The Medical News Report

November,#70

Samuel J LaMonte, MD, FACS

www.themedicalnewsreport.com

samlamonte@gmail.com

Subjects for November

1. Quick notes on late breaking medical news—medical cyberterrorism; resources for checking out different hospice centers

2. Hematological Disease Series—Part 4—Leukemia, Myelodysplastic syndromes(MDS)

3. As we age, is it ever time to consider stop taking many preventative medications or say no to treatment?

4. The most common food-borne illnesses

5. Osteoporosis update

6. Longer Waiting Times for Doctor’s Appointments

7. An update on the Opioid Crisis—a 10 step governmental plan; opioid addicts need different treatment

 

 

 

 

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, care instructions, possible side effects to look for, 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. Quick Notes on late breaking medical news

A. Another concern for single payer healthcare systems--Cyberterrorism

  In the August, 2017,NEJM (New England Journal of medicine), there was an article about the cyberattack on England’s government run healthcare system. Hackers attacked a Microsoft weakness in their operating system. A crisis occurred in May, 2017 creating confusion, bewilderment, and rumor throughout the country. Can you imagine when a single payer system run by one internet service is hacked? There was no access to and loss of all electronic medical records, loss of tracking patients loss of radiology, and other laboratory functions. Blood bank’s refrigeration was shut off. Major trauma centers had to be shut down.

  Hackers demanded payment to Bitcoin to restore the system. The UK health service previously turned down a 5.5 million pound ($7.7 million) annual deal with Microsoft to provide ongoing security support.

  Ransomware notified an undisclosed number of providers demanding payment  to un-encrypt their files.

  This was a wakeup call for all of medicine as we go to electronic medical records and are dependent on internet services to run healthcare even without a single payer system. The cost of cybersecurity will have to be an added line item to run such a system.

B. Hospice Website Resource

Considering hospice care? There is a new website provided by CMS (Centers for Medicare and Medicaid) that allows a family to compare hospice services in a specific area or city throughout the U.S. There may be several hospice programs in an area, and for the first time, this will provide comparisons of different programs. www.medicare.gov/hospicecompare

 

2. Hematological System Series—Part 4—I. Leukemia; II. Myelodysplastic syndromes

Electron micrograph of leukemic cells

I. Leukemia

A. Summary of what has been covered so far regarding the blood in the three previous parts of this series

  Continuing with the series on the blood, I have discussed the blood system in general, red blood cells, whilte blood cells, and platelets, which make up the solid part of blood. Plasma is the liquid part of the blood. The primary malignancy of the white blood cells is leukemia, and multiple myeloma. I discussed myeloma a few months ago. Leukemia is a big subject and very complicated. I want you to understand the basics of leukemia, how it occurs, and how they are diagnosed and treated.

B. Incidence of leukemia

  A person is diagnosed every three minutes with a blood cancer and every ten minutes a person dies from the disease or complications from the treatment. Leukemia was a death diagnosis in the past, but the treatments have greatly improved and some can be cured thanks to cancer research. In the 1960s, 80% of children died from leukemia and today 80% live!

  In 2015, 328,000 Americans were living with leukemia and 25,000 died of their disease or complications from treatment. 156,000 patients in the U.S. were diagnosed in 2014 with either leukemia, lymphoma, or myeloma. 15,780 children and adolescents were diagnosed in 2014. Leukemia accounts for 3.7% of all cancers in the U.S.

  90% of cases are diagnosed as an adult, although leukemia is the most common type of cancer diagnosed in children. The highest incidence occurs between the ages of 65-74. In 2017, it is estimated by the American Cancer Society that there will be over 62,000 cases of leukemia and over 20,000 of these patients will be diagnosed with chronic lymphatic leukemia (the most common). Interestingly, it occurs more commonly in the developed parts of the world pointing to enviornmental factors.

  The overall 5 year survival rate is 57%, and 90% will be cured in childhood. As I report on the divisions of leukemia, I will report on survival statistics. Note the average age when leukemia is daignosed is 66.

 To understand how leukemic cells form, you must understand how blood cells are formed. All cells form from a very primordial cell called a stem cell, which based on its genetic makeup, can mature into specific blood cells. The schematic shows how it happens to create red and white cells, and platelets.  


 

Image result for normal myeloid cells in the bone marrow images

 

Notice the word “blast”, because this word will be used to diagnose leukemia below.

D. How does leukemia occur?

   Leukemia occurs from malignant transformation of the bone marrow’s white (stem cells)cells called blasts. Leukemia manifests itself when these malignant cells suppress normal cell formation and or infiltrate organs. These cells crowd out normal blood cells resulting in low red and white cell, and platelet counts which makes these patients develop anemia, bleeding, and increased risk of infection. This is the basis of how these patients become symptomatic.

  With infiltration of leukemic cells in organs such as the liver, spleen, and lymph nodes, enlargement occurs. Even the kidney and gonads may enlarge with these leukemic cells. As the leukemic cells infiltrate the lining of the brain (meninges), symptoms of meningitis can occur including infiltration of the cranial nerves leading to paralysis.

D. Classification of leukemia

Leukemia is subdivided into large groups based on the following categories:

        Acute and Chronic Leukemia

        Leukemia by Cell Type

     1. Acute and Chronic Leukemia

     a) Acute leukemia is characterized by a rapid increase in immature white cells in the bone marrow. This brings on symptoms rather quickly and demands immediate treatment.

     b) Chronic leukemia is characterized by the excessive buildup of relatively mature, yet abnormal white cells. This takes months to years to become clinically manifest. Treatment may be delayed at first depending on many clinical factors including consideration for the side effects of treatment.

     2. Acute and Chronic Leukemias are also divided by  two white cell types—lymphocytic and myelocytic

a)Lymphocytic(also called lymphoblastic in acute leukemia) leukemia is derived from lymphocytes, which have been described in this series last month. Most of these leukemias come from B-cell lymphocytes (rather than B-cell lymphocytes). This is the main immune cell, and therefore immunity is greatly affected.

b)Myelocytic(also called myeloblastic in acute leeukemia)) leukemia is derived from the neutrophils in the blood. It is the most common white cell and the cell that responds to infection, thus impairment in fighting infection occurs. The term myelo- comes from the myeloblasts in the bone marrow, which are the precursor cells that become neutrophils (and other white cells), red blood cells, and platelets.

   The classic naming of a leukemia uses acute or chronc lymphocytic or myelocytic leukemias. This accounts for the most common leukemias treated. There are rarer forms (less than 10%) of leukemia including Harry cell, T-cell prolymphocytic, and other rarer types, which will not specifically be discussed, however, this discussion is pertinent to all types of leukemia.

D. Presenting signs and symptoms of leukemia

  All of the symptoms of leukemia result from interfering with the body’s ability to function normally. These patients suffer from infections because the leukemic cells push out the normal infection fighting cells and red cells which produce anemia also impairing the body’s ability to heal. Bleeding occurs because the normal platelets are also pushed out  by the leukemic cells not allowing for normal clotting.

  The lymphatic system (lymph nodes, liver, and spleen) enlarges from infiltration of leukemic cells and from these organs attempting to make normal blood cells since the bone marrow is not able. All of these signs and symptoms are magnified in acute leukemia, whereas in chronic leukemias, they may not be present or greatly delayed.

Symptoms include fever and chills, persistent fatigue and weakness, frequent infections, unexplained weight loss, swollen lymph nodes in the neck, groin, armpits, and abdomen, liver and spleen enlargement causes vague abdominal pain, easy bruising or bleeding, recurrent nosebleeds, petechiae (tiny bleeding spots under the skin), night sweats, bone pain or tenderness (from leukemic infiltration of the bone marrow inside bones), shortness of breath, and slow healing.

E. Causes

  The cause in many cases is unknown but thought to be from mutations of DNA. Genetic and enviornmental (industrial) influences are critical factors.

  Risk factors include patients who have had treatment for certain types of cancer (with chemo and/or radiation), Down’s Syndrome(trisomy 21), organic chemicals such as benzene, smoking tobacco, and a family history of the disease.

F. Workup

     1-Blood tests

  Although the workup for acute vs chronic leukemias will differ somewhat, the basic tests include blood tests to include a cbc (complete blood cell count, hemoglobin, white cell count (greater than 25,000 white cells indicates treatment must be started immediately), coagulation studies (abnormal clotting is common), chemistry tests for the liver and kidney functions, a peripheral blood smear to look under a microscope for the anatomy of the red and white cells. Most patients with AML will have elevate LDH (lactic dehydrogenase) test. Also uric acid levels may be high.

     2-Blood cultures 

Blood cultures are necessary to see if bacteria are in the blood indicating septicemia.

     3-Flow cytometry

  This test is a special immunoassay test looking for specific immunophenotypes in the DNA. The type of leukemias can frequently be differentiated with this test, which guides treatment.

     4-Bone marrow biopsy

  A large bore needle is inserted through the outer cortex of the hip bone to obtain a bone marrow specimen from the inner aspect of the bone. This is liquid and is drawn up in a syringe.

Analysis of the bone marrow cells determine the type of leukemia and certain characteristics of the wildness of the cancer cells and the subtype of leukemic cells present. There is an international classification of leukemias based on histology and immunocharacteristics. For instance, 25% of AML is classified as acute myeloblastic leukemia with maturation. Compare a slide of normal bone marrow cells with a bone marrow full of leukemic cells.

5-Genetic testing of bone marrow cells

  This testing is used to determine the abnormalities in the genetic makeup of the leukemic cells. They also have prognostic value as well. The most common mutated gene is the FLT3 gene mutation,which is activated in one third of AML patients. These tests help guide therapy and even prognosis.

  Another gene variant is the NPM1 gene which indicates a better response to chemotherapy. The CEBPA gene mutation is associated with a longer remission period.

  An abnormality of chromosome 22 (Philadelphia chromosome) in certain leukemic cells is present in 95% of patient with CML and 25-30% of patients with ALL. Successful treatment will rid the leukemic cells of this chromosomal mutation, thus a way to follow the progress of treatment.

      6-Imaging studies

Chest X-ray is used to determine the presence of pneumonia or enlargement of lymph nodes in the middle of the chest called the mediastium (means middle under the sternum). The right drawing shows the lymph node chain that connects with nodes in the neck. These enlarge in lymphomas and potentially in leukemia.

    

7- Cardiovascular studies

  An EKG is also necessary to get a baseline reading before chemotherapy is started and then performed on a routine basis to detect early electrical abnormalities indicating heart damage, which can occur from chemotherapy.  A certain type of scan (MUGA) is used to determine cardiotoxicity from chemotherapy agents (how chemo adversely affects the heart), many of whom can cause heart damage.

  If there is evidence of damage, a complete cardiology workup is necessary. In large cancer centers, there are oncologic cardiologists who devote their career to the care of cancer patients with heart issues alone or complicated by chemo.

      8-Evaluation of HLA protein typings

The testing of a certain blood typing for the protein human leukocyte antigen (HLA) is routinely performed in patients with acute myelocytic leukemia to determine eligibility for certain types of treatment.

G. Treatment of Leukemias-acute and chronic

  I wish I could make this discussion easy to follow, but that is not possible. I will give you a summary of some of the highlights of treatment. Treatments are based on several criteria—how fast the leukemia is growing, the cell type, capability of the patient to tolerate multiple drugs (side effects), age, other associated illnesses.

H. Approach to treatment of Acute Leukemia

The treatment of acute leukemia differs based on the cell type. The two most common types of leukemia are lymphocytic and myelocytic.

a) Treatment of Acute Lymphatic (lymphoblastic) leukemia

 

Lymphoblasts in the bone marrow

 

   Normal bone marrow

 

Acute lymphoblastic leukemia is the most common childhood (usually before age 5) form of leukemia, however does occur in adults usually over 50 years of age (40%). 5,970 cases are estimated to occur in 2017 with 1,440 deaths. Previous exposure to chemotherapy and radiation, or genetic factors particularly Down’s syndrome.  It progresses rapidly spreading from the bone marrow to the peripheral blood to the liver, spleen, lymph nodes, the brain, and testicles in males. If more than 25% of the bone marrow cells are lymphoblasts, it is considered kemia. If less, it may be diagnosed as lymphoma. Next month, I will discuss lymphoma.

---There are two types of lymphocytes, T-cell and B-cell, either of which can become leukemic.  

---The first ever FDA approved gene therapy has just been approved for B-cell type lymphoblastic leukemia—tisagenleclucel (Kemriah), a genetically engineered T-cell immunotherapy with a one time treatment price of $475,000. 83% remission rate in 3 months.

---Treatment is divided into three phases:

                 1--Induction therapy

·        The goal is to kill leukemic cells in the blood and bone marrow. This includes chemotherapy and corticosteroids for 4 weeks to put the patient into remission. This phase usually requires hospitalization.

·        If the patient has a specific gene abnormality (i.e. Philadelphia chromosome), they are treated with a tyrosine kinase inhibibitor (Gleevec), which increases cure rates substantially.

  2--Consolidation (postremission) therapy

·        This phase of treatment is to kill any remaining cells that might create a relapse and may take months using chemotherapy and stem cell transplant.

·        Selective treatment of the brain and spinal cord with radiation or chemotherapy may be necessary.

·        This phase usually does not require overnight  hospitalization.

  3--Maintenance therapy

·        Low dose chemotherapy (oral daily and once a month IV) usually for 3 years.

 ---New innovations

   Stem cell transplantation and targeted therapy-tyrosine kinase inhibitors--imitanib (Gleevec), dasatinib,and nilotinib have also improved cure rates if recurrence occurs. Those targeted drugs that inhibit the enzyme tyrosine kinase are responsible for activation of many proteins necessary for the leukemic cell to malfunction. Mutation testing improves selection of specific drugs.

---Defining Cure

    If remission continues for 5 years, the patients are declared cured. If the leukemia re-activates, the above alternatives are recommended in clinical trials.

I. Treatment for Acute Myelocytic Leukemia (AML)

          ---Definition

  AML is the most common adult acute leukemia and is characterized by clonal expansion of myeloid blasts (blasts are aggressive cells) into the peripheral blood, bone marrow, and other tissues. It also accounts for the greatest number of deaths from leukemia annually in the U.S. (21,000 diagnosed and 10,500 deaths annually). The mean age at diagnosis is 67 years of age. AML can also occur as a result of chemotherapy for other cancers accounting for up to 25% of the patients with AML (and myelodysplstic syndrome-MDS). It can also result from radiation before stem cell transplants.

      ---Diagnosis is made when 20% or more are blasts in the bone marrow. The slide below shows myeloblasts (AML).

---Treatment includes a variety of chemotherapeutic agents (anthracyclines, cytarabine, etc.) and stem cell transplants. The National Comprehensive Cancer Network updates their recommended algorhythms for treatment annually. These provide oncologists with the latest evidence medicine to treat leukemia.

 

a)         Treatment by age--For patients under 65 (and selected patients up to 75), the 2 two phases of treatment are induction chemotherapy and postremission therapy.

  1. Induction therapy

  IV chemotherpay for 4 weeks (in-hospital) with 3 weeks to allow the bone marrow to recover.

  2. Post-remission therapy

  Additional chemotherapy or a stem cell transplant.

Chemotherapy is used for several days per month for 3-4 months

           e)    Recurrence

Different chemotherapeutic agents will be used or a stem cell transplant.

Clinical trials also are an option.

 

f)          Genetic mutation--If there is a genetic mutation (1/3 of patients with AML), this will dictate therapy as well.

 

g)         Side effects of chemotherapy play a big role in treating these patients. There are acute and chronic side effects including those that do not show up for months and even years. For those patients that are not as strong or have other co-morbidities, stem cell transplants are considered after the first remission. Those over 75 are treated with lower intensity therapy.

 

h)        Common side effects of chemotherapy

  Unfortunately, chemotherapy affects normal cells as well as cancer cells and cause damage at times. Fatigue, temporary nausea, hair loss, and pain are common. Different drugs cause different side effects. Headache, muscle and nerve pain (neuropathy) is common. Mouth sores, diarrhea, constipation, loss of appetite, and chemo-brain (cognitive, memory loss, etc.) are not uncommon. Some of these may persist. Be sure to talk to your doctor about these and how they intend to try and combat them.

  Because of the complexity of treatment, I will not discuss specific chemotherapeutic agents due to the number. Newer agents are coming on the market as well.

i)           Response rates are based on the length of the first remission. If a patient stays in remission 2 years or longer, they have a 60% chance of responding to the front-line regimen. Clinical trials are always recommended for those who recur.

J. Approach to treating Chronic Leukemia

           a) Delayed treatment

Chronic forms develop very slowly and therefore are defined as chronic. The leukemic cells may look close to normal but do not function like normal lymphocytes, such as fighting infection, etc. These forms of leukemia may not need treatment immediately. Treating the chronic form of leukemia may not change the course of the disease.

           b) Lymphoma monitoring

Patients with CLL may develop lymphomas and vice versa. Lymphoma comes from the same cell (lymphocyte), but it develops in the lymph nodes while leukemia starts in the bone marrow. If a patient with either disease develop enlarged lymph nodes or the white count rises rapidly, suspicion for an advance in disease is likley.

          c) When to treat CLL

Criteria to proceed with earlier treatment includes a change in the clinical course of the disease (symptoms), increasing white cell count, increasing anemia, and enlarging lymph nodes.

  Besides the above mentioned indications, a protein test can differentiate between CLL that needs more immediate treatment(contain higher amounts of 2 proteins—ZAP-70 and CD30).

          d) Staging of CLL

  Staging is based on the extent of disease with earlier stages not involving (enlargement) the spleen, liver, and lymph nodes or having anemia. In the later stages infiltration and or enlargement of these organs and or the presence of anemia (indicates the leukemic cells are crowding out the red cells).

          e) Philadelphia chromosome

  If there is an abnormality in chromosome 22 of a myelocytic cancer cell, 95% of patients will have CML but also 25-30% of patient with ALL will have this chromosomal abnormality. There is also translocation of chromosome 9 in the cancer cell. If some other gene mutations are present, the success of treatment can be predicted.

K. Approach to Treatment of Chronic Lymphatic Leukemia (CLL)

This is the most common form of leukemia. Even though the lymphocyte is the cell that makes immunoglobulins that fight infections, these leukemic lymphocytes do not work normally. This type of leukemia develops slowly and may not need treatment for some time or may never.

      a) Risk factors

The cause is unknown, but there are factors that increase the liklihood of developing CLL are having a parent, sibling, or child with leukemia, middle-aged or older, white male, Eastern European or Russian Jew descent, or exposed to Agent Orange (during Vietnam War).

      b) Symptoms

  Symptoms include lymph node swelling (similar to lymphoma), fevers, shortness of breath, fatigue, weakness, night sweats, recurrent infections, loss of appetite and weight loss. The slide below shows the cells of lymphatic leukemia

c) Treatment of CLL

  This may include chemotherapy, radiation to parts of the body (where lymph nodes are increasing in size or a spleen is enlarging), targeted therapy, and immunotherapy.

There is still some controversy about the first line therapy. For young fit patients with mutated immunoglobulin genes, the latest treatment includes three drugs-FCR—fludarabine, cytoxin, and Rituxin. For those that are older patient or those without mutated genes, therapy will work for awhile but will fail, so second line drugs to consider are Imbruvica (tyrosine kinase inhibitor), Zydelig, or Venclexta. Revlimid plus Rituxin is also considered for maintenance or relapse.   If the spleen does not reduce in size, it may have to be surgically removed. Stem cell transplants are also being tried.

L. Approach to Treatment of Chronic Myelocytic Leukemia (CML)

CML in the bone marrow

 

CML in the peripheral blood

The treatment for this is not standard chemotherapeutic agents, rather, targeted therapy called  tyrosine kinase inhibitors (Gleevec, Tasigna, Sprycel). Tyrosine kinase is an enzyme necessary for cellular growth and drugs that inhibit this enzyem in leukemic cells are successful in treating CML. Gleevec changed the control and cure rate overnight when it was discovered to treat CML.

  If the gene mutation T351I is present, this may strengthen the desire to use another tyrosine inhibitor if one of the others fails.

There are backup drugs from the same class that can be used if the others quit working or side effects require a change (Bosulif, Iclusig). Stem cell transplants may be used as well.

      a) Monitoring treatment value

The progress is monitored by following the blood count, the amount of a certain gene present (BCR-ABL gene), or the bone marrow can be checked for the presence of the Philadelphia chromosome at about 3 months, and then every 3-6 months. If a patient is responding to treatment, there should be a blood, cellular, and gene response.

  The response rate is about 70%. For those who do not respond, the options include increasing the dose, switching to another tyrosine drug, interferon, or standard chemotherapy. A stem cell transplant is also an option.

      b) Defining different phases of disease

                        1- remission

                        2- recurrence (relapse)

                        3- accelerated phase

                        4- blast phase—this phase acts like acute myelocytic leukemia. Depending on what treatment had been used prior to this phase, other tyrosine kinase inhibitors drugs are used. Most patients in this phase can’t be cured, but can be controlled for a time.

     c) Maintenance therapy

  Most patients will stay on a maintenance dose of the tyrosine kinase inhibitors. Monitoring for side effects and recurrence will occur for the rest of the patient’s life.

     d) Clinical Trials

  If treatment is unsuccessful, enrolling in a clinical trial may be considered.

     e) Prognosis

  There are many factors that contribute to how successful treatment and survival will be. Poorer prognosis depends on widespread disease, advanced age, male, deletion of chromosomes 17 or 11, high levels of beta-2-microglobulin, faster growth of the leukemic cells, earlier forms of lymphocytes (prolymphocytes), high levels of 2 proteins-ZAP70 and PD30, and non-mutated gene IGHV.

  In children, 30 years ago, the death rates exceeded 80%, and now with advances in treatments, the overall 5 year survival rate for ALL is greater than 85%. For AML it is 60%.

  In adults, the 5 year survival rate for ALL--70%, AML-- 40%, CLL--85%, and CML—66%.

 

II. Primary Myelodysplastic Syndromes—overlapping diseases

1. Myeloproliferative neoplasms(MPN)

2. Myelodyplastic disease(MDS)

3. Myelofibrosis

These syndromes are confusing at best and these syndromes can overlap and be associated with leukemia as well. They must be differentiated because the treatments for all 3 syndromes are different. This information is taken from multiple sources but primarily MD Anderson Cancer Institute. It is complex and is included for those interested enough in these diseases.

Defining the 3 syndromes 

 Understanding the cells in the bone marrow

  The precursor cells in the bone marrow are called myeloblast cells (strem cells). These cells normally mature before being sent to the blood stream.

  When the bone marrow makes premature cells in abundance, it is called a myeloproliferative disease (MPN). If the bone marrow produces abnormally shaped cells, it is called myelodysplastic disease (MDS). If the bone marrow quits making cells, it is called myelofibrosis. Any of these conditions can result in chronic myeloid leukemia. That is why I include them with this report.

1. Myeloproliferative neoplasm (MPN)

      a) Definition--Myeloproliferative neoplasms are characterized by the body (bone marrow) making too many red cells, white cells, or platelets that are premature in nature. These are technically called cancers and get worse with time but can last for years. Genetic mutations are believed to be the cause but there is no known actual cause. This affects about 200,000 Americans annually.  

        b) Three types of MPN occur: polycythemia vera (red cell malignancy), primary thrombocythemia (platelet excess), and myelofibrosis. Polycythemia vera causes increased abnormal red and white blood cells, and platelets and is classified as a blood cancer. Thrombocythemia causes increased platelets and causes abnomal clotting. I previously discussed these three MPNs in th elast 2 reports.

  Treatment of polycythemia includes phlebotomy-removing a pint of blood as needed, hydroxyurea, ruxolitinib(Jakafi), interferon, anti-itch medications, and low dose aspirin.

  Treatment for primary thrombocythemia includes some of the above therapies plus the drug Anagrelide to reduce the production of platelets.

2. Myelodysplastic disease (MDS)

There is a difference between a proliferative disease and a dysplastic disease. Proliferation means too many cells, and dysplasia means creation of abnormal shaped blood cells that are not normal. If fibrosis (scarring) occurs in the bone marrow, cells are not created. The treatment is different and must be differentiated.  There are two FDA approved chemotherapeutic agents—azacitidine(Vidaza) and decitabine(Dacogen). There are other alternatives if these chemo agents do not work.

3. Myelofibrosis characterized by the bone marrow being replaced by scar leading to anemia, low white counts causing infections, and bleeding from low platelet counts as in leukemia. Either MDS and MPN can result in myelofibrosis (about 10%) and 50% have a genetic mutation (JAK2). Any of these syndromes can result in leukemia (fibrosis to leukemia in usually 36 months and myelodysplastic to leukemia in approximately 56 months).

  Symptoms include bone pain, fatigue, fever, itching, night sweats, and unexplained weight loss.

  Treatment of myelofibrosis--The targeted therapeutic agent Jakafi is the first line treatment, along with blood transfusions, removal of the spleen, and ultimately stem cell transplantation.

Ref. Conquer magazine, MPN Research Foundation, National Heart, Lung, and Blood Institute ,Leukemia and Lymphoma Society, The American Cancer Society, emedicine.net

 

3. As we age, is it ever time to consider stopping routine medications and consider saying no to aggressive treatments?

A. Stopping medication

  Did you ever wonder, as we age, when we might consider stopping such preventative drugs such as cholesterol drugs, a baby aspirin, vitamins, minerals etc. to prevent future illness? A recent study on the internet journal, Medscape, stated that primary care doctors are prescribing 1 in 5 medications inappropriately for certain subsets of the population. Statistics show that 10% of hospital admissions come from drug-related problems. It is estimated that 2/3 of these should have been preventable with either adjustment of doses or elimination.

  I am not surprised to find that there is little information on this subject. Also, most research on FDA approved medications are performed with relatively young people with few co-morbidities (other diseases). Are we to ask the pharmaceutical company for information??? Are you kidding! They want us to take those expensive pills “til the day we die”. Because of the side effects of these “routine” drugs can be be considerable, that is why I pose the question!

  People over 65 buy 30% of all prescription drugs and 40% of OTC drugs. The FDA does pay attention to effects on seniors and require an approved drug must have been tested on those over 65 (law since 1999). 40-75% of seniors do not take their medication at the right time or right amount!!!

  Here are some factors to consider:

1. As one ages, weight loss may influence the dosage of meds.

2. There is a larger chance of drug interactions as we age.

3. The digestive tract and changes in dietary intake can change absorption of drugs as we age.

4. Side effects of drugs can increase with age especially with liver and kidney diseases.

5. Because metabolism slows and organ function lessens, dosage should be re-assessed.

6 As we age, we become forgetful and don’t always take our meds as prescribed. If a dose of medication is missed, many think they should double the dose next time the med is indicated (not true!). Always know what to do when a dose is missed or delayed by  several hours.

7. If a prescription is too expensive, ask for alternatives. Seniors often have less money to cover the cost of their medications and are embarasssed to tell their doctors not filling the prescription. Always ask for senior discounts.

8. Abrupt stoppage of certain meds--There are many medications that have withdrawal symptoms if stopped abruptly, therefore, even if a medication is stopped, be sure you investigate the consequences of stopping and how slow to taper a dosage. For example, anti-depressants may take weeks and even months to stop, therefore, lowering the dose over time must be physician-directed. Cortisone, antidepressants, and ADHD meds are examples of medications that must be stopped over time.

Ref.—FDA

Preventative aspirin

  A new study reported in the medical journal, Circulation, cited a 37% increase risk in patients who stopped their preventative aspirin daily dose (heart attack, stroke, and crdiovascular death). Clearly this is not a drug you would want to stop unless there is a very good reason (bleeding, ulcers, etc.).

NEVER STOP OR ALTER A DOSE OF A MEDICATION WITHOUT DISCUSSING THIS WITH YOUR DOCTOR!!

 IT IS REPORTED THAT 1/3 OF PATIENTS STOP WITHOUT TELLING THEIR DOCTOR!!!!

  In discussing this issue, I am not talking about vital heart medications, anticoagulants, seizure, psychiatric, or diabetic meds, etc. that keep us alive and free of potential complications from a disease. But what about the obscene amount of drugs we take that are supplements, vitamins, minerals, cholesterol meds, etc.

  There are really no good studies that address this subject for those in later life. No drug is even tested on older patients when they are looking for side effects, necessary dose, etc. If a person is in a nursing home, do they really need to take a vitamin, supplements, etc.? Nursing homes will not discountinue any medication or OTC medication without a doctor’s order, and they charge the patient for every single pill they dispense.

  All nursing homes have physician advisors, and it would be a good idea to make an appointment with them, when a loved one is admitted or talk to the primary care doctor. Hospice care is another issue that should include a careful analysis of the need for continuation of certain medications and supplements or at least an adjustment of dosage.

B. Cancer screening tests in later life

  Many screening tests are not recommended routinely after age 75, and more evidence has been cited that some slow growing cancers can be watched carefully rather than treated. It is critically important to follow current guidelines for cancer screening, but depending on health quality, the guidelines may be adjusted. For patients with risk factors, these patients may need prolonged screening. This is the responsibility of your doctor and you to decide to continue Pap smear, prostate PSA, mammograms, colorectal testing based on family history, previous findings on screenings, risk, other co-existing health issues, and the realistic length of time a person has left to live. It is up to you and your doctors.

C. Prolonging cancer treatment in a terminally ill patient

  I just lost a great aunt who was given high dose chemotherapy at age 90 for an unresectable colon cancer, which essentially killed her. Another family member was given high dose chemo a week before he died with terminal lung cancer. I even suggested hospice be called in and that fell on deaf ears. I was unsuccessful in intervening in these situations, but it just reminded me about using common sense in dire situations, when treatments are clearly questionable and may actually could speed the demise of patients. These are decisions to consider early on in the course of an illness. Doctors will likely not even bring it up. It is up to the patient and family.  

   A lower grade cancer will not kill people before they die of “natural causes”. There is more information out in the medical literature about these kinds of less aggressive cancers, and even though just a few years ago it would have been heresy to delay treatment, this has become a real discussion with certain cancers, especially in the aged. Genetic testing and further knowledge of individual cancers has begun to separate out some of these cancers that might be better served to observe carefully before undergoing fullblown therapy considering severe side effects and loss of quality of life.

  As America continues to age, more of these cases are going to come up. As family members, we need to encourage dialog with the primary care doctors, because the specialists are likely not to back off. It is their mantra to treat until the end (some are coming around).

  As we continue to live longer, these are important questions. Be sure there is a living will and a power of attorney or a health advocate responsible for making health decisions age and senility progress. Also make sure the patient has a family will to keep probate court from taking over the estate.  

  Remember, 85% of the Medicare dollar is spent in the last year of our life. How can we reform healthcare with that statistic and with the aging of our country?

  I realize that there will always be well-meaning family members that don’t know when to consider doing less than more. Remember, these members are making emotional decsions not intellectual ones. That is why decisions at the end of life are critical to be discussed with loved ones long before they become an issue. Physicians are not well trained in this critical area.

  Patients should consider asking their doctor what their life expectancy is. As hard as it is to do, this can guide several healthcare decisions.

Note: Many of these comments are my personal opinion based on 30 years of private practice as a surgeon and as a professional medical writer reading thousands of articles about all fields of medicine including end of life issues. Many of these issues are delicate matters but need addressing nerertheless.

 

4. The most common food-borne illnesses (food poisoning)

A. Most common pathogens causing illness

  The three most common bacteria from contaminated food causing illness are Campylobacter, Salmonella, and Shigella. E.coli, Cryptosporidium, and Yersinia are on the rise as recently reported.

  In the past these food-borne illnesses were considered ptomaine poisoning caused by a variety of toxins. This name has been discarded, because most these cases are bacterial poisonings. Ptomaines are not injurious to humans, and were found out to be mostly from Clostridium botulinum, commonly called botulism.

  About 9.4 million cases per year are verified by laboratory identification, however, about 39 million additional cases are unspecified totaling almost 50 million cases. Approximately 128,000 Americans are hospitalized yearly with 3,000 deaths.

  With all the flooding and loss of power with natural disasters, I am concerned that this issue could be problematic in Texas, Florida, and Puerto Rico (and V.Is).

   By far, the most common food borne illness is viral in origin…Norovirus (5 to 1). 1 in 6 Americans get sick from contaminated foods and beverages. Loss of refrigeration has become an issue after hurricanes and not boiling water as well.

  Toxins are produced by certain bacteria, plants, and animals/fish which are considered poisonous.

  Parasites such as Amoeba, Giardia, and Trichinella can infest humans causing intestinal upset and even liver damage. With so many refugees and immigrants, these diseases are becoming even more prevalent.

  As many as 80,000 chemicals in our environment and food potentially could cause unspecified poisonings, including pesticides (GMOs are causing quite a stir). There are very few studies to support their harm, but we all know with genetic engineering of our food, the use of pesticides is a real issue. What about the Roundup controversy?

  The most common pathogen causing death is Salmonella. Poison, chemicals, and other substances cause illness as well.

B. Sources for Contamination

  The sources for food contamination come from fecal material from animals on plants and fruits. The pathogens grow in the intestines of animals and contaminate the meat in the slaughterhouses. Never handle raw meat or fish without washing hands and surfaces of food.

  Raw foods of animal origin, poultry, raw eggs, raw shellfish, and unpasteurized milk all are potent sources of contamination. Regular ground beef is a source of E.coli., especially those with higher fat content. Low grade hamburger meat may come from multiple sources of animals and is the reason restaurants cook it well-done to prevent contamination (the law). Higher quality beef products are usually from a single source and are the reason it is considered more safe to eat, and therefore, restaurants can offer them cooked to order. However, there is still higher risk especially if you like meat cooked rare.

  Cooking to 160-170 degrees is recommended. Broiler chickens on a rotisserie at grocery stores have drippings from hundreds of other chickens, raising the risk of contamination. 

  Fruits and vegetables are contaminated with manure and human feces out in the fields. Processing by food handlers is another major source of contamination. Raw foods are a risk anytime. Cross-contamination from one food to another at the store or at home is risk (use plastic bags).

  Soft French style cheeses, pates, uncooked hot dogs, and deli meats are also sources of contaminated products because delis slice on the same machines. Alfalfa sprouts and unpasteurized juices should be considered higher risk as well.

C. Symptoms of food poisoning

Nausea, gut cramps, vomiting, diarrhea, and fever are common usually lasting 1-2 days, although if more serious, it could last several days, and require IV fluids.  

D. Prevention

Refrigeration (at or below 40F), washing foods, and adequate cooking of all foods are the main preventative measures but by no means foolproof. Can we really trust spinach that is “washed”? It just means they washed the dirt off. Lettuce is a major source of contamination.

  Foods heated to 170 degrees for even seconds kill parasites, bacteria, and viruses except for the bacteria Clostridium, which requires boiling to prevent botulism. However, The Staph germ toxin is not inactivated with boiling.

  Eggs can be contaminated with Salmonella because hen’s ovaries can carry the bacteria transmitting it to the embryos (eggs). Cooking eggs medium may prevent this.

  High salt, high sugar, and high acid content keep bacteria from multiplying. That is why salted meats, jams, pickled vegetables are classic preserved foods are usually free of bacteria.

E. Other infections along the Gulf Coast

  Vibrio vulnificus infections occur along the Gulf Coast of the U.S. There are in two groups: Vibrio cholera and non-cholera Vibrio: The non-cholera type is seen in the U.S. The CDC estimates that 50 million food borne infections occur annually, and about 8,000 are Vibrio infections. The increase of Gulf water temperature and salinity contributes to an increasing number of infections from contaminated shellfish, especially raw oysters, clams, crabs and other raw fish (sushi). The rate of infection has risen 75% since 2008. Flood waters have increased these infections in wounds.

  Patients with any type of compromised immune system, liver and kidney disease, and older people are the most vulnerable to these infections becoming severe.

F. Cholera not in the U.S.

   Vibrio cholera cause serious outbreaks from contaminated water mostly in undeveloped countries (Africa, Asia, and Latin America). This causes severe watery diarrhea, vomiting, and dehydration and kills people if not treated. This is not an issue in the U.S. unless brought back here from other countries.

G. Hepatitis A

  This type of hepatitis can also be contracted from foods. This is a serious problem in undeveloped countries. There is a vaccine that should be taken if going out of the country. Always check with your physician about immunizations before going to other countries.

H. Turista (Montezuma’s Revenge)

  Many people get diarrhea just from eating different species of innocent bacteria from other countries, although many are from E.coli. The water (and ice) and any raw vegetables (especially lettuce) should be viewed with great caution with foreign travel. Turista occurs in 20-50% of those who do not heed caution especially in Latin America, Africa, the Middle East, and Asia.

  People takng reflux and indigestion medicine daily (Nexium, Prevacid, Prilosec, etc.) are more susceptible because they have less acid to kill offending bacteria.

  It is recommended, if probiotics are to be used, that they are begun 2 days before leaving on a trip and continued throughout the trip.

I. Treatment of food posioning

  Rarely are antibiotics necessary, therefore, treating the symptoms is the usual approach. Imodium, Lomotil, anti-nausea, and medications such as Bentyl are helpful for relieving symptoms. Pepto-Bismol tabs may prevent diarrhea and potentally prevent infection. Gatorade, Pedialyte, or Powerade can be used for replenishing fluids and electrolytes (sodium and potassium). The symptoms should abate in less than a week.

  If a patient has a severe event or is immunosuppressed, it is recommended that Cipro or Levaquin be prescribed and will be successful. Many request a prescription of Cipro to take with them when traveling to high risk countries.

  Probiotics have been proven to be of value in bacterial infectious diarrhea. 5 billion units of a broad spectrum probiotic (multiple different bacterial species) is recommended and proven to reduce the number of days of diarrhea.

  When you buy vegetables at the grocery, keep them in separate plastic bags to prevent cross-contamination. Wash your hands when touching raw vegetables and raw meats. Because cut onions are particularly risky to store in the refrigerator, keep them separate in a storage bag. Wash vegetables when they are brought home from the store.

J. Who is at high risk?

  Children under 5, pregnant women, seniors over 65, are chronically ill, or those immunocompromised or on medications that suppress the immune system are at higher risk.

K. Summary

  Being aware of where you eat, what you eat, how your food is cleaned and prepared, adequate refrigeration and freezing will minimize your risks.

  If you are away from your home for an extended time, if the electricity goes off, the food may become contaminated. A little trick to know is put a small bowl of ice in the freezer with a quarter on top. If the ice melts, the quarter will sink to the bottom, and it must be assumed the food is contaminated and be discarded.  

  If you get intestinal issues after eating, chances you have been infected, however, you should recover in a couple of days. If not, see your doctor especially if you are high risk.

  Always consult your physician about travelling to other countries especially Latin America, Africa, the Middle East, and Asia. Vaccinations updates should be discussed.  

 

5. Osteoporosis--updates

A. General information

  I provided an in depth discussion on osteoporosis in the 36th Medical News Report. You can update your knowledge on the basic information about calcium metabolism, the hormones that govern the levels, and the diagnosis of osteopenia and osteoporosis with the DEXA scan. The risk factors and treatment regimens are outlined.  www.themedicalnewsreport.com #36

B. Here are some updates from the recent medical literature:

    1. Bone health and heart disease linked to each other

  Elderly patients both men and women with ischemic heart disease are prone to osteoporosis, and should be screened with a bone density study, especially the wrist. Weight bearing may help prevent lower extremity osteoporosis.

2.  Managing bone loss with cancer drugs (aromatase inhibitors)

  Menopausal women who are taking drugs to prevent recurrence of breast cancer are at a significant risk of osteoporosis. Aromatase inhibitors (i.e. Tamoxifen)have the side effect of creating bone loss. A recent article on this subject noted that 1 in 5 women taking these drugs will experience a fracture in the first 5 years.

      3. In the Journal of Bone Oncology, the authors have provided guidelines for cancer patients.

    a. Pre-treatment analysis of bone density and risk of fracture should be performed. Education regarding taking Vitamin D and calcium supplementation should be provided.

    b. Bone-directed treatment should be initiated in high risk patients (T-score less than 2.0 SD), all over 65, or who have low weight(body mass).

     c. Zoledronic acid injections once a year or denosumab every 6 months is recommended. 

       4. New drug approved

  The FDA has approved another drug similar to other synthetic analog of human parathormone (the hormone secreted by the parathyroid glands that governs calcium in the blood). The new drug is called abaloparatide (Tymlos) which cuts non-vertebral fractures by 43%. This drug does have a warning that it could potentially cause an osteosarcoma (bone cancer). International Osteoporosis Foundation

         5. Bone density is scored in 2 ways using the DEXA scan—the T score and the Z score:

Z score (standard deviations above or below normal)

-2.0 or lower---------------there is concern for bone loss and the causes need to be explored and treated.

T score (# of units)

-1.0 and higher------------normal density

Between -1.0 and -2.5-----osteopenia

-2.5 and lower-----------osteoporosis

 

          6. American College of Physicians has updated their guidelines for treatment of osteopenia (low bone density) and osteoporosis.

      a) Post-menopausal women should not be prescribed estrogens or raloxifene for patients with osteoporosis.

      b) Osteoporosis patients should be treated with bisphosphonates* or denosumab (Prolia) in women (bisphosphonates for men). Drug therapy should be continued for 5 years. Generics should be used if available.

*bisphosphonates include alendronate (Fosamax), risedronate(Alelvia), zoledronic acid(Reclast), Didronel, etc.

        c) Bone density does not need to be monitored routinely during those 5 years, since these medications reduce fractures.

        d) Clinicians should offer bisphosphonates (Fosamax, Boniva, Reclast, etc.) to men if osteoporosis is present; if there is low bone density(osteopenia) the evidence is weak.

         e) For women with osteopenia 65 and over at high risk for fracture, decisions to treat should take into consideration patient preference, fracture-risk profile, harms/benefits, and price of medication. Annals of Internal Medicine, May, 2017

C. Medications that increase the risk of osteoporosis

         1. Psychiatric medications

  This includes antidepressants (SSRIs), antipsychotics, and benzodiazepines (anti-anxiety) increase the risk of hip fractures, and other major osteoporotic fractures. If long term treatment is warranted, the risk of osteoporosis exists.

         2. Corticosteroids—after initiation of long term steroids, fracture risk should be assessed in 6 months, and every 12 months. Calcium and vitamin D should be taken. Medications for osteoporosis must be assessed.

         3. Seizure medication including phenyltoin, and Phenobarbital.

         4. FSH and LH—These are pituitary stimulating hormones (Gonadotropin releasing hormone agonist release follicular stimulating hormone and luteinizing hormone are the hormones) that suppress ovulation and suppress male hormone release in prostate cancer patients. It is also used in female disorders such as heavy periods, endometriosis, and uterine fibroids. It suppresses the release of hormones for trans-gender patients. With lack of female and male hormones, osteoporosis risk increases.

           5. Heartburn drugs (PPIs-Prevacid, Nexium, etc.)

           6. Diuretics (i.e. Lasix) increase fluid out of the kidneys and promote the excretion of calcium.

           7. Prostate drugs (Flomax, etc.) do not directly cause osteoporosis, but these drugs have vascular effects that can drop the blood pressure thus causing falls.

           8. Antacids

           9. Opioids

         10. Some anti-diabetic medications (Avandia, Actos)

 

D.  Prevention

           1. Weight bearing exercises

           2. Diet rich in calcium and vitamin D (leafy green vegetables, meats, figs, salmon, nuts, dairy, tofu, prunes, and molasses),

            3. Foods rich in potassium and magnesium (sweet potato),

            4. Fruits with vitamin C

  Being aware of the potential for osteoporosis because of certain diseases (as described) will allow women in particular to prevent osteoporosis.

With menopause, it is particularly important to be aware of the potential. Get tested for vitamin D levels and have a DEXA scan.

Webmd.com

 

6. Longer waiting times a problem for doctor’s appointments

The reality of Obamacare (in favor of it or not) was an additional 11 million people were given access to healthcare insurance through the exchanges. Everyone would like for all Americans have healthcare, because in the end, if people can’t have their health issues tended to, they get sicker before seeking care, and we all wind up paying for them anyway.

  Unfortunately, the medical profession was not ready to handle the additional numbers. Because the government can’t make all physicians accept the dismal pay for Medicaid and Obamacare plan patients, those that would accept them are even fewer in number. This has created longer waits to see our doctors.

  A recent study reported the time it took to get an appointment since 2014 has increased by 30%. New patient appointments were affected the most. This affects us all, and some would feel it is worth the sacrifice, but when you are sick, that feeling may change, or when you are being referred for evaluation of a potential cancer, waiting as much as 30 days on the average may impact people differently. Patients are being referred more and more to acute care and urgent care facillites and emergency rooms instead of being able to see their own doctors.

  This survey was aimed at specialties ranging from cardiology, orthopedics to family practice.

  Medicine was not prepared to take on these additional patients all at once, and it has caused a strain on obtaining access for care. These surveys were obtained in 15 major cities, and varied from 52 days average in Boston to 15 days in Dallas. Newer studies also included medium sized cities and the trend was the same—a 30% increase in wait time.

  I have encouraged people to stay with their current doctors, because many doctors are not seeing new Medicare patients (15%) and as many as 47% are not seeing new Medicaid patients. For those who have very few options with their healthcare plan, it is hitting them the hardest.

  The push for more nurse practitioners and PAs to fill the gap so far has not eased the wait time. All these schools can produce just so many positions per year, and the number of physicians retiring is almost exceeding new doctors entering into the field, especially in certain specialties.

  The American Academy of Medical Colleges predict a shortage of 40,000-100,000 physicians by 2030. We just can’t turn out doctors fast enough to keep up with the demand.

  The U.S. is seeing a huge influx of foreign medical graduates, which has its challenges. Will the quality of doctors drop trying to shorten their years of training? They already dropped internships, which was one of the most rewarding years I ever spent in medical training. There is a push to specialize as soon as possible when encouraging doctors to be generalists is not. We need more primary care doctors than any other area of medicine.  

  America can’t have it both ways. We all suffer because of the huge influx of people into our country, especially if they have no skills without jobs, and put even more burden on our healthcare system.   Ref-- Medscape Medical News

 

7. Opioid Crisis—an update 2017-a 10 step plan to combat the crisis—treatment different for drug addicts

 I have discussed this national crisis on 2 different occasions, but the subject needs an update, and a 10 step plan is reported. For review of 2 previous reports: Medical News Report #47 and #58

An update on the scope of the opioid crisis

  Doctors today are writing fewer prescriptions for opioids, however, the number of overdose deaths is still increasing…but it not because of legally prescribed opioids, although it started there. It is because of heroin and an even more potent synthetic drug called fentanyl, which man made and 50 times more potent than heroin primarily being produced by China. It is commonly used by anesthesiologists. But on the street, heroin is laced with fentanyl, killing people even faster. Addicts have no idea about the strength of drug they are injecting in their veins.

 

  These three charts show the rise in use of these drugs in the U.S. (JAMA, Oct 11, 2017)

Here are some troublesome statistics:

     a) 1 in 3 adults in the U.S. had a opioid prescription in 2015 (Annals of Internal Medicine Journal)

     b) 12 million Americans reported misusing opioids.

     c) 1% of adult Americans (2 million) have an opioid use disorder.

      d) It is the #1 cause of death for Americans under 50 years of age (138 people are now dying from overdoses every day in the U.S.). Of the 64,070 deaths in 2016, the CDC stated that the 20% increase in deaths was almost all due to the synthetically produced fentanyl.

      e) The number of prescription opioid overdoses is decreasing while illicit opioid overdoses continue to increase.

      f) A recent study reported that in 2013 that just 10% who received opioid prescriptions accounted for 76% of those prescriptions. This means we should be able to address this smaller group of true abusers with interventions and treatment.

  More men than women filled these prescriptions with an average age of 47. An analysis of what conditions required opioid prescriptions and the doctors that wrote them must be performed. This was an analysis of 19 million prescriptions in pharmacies across the country. Medscape-Psychiatry, September, 2017

  Even though some physicians were sold a “bill of goods” that were told by certain pharmaceutical companies that the long acting opioid, Oxycontin, was less addictive (because it was a time-release pill), physicians still bear part of the responsibility along with the pharmaceutical industry.

  Now even the most deserving patients are being given smaller amounts of opioids for legitimate pain (maximum of 7 days now), and when the physician refuses refills, patients can just go to another doctor or easily obtain illicit drugs over the internet and from local drug dealers.

  After 30 years of private practice performing thousands of surgical procedures and writing as many pain prescriptions, very few needed opiates after a week. For those that need refills, physicians must have the patient return to discuss reasons for more prolonged pain. If it is a chronic problem, opioids must be used very carefully.

  Some despersate patients are demanding refills and when physicians refuse, they are even turning on their doctors with physical harm.

More pressure by patients on physicians to prescribe opiates

  Patients are threatening and in a few cases killing their doctors when they refuse to refill their pain meds. An orthopedic surgeon in Indiana is the latest casualty, who was shot to death by a patient who then killed himself, because he refused to continue writing prescriptions for pain medication.

  The American Society of Interventional Pain Physicians published an article stating that 52% of their members had been threatened by patients including 7% who were threatened with a gun. 3% were injured by a patient. Pain management doctors and surgeons are targeted more than other physicians, but no physician is safe in the current toxic environment. Where is the media on this story?

  Because of patient satisfaction surveys, physicians who refuse to prescribe opiates are receiving criticism and poor ratings which influences the physician’s reimbursement now from Medicare and Medicaid. There are so many unintended consequences when trying to do the right thing.

New information

  It is estimated that 70% of chronic pain patients also have some underlying psychological issues either prior to ingesting  opioids or because of their pain and being addicted. Refusing a patient pain relief is a delicate matter, and the public needs to understand the physician is caught in the middle. Patients have responsibility too.

  Newer studies cite the risk of addiction and abuse rises after 90 days of use, even at low doses.

10 Steps the Federal Government should take to alleviate the crisis (a view from JAMA, 2017)

1. Improve surveillance to assess real time evidence about the numbers, patterns, and trends of opioid use and addiction. Seeing a hotbed of cases (certain doctors, neighborhoods, etc.) will alert authorities where the potential abuse is occurring. Prescription drug monitoring through a database through the pharmacies is mandatory. Alerts for prescriptions from more than one doctor must be sent to the pharmacy and doctor.

2. Improve reporting on overdoses, type of drugs, etc., to have up to date information on the changes occurring in drug abuse.

3. Promote cautious prescribing for acute pain and even more for chronic pain. There is a bill in Florida (and the CDC recommends) that limits prescribing to 3 days of pain medications. As a retired surgeon, limiting to 7 days is more acceptable. After 3-5 days, tapering the strength and type is an easy way to prevent overuse.

4. Change labeling for chronic pain, and prevent marketing by pharmaceutical companies for chronic back pain, etc. This should prevent the use of opioids for long-term pain with emphasis on alternative therapies.

5. Increase insurance coverage for non-opioid pain medications (that would normally be over-the counter, but still expensive.

6. Stop influx of illegal drugs (heroin and fentanyl) flowing across borders, water routes for coastal states and airways. More manpower (and funding) is necessary for inspections. The prison system could initiate much better treatment programs for incarcerated offenders. Amend the federal law—Confidentiality of Substance Use Disorder Patient Records—that treating drug addiction is like any other medical illness.

7. Identify and treat opioid misuse before it is an addiction. The possibilities in this area are endless, but doctors must get more involved and be reimbursed for their efforts.

8. Expand the access to methadone and buprenorphine, medications known to curb the euphoria of heroin, fentanyl, and other opioids. After expansion in France using buprenorphine, the death rate dropped by 79%. Courses for doctors should be more available for a special license to prescribe these special drugs.

9. Harm reduction with access to clean needles, and education about overdose treatment (narcan). The FDA should approve an over-the-counter narcan. Europe has been doing this for decades.

10. Remove Oxycontin and other high potency opioids from the general market and reserve for cancer pain, in-hospital use, etc.  From JAMA, October, 12, 2017

Assessment of potential for abuse or addiction

    Recent research has cited genetic factors have been found in higher risk patients. Physicians must also assess patients for their likelihood of abusing medication investigating family history, previous experience with opioids, underlying issues with alcohol dependency, psychological stability, and expectations for relief of pain. All of these measures will help identify those who will need closer monitoring by their physicians.

 Pharmacy databases are necessary to also assist physicians in case other doctors are prescribing these same medications as well and how often.

Treatment is different for opioid addicts

  The treatment for opioid addicts is different than for alcoholics. The 12 step program may be of additional assistance, but for these patients, they need psychiatric care including placing them on the alternative low euphoria drug, buprenorphine. The stigma and extra hoops a doctor must go to be able to prescribe this drug is unnecessary, and it has limited the use and prescribing of this life saving drug. Yes, it is like methadone, and the patients are still addicted, but can wean off this drug much more effectively. The government has been extremely slow to accept the value of this treatment. It is time they listen to the experts.

Retraining physicians to manage pain differently

  The CDC put out a guide in 2016 for physicians treating chronic pain. Multiple medical organizations have offered continuing education welcomed by physicians as they are adjusting their prescribing practices, educating their patients prior to needing pain medication, prescribing milder opiate pain meds (Tramadol), non-narcotic additives alternating with opioids, and tapering the doses to prevent withdrawal and acceptance by patients.

  Physicians need to learn to trust alternative therapies including acupuncture, chiropractic, physical therapy, massage therapy, yoga, and other exercise regimens. Also reimbursement for these treatments should be improved.

  The FDA recently took a long acting morphine (Opana) product off the market because of its potency and risk for addiction. Unfortunately, there are no new medications that control pain without some euphoria (has to do with the pain and pleasure centers in the brain, however, buprenorphine is a much better option than methadone (still used widely).

  The FDA accepts a direct responsibility for what opioids are being approved and continues to take into consideration the benefit/risk considerations of all opioids.

  The approach to this crisis has to be multi-faceted including public awareness, prevention, education, marketing, border control of drugs, cracking down on drug dealers, access to naloxone (reverses overdose), and access to treatment centers. The fix cannot come from the government alone. Until young people get back to work, this factor will continue to feed the crisis.

Vaccine Research

  A vaccine against opioids that would prevent the brain from feeling the euphoria of all opioids is being developed and also helping to prevent overdoses. This is still at the animal research stage, but it is very encouraging to help those addicted to pain meds. Clinical trials in humans should start in the next few years. (Skaggs Institute of Chemical Biology).

The Congress must dedicate more money to this effort as well. It must be a partnership across all sectors of America. The opioid crisis is a national priority. JAMA, July, 2017

The repercussions of limiting opioid prescriptions to patients in legitimate pain?

  We are witnessing the pendulum effect…the media and some governmental agencies blame the doctors for the opioid crisis for over-prescribing…doctors are now reluctant to prescribe opiates and new regulations limit pain meds to less than a week…patients are in pain and blame the doctors…a certain percent reach out to illicit drugs…and some are becoming addicted at a rate never seen in America.

  Still there are patients remaining in pain and if you are one of these patients, you also are caught in the middle of these plans to curb the crisis.  

This completes the November Medical News Report.

Next month, the subjects for December, 2017 will be:

1) Hoarding disorder

2) Acne rosacea

3) Pedophilia

4) Lymphomas—Hodgkins and non-Hodgkins

5) What is the spleen?

6) The dangers of periodontal disease and your health

Stay healthy and well, my friends, Dr. Sam