyelogram

    

Iodine containing dye is injected into the vein, and the dye is taken up by the urinary tract as seen in the above X-ray. It shows the outline of the kidney, the calyces (the collection anatomy in the kidney that connects to the ureters, and dye is also seen in the bladder (in the pelvis). These anatomical sites are labeled in the right photo.

  Cultures of the urine are necessary to diagnose the offending bacteria and tests are used to find the best antibiotics to treat infections. The bacteria,E.coli, is the most common bacteria causing kidney infections. Even a dipstick (see below) can determine an infection is in the system.

4-Treatment of Kidney Infection

Oral antibiotics are the treatment of choice unless the patient is sick enough to be admitted to the hospital, where IV antibiotics are used.

  Recurrent infections require an intense investigation for abnormalities of the anatomy, stones in the kidney or bladder. Dye studies, scans, etc. can diagnose these issues. It may be necessary to prescribe a low dose of antibiotics over an extended time, or even a single dose of antibiotic after sex. Prompt usage of antibiotics when symptoms first appear can prevent the infection from getting out of hand.

  Diabetes can cause nerve damage to bladder function, which can be a complicating factor. Any infection can complicate diabetes. Also menopause and multiple pregnancies can create pelvic relaxation and cause complications of bladder function as well.

  Patients in the hospital, nursing home patients, and those who are not ambulatory are at risk for infections. Dehydration is a common denominator in all these cases.

B. Bladder infections (cystitis)

1-Definition

I have discussed pelvic relaxation and prolapse in a previous report as well as overactive bladder: The Medical News Report #16, #17, #19, and #20

These bladder conditions complicate infections.

  Urinary tract infections (UTI) can include any part of the renal system, but since bladder infections are so much more common, especially in women, you will hear doctors and patients say a UTI is present.

  Bladder infections occur for the same reason that kidney infections occur….contamination from the genital and GI (anal) tract. Sexual intercourse plays a significant role as well, as pointed out above in kidney infections.

  Bladder infections are much less dangerous than kidney infections. They are more easily treated, but recurrence is more common, especially in women. Prostatitis, an enlarged prostate and urinary stones are more common reasons for a male to develop a bladder infection.

2-Symptoms of an enlarged prostate

Women are more prone to bladder infections because of a short urethra with the added anatomical closeness of the vagina and anus.

  Risks increase with dehydration, frequent sexual intercourse, advanced age, immobility, urinary anatomical abnormalities, an enlarged prostate or infection, instrumentation of the urinary tract, urinary stones, pregnancy, pelvic relaxation, and diabetes. These are similar to the risks for a kidney infection (pyelonephritis).

3-Symptoms of a bladder infection

Symptoms include pain on urination or pain in the lower abdomen, cramping, burning, urgency, frequency of urination, and foul smelling or cloudy urine. Low back pain can occur as well.

  Diagnosis can be made looking at the urine in the lab (UA-urine analysis), dip stick testing, cultures for specific bacteria or parasites (E.Coli, Mycoplasma, and Chlamydia).

Male cystoscopy

Female cystoscopy

The workup may include a direct exam (cystoscopy), manual prostate evaluation, an IVP (intravenous pyelogram) as seen in previous pages, X-rays of the abdomen looking for stones, and status of the kidneys and ureters. A tumor must be ruled out as well. If pelvic relaxation (prolapse) exists, it must be investigated and treated.Cystometric exams are also used to define bladder volume and ability of the bladder to adequately empty.

4-Treatment of Bladder Infections

   This includes antibiotics, pyridium (a urinary anesthetic) to relieve pain on urination, extra hydration, treating an enlarged prostate or other anatomical abnormalities.

  Recurrent infections may require long term low dose antibiotic and or a single dose of antibiotic after sex.

 

C. Prevention of Urinary Tract Infections

Post-operative UTIs occur in 2-5% of surgical patients. These patients usually have an indwelling catheter in place for one to several days. It is critical it is placed with sterile technique, be removed as soon as possible, optimal positioning of the catheter so that urine in the tube cannot reflux back into the bladder and drain by gravity, and if there is suspicion of a UTI, urine samples must be obtained for culture. Adequate hydration is essential. If the urine is yellow, consider the patient dehydrated and increase water intake.

Drinking cranberry juice (prevents Ecoli infections but no longer proven to prevent UTI's), urinating as soon as there is an urge, wipe from front to back, take showers instead of baths, clean the genital area immediately and urinating before and after sex, wear cotton underwear, change underwear daily, use sanitary napkins instead of tampons, avoid spermicides, douching, powders, and feminine hygiene sprays, avoid diaphragms, and use non spermicidal lubricated condoms.

Next month, I will report on urinary (kidney, ureter, and bladder) stones and their management.

Reference-medicine.net; healthline.com

 

5. The Gastrointestinal Series—Colorectal cancer(CRC)

A. Incidence and Mortality

a)Colorectal cancer (CRC) is the second most common of all cancers (over 135,000) and there are 51,000 deaths each year. 1 in 20 men and women will be diagnosed with CRC in their lifetime costing an annual $14 billion in direct medical expenses. 70% of Americans will develop a polyp in their colon and about 10% of those will go on to become cancer by age 70. About 7,000 Americans will be diagnosed annually before the age of 45. Before 65, men outnumber the women, but after 65, it is about even (40,000 each). Deaths are about even in both sexes. (Ref. ACS Facts and Figures 2016)

b)The news about colorectal cancerhas improved since 1975 with a drop of 40% incidence and 50% mortality. This has been primarily due to screening (colonoscopy), and yet only 65% of qualified Americans get screened. Colonoscopy and or fecal tests are easy to perform and the preps for a colonoscopy are greatly improved, so don’t let fear get in the way of good healthcare screening.

c) It is clear that most cancers begin as a slow growing polyp (adenoma), and if these polyps are removed, most people won’t get colon cancer. The cause of colorectal cancer is, however, multifactorial—genetic, environmental, and inflammatory conditions of the digestive tract (i.e. ulcerative colitis).

d)The value of screening (stool blood samples and colonoscopy) is clear, especially with a 51% increase in incidence (13,000 per year) in people younger than 50. It is currently recommended to begin screening at age 50 unless there are risk factors present. As expected, younger people are diagnosed with later stage disease and a resultant higher mortality rate. This increase parallels the increasing incidence of diabetes obesity, consumption of sugary beverages and decreased consumption of dairy products (calcium is protective). As high as 50% of young CRC patients are initially misdiagnosed. 75% do not have a family history of CRC. 

e)The mortality has dropped because cancers are being detected earlier, but treatment advances get credit as well. The incidence and mortality has also decreased due to improved diets (especially less smoked and cured meats), and the daily intake of aspirin. Also the use of antibiotics for infections decreases the gut bacteria of harmful bugs that have been linked to cancer such as H.pylori (Helicobacter pylori). Give a little credit to patients and doctors for having better awareness of the danger signs of colon trouble(reference-NEJM-April 28, 2016). For information on an advocacy group to bring awareness to younger people on CRC, click on www.ccalliance.org/young-and-brave/coalition

A reminder—most colon cancers are preventable, because they arise from polyps that on average take 10 years to become malignant. Fecal tests and or colonoscopy saves lives! Start at age 50unless there are increased risks! The ACS will have their recommendations out in the next couple of months-our committee just completed our studies on this.

B. More young Americans are being diagnosed with colon cancer

The incidence of colorectal cancer is rising in younger age groups (13,000 per year under 50 years of age). There are plenty of reasons to discuss colorectal cancer, but since these folks are below the recommended screening age, it is important to emphasize younger people are experiencing more colon cancers and since symptoms of are so late, the death rate is greater. 86% are not diagnosed until they have symptoms and the disease is advanced. The rates have been increasing every year by 1.5%. The rectal cancers far outweigh the colon cancers.

These increases of colon cancer in younger people parallel the rise in consumption of sugary drinks and less consumption of milk (calcium has some protective capability against CRC).  Even the makeup of bacteria in the colon is being researched. There is a coalition recently formed to address this rising problem for younger patients (Never Too Young Coalition)

www.ccalliance.org/young-and-brave/coalition/

Cancer in the colon

Cancer with ulceration

C. Risk Factors

a) Environmental risk factors include a fatty diet, inactive lifestyle,being overweight, type 2 diabetes, genetic predisposition (5-10% of CRC), high alcohol intake,and  smoking tobacco.

b) Hereditary syndromes (accounts for about 10% of colon cancers), African-Americans, Ashkenazi Jewish, various familial polyposis syndromes (they have the APC gene mutation and cancer by age 40), and a non-polyposis syndrome (Lynch syndrome).

Patients with Lynch syndrome also have a higher risk of breast, gynecologic, and kidney cancers. 3% of colorectal cancers are thought to have Lynch Syndrome. There is a screening test (MSI) for this syndrome. If a person has this syndrome, they have a 40% lifetime chance of developing colorectal cancer and usually at an earlier age. Screening in these individuals should be strongly considered at a younger age.

  Developing colorectal cancer at an early age (before 50) should raise a flag about a genetic cause and genetic testing with genetic counseling!

D. Symptoms of CRC

Unfortunately, cancers in the colon do not have symptoms early in the disease, and because of that as many as 20% present as emergencies, 80% of those patients present withintestinal obstruction. 

Vague abdominal discomfort, bowel habit changes, gas, bloating, cramps, darker colored or bright red blood in the stools, hemorrhoids, unexplained fatigue or weakness are present to some extent.Anemia, weight loss, intestinal obstruction, and ascites (fluid in the abdomen) might point to a more advanced disease. 

E.Prevention

  Although maintaining a healthy diet, a normal weight, adhering to CRC screening guidelines, and being aware of bowel habit changes, aspirin is the only known medication recommended as a preventative. The USPSTF (US Preventive Services Task Force) currently recommends people from 50-69 years of age to take a low dose aspirin (less than or equal to 100mg) daily for at least 10 years to help prevent colon cancer. I will discuss aspirin as it pertains to cardiovascular disease prevention next month.

  Of course, the best way to prevent CRC is do recommended colon and stool testing with one of the following for normal Americans without a positive family history, genetic colon diseases, and no symptoms:

1) Annual fecal tests 2) Sigmoidoscopy with fecal test every 5 years-rarely used 3) Colonoscopy every 10 years from age 50-75. At 76-85, it is up to the individual patient and their doctor. Ref. USPTFS

F. Stages of colon cancer and 5 year survival rates (Ref-ACS)

The stage determines the recommended treatment. Adjuvant treatments may be recommended for more advanced local disease to shrink the tumor before surgical removal. If intestinal obstruction is eminent, a colostomy may be recommended without actual surgical removal of the cancer. Chemotherapy may recommended to prevent metastases and advancing disease.

5 year survival rate by Stages:

For colon cancer:

 I- 92%, II-A 87%, IIB-67%, IIIA-89%, IIIB-69%, IIIC-53%, IV-11% (Stages A<B<C imply less or more advanced disease). A, B, and C indicates various advancing disease.

For rectal cancer:

Stage I-87%, IIA-80%, IIB-40%, IIIA-84%, IIIB-71%, IIIC-54%, IV-12%

 

G. Percentage of cancers diagnosed based on location

H. Treatment

Surgical resection is the only curative procedure (Stage III, and III).  Chemotherapy is the treatment of choice for metastatic disease (Stage IV), but is often used either before or after surgical removal to prevent growth of the local tumor and prevent metastases in stage III. Adjuvant chemotherapy is controversial in stage II.

Various surgical resections (colectomy) with reconstruction:

Tumor of resected colon

The above slide shows the typical amount of colon removed for each part of the colon.For hereditary syndromes, a total colectomy is recommended. This is performed as an open surgical procedure, however, laparoscopic removal has shown equal effectiveness in experienced surgical hands.

 

I. More advanced diseaseis associated with an ulcerative pattern in the cancer, bowel obstruction, perforation of the colon, and an elevated CEA antigen (chorioembryonicantigen) all are predictors of more advanced disease. 

J. Advanced cancer treatment

a)Chemotherapy (combination of 5-flurouracil, levamisole, and leucovorin) is the standard treatment for metastatic disease. Studies have shown that adding oxaliplatin (FOLFOX 4 and FLOX) has shown a better 3 year survival in stage III patients. FOLFOX 4 is also used in metastatic disease.

  b) Biologic agents (immunotherapy) are newer treatments being tested. There are immune checkpoints now known using biological agents in advanced disease. It is thought that CRC is a heavily immuno-edited cancer, meaning it has certain vulnerabilities to these biological immune drugs,especially in combination. Nivolumab and ipilimumab are biologics showing promise. Here are others being used.

c) Experimental treatments—Clinical Trials

  Precision medicine has become the new buzz word since President Obama created an initiative to start looking at cancers, not where they occur, but the genetic markers they have in common. This has already begun in lung cancer, and may become part of colorectal cancer treatment, as we learn more about the genetic characteristics of cancer. It is known that there are colorectal cancers that have the KRAS and HERS-2 genetic markers. This occurs in other cancers too.

  About 30-50% of colorectal cancers have the KRAS-gene mutation, and in some of these tumors, certain biologic therapies (anti-EGFR antibody therapy—epidermal growth factor receptor) will positively affect colorectal tumors usually in patients with metastatic cancers, where these biologic therapies are so important.

  Before therapy is initiated in these patients, they need to be tested for the KRAS mutation.  It turns out that part of the reason these tumors may not respond is the presence of an additional mutated gene called BRAF (also found in melanoma) especially the wild type KRAS mutation. About half of these patients will respond to biologic agents.

  Genetics continues to play an increasingly important role in treating cancer. Screening saves lives!!!

Reference-emedicine/Medscape

 

This completes this month’s MEDICAL NEWS REPORT. Next month, the subjects are:

1) NSAIDs-non-steroidal anti-inflammatory drugs

2) Functional and Cosmetic Genital Surgery

3) Kidney and Bladder Stones

4) The diagnosis and treatment of Atrial Fibrillation

Stay Healthy and well, my friends, Dr. Sam