The Medical News Report

May, 2018

#76

Samuel J. LaMonte, M.D., FACS

www.themedicalnewsreport.com

Subjects for May, 2018

*Late breaking  News---New data on marijuana use and decreasing opioid prescriptions

1. Options for managing chronic pain—part 2—Chiropractic care    

2. An update on blood clot removal after an ischemic stroke

3. The homeless problem and their medical issues

4. Insomnia—new guidelines for management

5. Healthcare costs have skyrocketed—5 factors

6. Low Lead blood levels responsible for 400,000 cardiovascular deaths annually in the U.S.

7. New guidelines for Seasonal Allergies-they are getting worse every year!

Kuekenhof Gardens outside of Amsterdam, A must!!

Please note this important message!

 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 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.

  Also, please let me know if you change your email address. Also sometimes emails go to spam, so check if you don’t receive your monthly report.  Thanks!! Dr. Sam

Late Breaking News

New data on marijuana reducing the need for opioid prescriptions

  Before reporting on this month’s subjects, I wanted to mention 2 new studies that may in some small way be another successful option for chronic pain patients—medical marijuana. As more states are legalizing pot, 2 studies have confirmed a drop in opioid prescriptions in patients who qualify for using medical marijuana. JAMA-Internal Medicine reported that states that have legalized medical marijuana are seeing a drop of 14% in opioid prescriptions according to Medicare data from 2010 to 2015 from medical dispensaries compared to a 7% drop in those states that only allowed home cultivation.

  A second study obtained from Medicaid data showed a 6% drop of opioid prescriptions in states with medical marijuana, and an additional 6% drop in Medicaid patients if they were allowed to use pot regardless of the medical indication. That is 12% which would equate to a drop of thousands of patients needing either less or no opioids for pain relief. These are observational studies, so we must be guarded in our enthusiasm.

  The FDA just authorized a marijuana substance (cannabidiol) undere the brand name Epidiolex to treat syndromes that have seizures in children. This substance does not have euphoric effect pot (THC-tetrahydrocabinol) and has been placed rescheduled not to be a controlled substance.

  Because our federal government still states that marijuana is illegal, because of our laws, no federal funds can be used to study marijuana, which is a crying shame. When is our government going to realize if our country wants to address the opioid crisis, they must wake up and fund major research on this potentially and other helpful substances (and other complementary therapies)? Cannabis is to stay, like it or not.  

Subjects for May, 2018

1. Chronic pain management—Part 2—Chiropractic care 

Before I report on Doctors of Chiropractic as an option to treat chronic pain, I want to review what I discussed in last month’s report with part 1 of the chronic pain management series, define certain terms, and report some good news on opioid prescription writing.

  I discussed the need for a variety of treatment regimens (now named integrative medicine) to avoid or decrease the number of prescription opioids for chronic pain. I also reported on the option of using non-opioid medications, many of which have been proven (in comparison studies) to be as effective as opioids.

   As this issue is being addressed, there is good news from the April, 2018, JAMA Psychiatry. They reported a drop in the number of opioid prescriptions being written!! There is one caveat….those who take benzodiazepines (Xanax, Valium, etc.) are more likely to request opioid medications and are at a higher risk for abuse. Also, there is a significant lack of prescribing naloxone (Narcan), the antidote to reverse opioid overdose. Even the Surgeon General of the U.S. is encouraging people with family and friends who take opioids regularly to carry the antidote to save their lives. (prescription needed—nasal spray, injection—but soon may be over the counter.

  Unfortunately only 4% of physicians are certified to treat opioid addiction with new products such as buprenorphine. Certification is complicated and time consuming and many physicians are just not willing to go through the process. This needs to change.

  CMS (Centers for Medicare and Medicaid Services) has directed Part D Medicare to only pay for opoid prescriptions lasting 7 days for acute pain.

Another epidemic is rising

  And as we are fighting the opioid crisis, another epidemic is being identified—stimulant abuse (cocaine, crystal meth, and prescription Adderall and Ritalin (for ADHD), because it is cheap and readily available on the streets. People who are unemployed are the biggest market. The unemployed factor has to be considered when substance abuse is being addressed. I will report on stimulant abuse in the future. 

Definitions of terms (distinction between opiate, opioid, and narcotic)

  Because of some confusion in the public, I remind you that the term opiate refers to actual poppy plant naturally based chemicals (opium) that relieve pain (i.e. morphine, codeine, and thebaine), whereas the term opioid refers to those that “act like” morphine that are synthetically produced (i.e. Demerol, Oxycontin, Fentanyl, Dilaudid, Vicodin, etc.). The term narcotic refers to any drug that directly affects the brain in certain receptors and is either a natural or synthetic product of opium.

Consultation with a Doctor of Chiropractic (DC) for chronic pain management

  It is time for mainstream medicine to consider referring patients to Doctors of Chiropractic for evaluation and possible management of chronic pain.   

  Traditional medicine has been slow to accept chiropractors to treat chronic pain patients primarily out of ignorance of their value (and lack of good evidence-based research), and because it is competition for patients. Only recently has there been some evidence-based research to prove the value of chiropractic in comparison to other options (for example NSAIDs*). *non-steroidal anti-inflammatory drugs

  In my 30 years as a surgeon, I and many physicians have found chiropractic care to be of value in selected patients. With the current opioid crisis, it is a perfect time for all disciplines of healthcare to team up and provide comprehensive quality care to include other forms of therapy including chiropractic care.

Primary Care Doctors are Gatekeepers

  The primary care physicians (MD and DO), in my opinion, are in a perfect position to be gatekeepers for the management of chronic pain (guidelines and continuing education programs are finally being offered by the CDC). Classically physicians refer pain spinal pain patients to orthopedics or neurosurgeons. That may be totally appropriate, but other conservative measures should be considered unless there are clear cut indications for surgery. There are many types of practitioners that deal with pain and that creates some confusion for the public. This is why seeing a primary care doctor to start the evaluation is logical.  

  Since many patients continue to have pain after spinal surgery, more than one opinion should be considered before accepting surgery. One option should be a consult with a Doctor of Chiropractic (DC).    

  It is estimated that between 6-12% of American adults utilize Doctors of Chiropractic at some time in their lives. Patients must be proactive in asking their primary care doctors for alternatives to pain medicine including chiropractic care (they do not need a referral).

  Chiropractic care is an option for a drug-free and relatively non-invasive form of care. Pain medication may be needed initially, but there comes a time to pursue non-medication options.

The spectrum of chronic pain management

 I suggest that these other options for care be called complementary treatments, and perhaps drop the term “alternative”, since it has somewhat of a negative connotation.

  These complementary options include chiropractic care, acupuncture, massage therapy, physical and occupational therapy, meditation, biofeedback (meditation), counseling, yoga, palates, and other forms of physical exercise, etc. all of which this series will discuss. Chronic pain patients must take responsibility for pursuing these options to try and drop their dependence on opioids. This includes losing weight, exercising, and getting stress under control.

Understanding chiropractic care—neurology of the spine

   It is necessary to understand the nerves that are the origin of pain to discuss how chiropractic care helps chronic pain. The basis of pain management in the field of chiropractic is the relief of mal-alignment of the spine (and other joints) by adjusting the spine to relieve pressure on nerves.

  Every cell in our body is innervated by nerves that exit the brain (the 12 cranial nerves) and the spinal cord which travel between each vertebrae (C-1 to S-5) through passages called neural foramen canals. Along that path nerves can be compromised in many ways causing several symptoms.  

  The main function of spinal nerves is to provide sensation and function to muscles, tendons, and ligaments supporting the skeleton, but there is a spinal neural contribution to the major organs as well (as shown on the diagram below), which may create symptoms. I am limiting this discussion to musculoskeletal conditions. Treating organ disease with chiropractic care does not have as much scientific evidence that it is any better than the placebo effect.

  I have reported on the spinal anatomy, diseases, and treatments in previous reports:

www.themedicalnewsreport.com #18 , #19, #52

Below are drawings of the spine and spinal nerves! Take a moment to study these drawings!

Drawing 1--Neuro-foraminal canal of the spinal nerves between boney prominences (dorsal root ganglion and spinal nerve).

Drawing 2--a normal spine and disc.

Drawing 3--a bulging disc putting pressure on a spinal nerve.

Above, this is a cross-section of the boney spine demonstrating how each spinal nerve from the spinal cord traverses between the vertebrae and out to the body (through the intervertebral neuro-foraminal canals).

Below is an example of a normal spine and spinal nerves and what it looks like when there abnormal pressure on the spinal nerves.

Look closely (left) and see where the neural foramen and the facet joints are located. On the right is an example of a pinched spinal nerve in the neural foramenal canal from a ruptured disc.                                                

The drawing below demonstrates the distribution of nerves to the skin and muscles, which assist physicians in determining which level of spinal involvement might be a problem by testing for numbness and weakness. Patients may complain of pain in a specific distribution down the arm or leg to the hand or foot.

Muscular function or sensation can be affected by nerves that are trapped by scar tissue, misaligned vertebrae, etc. 

The many functions of the spine and the value of chiropractic care (distinction between chiropractic and medical subluxation)

  The spine and its attached soft tissue allows our body to twist, bend or stretch as we desire, and the flexibility of the spine is key for smooth mobility of our body. With impairment of these functions, pain, numbness, and weakness can occur.

  Chiropractors focus on the detection, and analysis of joint misalignment of the spine and extremities known as chiropractic subluxation. This condition can cause pressure on surrounding nerves and soft tissue which can subsequently cause pain and musculoskeletal degeneration. X-rays may not demonstrate this degree of subluxation, but can be felt by palpation from the experienced hands of a chiropractor.

  Medical subluxation (called spondylolisthesis) is different in that it is more severe and obvious on images such as these X-rays below.

Imaging of spinal disease

arthritic spur loss of disc space

An important difference in spinal treatments--Differentiation between mobilization and manipulation

  There is a distinction between mobilization and manipulation of the spine that needs to be understood. As always, treatment from any practitioner may require a spectrum of care.

  Mobilization implies slow, sustained, and repeated movement. Massage and physical therapists perform these types of maneuvers, however, chiropractors often have massage therapy, electrical stimulation, etc. provided in their offices or have various techniques that may accomplish this as well. Sometimes the misalignment may be quite minor, and with chiropractic adjustment, the pain might be relieved once the spine is realigned and the punched nerve has time to heal.

  Manipulation implies a higher velocity stretch at the end of the joint’s range of motion. These chiropractic adjustments are performed with great precision and rarely cause pain. The founders of this technique stated that these moves increase circulation and relieve misalignment of the spine which relieves pressure on nerves. Of course, that is simplifying a very sophisticated form of therapy.

Theory of spinal manipulation

  Below is a quote from an article that clarifies some of the techniques commonly used in chiropractic care. I have attempted to define the medical terms used in the explanation. Articulation implies how two vertebrae meet each other and move. The synovium is the lining of joints that make the joint fluid. Hypertonic muscles imply spasm. The nerve receptors send messages to the brain (proprioception) regarding the position of the joints, and endorphins are natural brain chemicals (very similar to morphine) that are powerful pain relievers that we all can secrete.

  Here is the theory of spinal manipulation:

The above quote was taken from a recent article on this subject in Medscape, 2017. Relieving the pressure on a nerve being pinched (entrapped) may relieve pain and muscle spasm, and restore normal function, but this technique may require a series of chiropractic treatments (adjustments) to give time to re-educate muscles and repair damage.

  Chiropractic treatment aren’t just about spinal adjustments, rather electrical stimulation (TENS), heat treatments, massage therapy and or acupuncture may enhance relief and many Doctors of Chiropractic (DC) provide all or some of these modalities. Time also heals many spinal problems, therefore, conservative treatments such as chiropractic treatment also gives the body time to recover. When appropriate exercise, yoga, massage, etc. will need to be added.  

  Cervical spinal chiropractic manipulation has value in subacute or even acute neck pain and often requires a series of treatments. Any technique that takes spasm out of muscles will allow a natural readjustment of the spine and may in fact relieve pain. Some legitimate studies found that this technique was more effective than non-steroidal anti-inflammatory medications (NSAIDs) and muscle relaxants.

The most common adjusting techniques are presented below. The Doctors of Chiropractic determine which technique(s) may benefit each patient to achieve the greatest result.   

1. Gonstead technique—adjusting the spine while the patient lies on their side, back, prone, or sitting position. This technique is used to “realign joints, reduce pain and stiffness, and increase mobility”. Specific adjustment can be performed with or without special chairs or adjustable tables. The goal is to provide maximal eefect on the discs while restoring normal alignment and motion of the spine.

3. Cox technique—decompression technique used for patients with a herniated disc. This is a stretching technique requiring a special type of adjustable table. You can get online and see a video regarding it’s function.

4. Spinal decompression therapy (non-surgical)—works by lengthening and releasing the spine creating negative pressures within the spinal disc. It is stated that this reversal of pressure creates a vacuum within the disc space and helps to pull the bulging disc material back into place. This takes the pressure off the pinched nerve(s) and surrounding tissue. Lasting results for neck and back pain can be achieved with this innovative technology with multiple treatments.

5. Diversified technique—similar to the Gonstead technique using hands-on thrust movements designed to readjust and realign the spine.

6. Graston technique—uses an instrument that uses a massage movement with a gentle scaping of the skin. This is used to release scar tissue that has restricted motion in the spine. It is based on the similar technique called myofascial release, an intensive treatment used to stretch scar tissue. I have had this technique performed by a physical therapist for the severe scar tissue I have in my neck from radiation fibrosis, and it helped in about 3 months with weekly treatments.   

  A great resource is the American Chiropractic Association website for more indepth information.  Click on: www.acatoday.org

Selection of a Doctor of Chiropractic (DC)

  Be as selective about choosing a chiropractor as you are about your primary care doctor. Check reviews, talk to their patients, your personal doctor, and if symptoms do not improve, seek another opinion. There is no one answer in treating chronic pain, but chiropractic can be a viable option.

Comparing chiropractic techniques

  There are no comparison studies of these different chiropractic techniques as to which of these are more effective than another, as it is a very complex issue. As in medicine, chiropractors are taught to use various techniques and with experience learn which technique(s) is most effective in their hands. The art of the practice of medicine or chiropractic always plays a significant role in the care of any patient. Every doctor should know their capabilities and limitations and when to refer to other specialists when treatment goals are not being met. Trusting and believing in a doctor or chiropractor to help them is critical in a patient’s road to recovery.  

Insurance can be a stumbling block in seeking certain forms of treatment

  Insurance coverage for chiropractic physicians can be limited and should not be. That is even more true for other forms of therapy. Consultants to the insurance industry must get them on board to reimburse these complementary treatments at better rates and for multiple treatments if they are effective.

  We as advocates must encourage our congressmen to  support reimbursement and research for a variety of therapeutic interventions. Comparison research is also sorely needed.     

  If X-rays are requested by a chiropractor, insurance may not cover them. Talk to your chiropractor about coordinating these X-rays with your doctor, and then it will probably be covered.

Guidelines for pain management needed

  There is a great need for established guidelines (called algorithms) for treatment of acute and chronic pain conditions that includes complementary modalities such as chiropractic care. The CDC has just begun providing intensive continuing education and guidelines for the use of opioids (just published in Medscape) to primary care physicians, but more general guidelines are needed to utilize all options of therapy.

Summary

  Living with chronic pain can make quality of life poor, and every attempt to help these patients must be tried. There are many types of pain, and one type of treatment will not not necessarily be successful for types of pain. A dedicated primary care doctor is greatly needed, who is willing to refer their patients to different types of practitioners including chiropractors when surgery is not indicated.

  It should be noted that a short course of medication (opioid or non-opioid) may be indicated while the evaluation and treatment is ongoing.

  The degree of abnormality in the spine may require evaluation by an orthopedic or neurosurgical consultation. If severe enough, a pain management specialist may be required before surgery is indicated (discussed next month). If surgery is not indicated, this may be a good time to consult a Doctor of Chiropractic and certainly in less severe cases. Chronic pain requires ongoing treatment, and more than one or two therapeutic options may be required over an extended period including time to heal the condition. Recurrence of pain with re-injury is very common, therefore these treatments may be necessary over an extended period of time.

Acknowledgements

  I would like to thank Dr. Dennis Hayes, D.C. (retired-Michigan) for a major contribution to this report. Also, I want to acknowledge Dr. Carl Lynn, D.C., and Archbishop John Erbelding, D.C. (retired Georgia) for additional review for accuracy and contributions. Dr. Lynn continues to practice chiropractic in Clayton, Georgia.  

  Next month, I will discuss what pain management specialists can add to the care of patients in chronic pain. These are MDs who have become fellowship trained to perform special techniques to treat pain and are invaluable in treating pain.

2. An update on clot removal after an ischemic stroke

  The FDA has just extended the time that a clot removal device (Trevo device) can be used in an ischemic stroke from 6 hours to 24. This is great news especially for those at a significant distance from a facility capable of evaluating and treating an ischemic stroke.

  There is still a narrower window for starting anticoagulants to treat smaller clots and preventing further emboli.

  The latest study cited that almost half of patients at 3 months post-stroke were functioning independently with clot retrieval versus only 13% with medical therapy alone. This is huge!! NEJM Journal Watch Neurology, Feb, 2018

For an in depth discussion of stroke, click on:

www.themedicalnewsreport.com #23 , #25, #27, #72

3. The Homeless problem—medical issues

  This subject makes most of us uncomfortable, because it is truly a national tragedy and one that could be handled better. We all have turned our heads on street corners when we see homeless people with a cardboard sign asking for work or help. I have many times handed them a dollar wondering if they are really homeless or just panhandling.

  We are all paying for them one way or another, and when they come to the emergency departments, we are paying. Are they just a bunch of drunks or addicts wanting to pay for their next fix? I am sure there is a percentage of those individuals that are, but most are for real and in great need. We are talking about families with children struggling to survive. Many have become homeless through no fault of their own.

The demographics of the homeless 

  The complexion of homeless has changed over the past decades. Formerly they were mostly men, but today, they are made up of women and children, and entire families. Although it is hard to estimate the number of homeless people because of the actual definition, but the best estimate is that on any given night, there were 550,000 homeless individuals in 2016, of whom 32% were unsheltered and 35% were families with children. The highest number of homeless occurred in Los Angeles (32,803) of which 82% were unsheltered.

Cities struggle with the issue

  Although we are all concerned for their welfare, cities are frustrated with open drug use or public intoxication, public display of aggressiveness, public urination and defecation, parks and streets with scattered homeless blocking areas, aggressive panhandling, etc. Outbreaks of disease are not uncommon with hepatitis leading the pack. Using unsterile needles is just one way this occurs. Many countries dispense needles free to prevent these diseases, but not in the U.S. Last year, 600 homeless people in California became ill with hepatitis A, requiring 395 hospitalizations, and 11 deaths in just one outbreak. This impacts all of us and begs for sanitary facilities for these people.

The issue, causes, possible solutions

  It is useful to separate those who become homeless because of economic circumstances (more likely acute), and those who are a result of addiction and mental illness in addition to economic issues (usually chronic).

  Gentrification in downtown areas has forced out low income housing and funding is $3 billion less than 2010 (proposed budget $40.7 billion) for HUD. Add that to underfunding for mental illness and the cheap cost for heroin on the streets, and we have a perfect storm. Many of these people are not being imprisoned due to prison space issues and changes in laws for low level drug users.

  The solution is multifaceted but starts with housing for these individuals. Facilities to help with medication adherence, mental health treatment, drug addiction therapy, improved sanitary conditions, and management of these issues are necessary. Housing First is a program that has been successful in alleviating this problem in certain cities. Taking in those that are addicted and not sober is a challenge but necessary.

  The myth that homeless prefer to stay on the streets is not true. Lack of engagement with the homeless has led to this untruth.

   For those in economic straits, housing and time-limited funding is helpful. Funding such a huge undertaking has been a challenge, and I suspect there is always administrative waste. Hopefully, Dr. Ben Carson, head of HUD (Housing and Urban Development) can clean up this agency and see to it that more of the dollar goes for services directly to the homeless. Consider the billions we are spending on immigration issues when we could be directing these funds to HUD.

  The cost estimate is approximately $15,000 per year to house a homeless person (remember 550,000 homeless in 2016—do the math!). If we can keep these patients off drugs and alcohol, find them a job, and keep them with their families and out of the hospital, this cost can be countered with the savings. Leaning on Medicaid to handle these costs is only cost-shifting and not relieving this horrendous national tragedy.

  One cannot lean on the federal government for all the answers. Local communities must address this and taylor the solution to the specific community’s needs.

    Bridging the gap between housing and medical needs is far from satisfactory. Establishing partnerships with medical facilities and providing navigation to housing and services as they are discharged from the hospital is greatly needed. Non-profit organizations are overwhelmed with filling the needs of the homeless. Dealing with over a half million people homeless at any one time is a enormous task, and with so many other needs that our nation faces, I am afraid this issue is not receiving its just due.

  There is another issue and that is acceptance of this type of housing in local neighborhoods. Most agree there is a growing need but “ not in my neighborhood” is often the problem when city councils address this issue.

  JAMA, Oct 31, 2017

4. Insomnia--new guidelines for management

Incidence

  It is estimated that 49% of the adult population suffers from acute insomnia at some time in their lives and 30% suffer from chronic insomnia disorder *. Women are more prone to insomnia especially around the time of menopause or monthly menstrual periods. Co-morbid (additional medical issues) conditions contribute considerably in the elderly and aggravate insomnia. The most common conditions are chronic respiratory issues (COPD, snoring, sleep apnea), gastrointestinal reflux (GERD) and pain.  Restless leg syndrome often presents to the doctor as insomnia. The physician should explore these medical conditions in anyone presenting with insomnia.

*chronic insomnia is defined as at least 3 nights of insomnia per week for at least 3 months

  Mood disorders commonly (56%) follow a bout of insomnia. There is much to evaluate when a person presents to a doctor with sleep disturbance, and it certainly isn’t as simple as prescribing a sleeping pill. Insomnia creates real quality of life issues for patients, and it must be addressed and treated.

  I have addressed sleep physiology and abnormalities of sleep including insomnia at length in previous reports. I would strongly suggest you review these reports for an inclusive review of the subject.

www.themedicalnewsreport.com #23 , #24, #56

  This current report will update your knowledge in the latest information from the medical literature.

Impact on quality of life

  The implications on quality of life are major. It has been well established that having at least 5-6 hours of quality sleep per night is essential for good health. There are many studies that demonstrate increased cardiovascular deaths from those who do not have adequate quality sleep. There are even studies that demonstrate that night shift workers are at higher risk for all cause mortality. Stress comes in many forms, and we all know that chronic stress is a killer. Sleep deprivation is a form of torture, lowers the threshold for seizures, and weakens the immune system. As complicated as our brain is, we have a long way to go to unlock all the mysteries of our “master computer”.

  Compared to those without insomnia, these patients experience higher rates of accidents, loss of work days, diminished work performance, going to the doctor’s office more frequently, and report a decreased quality of life.

Definition and impact of insomnia

  Chronic insomnia is thought to be a hyperarousal state throughout the day and night. Anxiety and depression can cause this state and once again begs the question of the link to these disorders. More evidence of a neuroendocrine link comes from a study that performed PET scans on these patients to measure the glucose uptake by the brain (metabolic rate) which is increased in those with chronic insomnia. An increased metabolic rate raises the arousal state of the brain preventing sleep onset. Reference from the NIH (National Institutes of Health).

Defining chronic insomnia

  A recent article in JAMA (Journal of the American Medical Association) updated the clinical management of insomnia disorder. They define chronic insomnia disorder as dissatisfaction with sleep quantity or quality associated with difficulty falling asleep, maintaining sleep, or awakening earlier than desired. It is clinically diagnosed when it occurs 3 times per week for 3 months. This definition excludes those on certain medications or substances that interfere with sleep or other disorders that are the cause for sleep abnormalities. Co-existing medical issues require additional management such as a chronic cough, obstructive sleep apnea, or a painful condition.

  Acute insomnia can occur intermittently depending on a multitude of factors mostly psychological stress from work, family worries, financial concerns, etc.  

Anxiety and Depression linked to chronic insomnia (distinctions between the two)

  Patients who suffer from chronic insomnia and pre-existing anxiety usually experience anxiety prior to insomnia. Depression also is commonly linked to insomnia. Usually anxious patients have trouble getting to sleep but once asleep stay asleep, and depressive patients can get to sleep but often wake during the night and cannot get back to sleep.

  Recent research has linked certain neuroendocrine abnormalities in both disorders (cortisone dysregulation in insomnia in patients with anxiety/depression).

Insomnia causes other conditions and is aggravated by many

  Difficulty in falling asleep (most common) can trigger other sleep issues (delayed sleep phase syndrome*, restless leg syndrome, or anxiety). Difficulty maintaining sleep can result from sleep apnea, nocturia (need to empty the bladder at night), or pain. All these issues must be addressed (see the subject index on my website on all these issues).

  *Delayed phase syndrome is a chronic circadian rhythm disorder from abnormal regulation of the biological clock. It affects the timing of sleep, peak periods of alertness, and even hormonal regulation. These patients frequently can’t fall asleep until well after midnight and then have difficulty waking up in the morning. These patients tend to have longer circadian rhythms than 24 hours and is thought to have a genetic origin. It does respond somewhat to melatonin and other medications that can regulate the circadian rhythm. Light therapy also is used.

  New studies are now linking chronic insomnia with an increased risk for cognitive decline including Alzheimer’s disease.

  Certain sleep agents also used over a long period of time (diphenhydramine {Benadryl} and benzodiazepines (anxiety meds) may take the edge off and get patients to sleep but do not provide restful sleep. Overuse may also increase the risk of cognitive decline and Alzheimer’s disease. Much more research is necessary to elucidate the connection between insomnia and cognitive decline.  

Measurement of insomnia

  There is an insomnia severity index to quantify the severity, a questionnaire that takes 2-3 minutes to complete. To access this questionnaire, search for it under the National Institutes of Health www.nih.gov

Factors that influence quality sleep

  There are many medications and illegal substances that can interfere with sleep including certain foods. Caffeine after 1-2pm is known to interfere with sleep. There are also some foods that are conducive for sleep. There are many suggestions to enhance sleep, provide the best atmosphere for quality sleep including the bedroom environment (no TV, eating, or reading in bed, and no blue lights).

  Another factor that is being studied is the amount of light emitted by electronic devices (cell phones, tablets, Kindles,TV, etc.) since insomnia is on the rise. Not only light stimulation but brain stimulation from these devices may be playing a larger role than thought, since our circadian rhythm is based on a certain number of hours of light and darkness. Medscape Neurology April 6, 2018

  The avoidance measures and preparation for the hours prior to bedtime are all previously covered in my reports. www.themedicalnewsreport.com #23 , #24

New Guidelines for management

  In the JAMA (Journal of American Medical Association), the American College of Physicians (ACP) reported new guidelines for treating insomnia.

  ACP recommends cognitive behavioral therapy as the initial treatment for chronic insomnia disorder. This must be differentiated from acute insomnia disorder which can be managed more commonly with medication. There are new FDA approved medications for insomnia that I will discuss.

  Behavioral types of therapy are infrequently used, but there are some new more patient friendly ways of using this mode of therapy.

  Cognitive therapy deals with the realities of issues that may be creating a negative environment for sleep. This form of treatment is multimodal including education, stimulus control instructions, time-in-bed restrictions, and relaxation techniques. Properly followed, this therapy yields 70-80% success.

  Cognitive behavioral therapy (CBT) can be performed by a trained professional but now there are self-guided, fully automated online programs (there are several—SHUTI, Sleepio*, and others) that hopefully will increase use by the general public.

  *Sleepio is a virtual website program using mobile devices to provide 6 interactive weekly sessions and may be as effective as face to face cognitive therapy.

  There is also a brief encounter type of therapy called Brief Behavioral Treatment for Insomnia (BBTI), which is delivered in a single session with 2-3 follow up visits in person or by telephone. It includes 4 behavioral interventions: 1) Reduce time in bed to match actual sleep duration, 2) Get up at the same time each day regardless of sleep duration, 3) Do not go to bed unless sleepy, 4) Do not stay in bed unless asleep.

  Patients should keep dairies and communicate with the therapist weekly by phone and or electronic communications. As sleep consolidation (staying asleep longer) increases, the patient can stay in bed for longer periods of time to balance sleep continuity and sleep duration.

Pharmacological interventions

  Although CBT is recommended, there is also room for medications to help induce sleep and maintain longer durations of sleep. As stated above, this form of therapy is more advisable for acute insomnia disorder patients (insomnia less than 3 months). Research has not been able to prove that medical therapy is of much value long term. Better research is needed to define the value, since most of the studies have been financed by the drug companies themselves.

FDA approved medications for insomnia

(medications are generic with the brand name in parentheses)

1) benzodiazepines--diazepam (Valium), lorazepam (Ativan), quazepam (Doral), clonazepam (Klonapin), etc.

2) benzodiazepine receptor *agonists--flumazenil (Romazecon, etc.), considered minor tranquilizers  

3) melatonin receptor *agonist—ramelteon (Rozerem)

4) tricylic anti-depressant—doxepin (Silenor)

5) the orexin** receptor antagonist suvorexant (Belsomra).

6) zolpidem (Ambien) slows down the brain by affecting gaba-amino-butyric acid which is a neurotransmitter. There is a short acting preparation and CR prep which is better to not only help you get to sleep but also stay asleep.

  * Agonist means it stimulates the receptor. Antagonist means it blocks the receptor.

  **Orexin is a brain hormone that creates wakefulness. Belsomra inhibits this hormone to create drowsiness.    

Adverse effects of sleep medications

  Adverse effects of the benzodiazepines should be considered: amnesia (anterograde), complex sleep related behaviors, daytime drowsiness, falls, cognitive issues, and even an increased risk of Alzheimer’s disease, rebound insomnia, dependence on the medications, and even respiratory depression.

  Clinicians favor short acting medications to prevent side effects when the patient wakes up. Doxepin (Silenor) 3-6 mg is preferred as a maintenance drug 3-4 nights a week and don’t have many of the side effects of the benzodiazepines. Suverant (Belsomra)is also a good choice for sleep maintenance symptoms as it does not create the need for higher doses over time (called tolerance issues). Ramelteon is most appropriate for sleep onset insomnia issues.

Off-label medications (means not FDA approved for sleep disorders)

  Many medications have sedation side effects and are often used for sleep especially if over the counter (OTC).

  There are many off-label and some over the counter medications used for sleep that are sedative such as antihistamines--diphenhydramine (Benadryl).  Hydroxyzine (Vistaril) and phenergan (Promethazine) require a prescription. As stated earlier, these are not found to provide restful sleep even though they may get patients to sleep.

  Quetiapine (Seroquel) a psychiatric drug, is used for sleep as well.  

  Melatonin and valerian root have some value in selected individuals, but because the pharmaceutical industry has little to gain from performing research, the evidence-based studies are few.   

  Sedating antidepressants (trazadone, mirtazapine) and anti-psychotics (olanzapine, quetiapine) are NOT FDA approved for insomnia because of adverse side effects (neurologic, cardiovascular, etc.) unless the patient has the appropriate psychiatric diagnosis which includes insomnia. Often antidepressants that stimulate such as (Wellbutrin) may require benzodiazepines to counter the drug induced insomnia.

Summary

  The article I am citing in JAMA suggested a pragmatic approach to insomnia:

1) Evaluate sleep and daytime symptoms including other disorders complicating the issue (comorbid conditions).

2) For acute insomnia disorder consider zolpidem (Ambien) or tamazepam (Restoril) 3-4 nights per week for 3-5 weeks

3) For chronic insomnia disorder, implement cognitive behavioral therapy as the first treatment with or without medications.  

4) Evaluate treatment success (sleep and daytime response); continued insomnia with CBT, consider medications (drugs mentioned above). If symptoms continue, switch to another choice of medication.

5) If symptoms persists, reevaluate and explore comorbid issues (psychiatric, sleep apnea, etc.) and contributing factors (marital, job stress, and other social issues).

6) Monitor for side effects and long term neurodegenerative issues, substance abuse, and depression or anxiety as a result of long term chronic insomnia.

JAMA, 2017; National Institutes of Health (nih.gov)—Journal of Clinical Sleep Medicine, 2017, August

5. Why healthcare costs have risen so rapidly—5 factors (and much more)

  We all have our attitudes about why healthcare costs are rising so rapidly. But there has been an analysis of factors that was reported by the JAMA, November 7, 2017. The authors cited 5 factors that were responsible for rising costs regarding inpatient, outpatient (ambulatory), retail pharmacy, nursing facility, emergency department, and dental care increased by $933.5 billion from 1996-2013 from $1.2 trillion to $2.1 trillion. These factors are adjusted for price inflation. The 5 factors cited are:

1-Population Growth—23%

2-Population Aging—11.6%

3-Changes in disease incidence and prevalence—reduction of 2.4%

4-Changes in medical services utilization—no change

5-Changes in prices and intensity—50%

 *This is one paper with these 5 factors, however, there are clearly many more factors that I will report on.

6-Red tape (paperwork/administrative excess) from over-regulation by the government and insurance industry—administrative costs-- I am adding this 6^th factor!!! It is three times higher than other affluent countries. Many health clinics employ more clerks than care providers to perform several tasks: a) send invoices to insurance companies b) get approval for testing, procedures, etc. c) dispute rejections of payment from insurance companies d) fix mistakes e) handle patient’s questions and concerns to name a few. There are many solutions outside of a single payer plan.

  A recent study cited the administrative cost for a primary care doctor to see a patient is 17.5% of the doctor’s revenue. That is as highest it has ever been thanks to regulations and unnecessary paperwork (computer work).

  For every $1 billion in revenue, the healthcare system employs 770 fulltime employees to settle bills (8 times higher than other countries). There is no standardization of these billing practices which could streamline the process. (Bloomberg)

The overall picture

  Spending on healthcare exceeds most countries, and is rising. In 2015, spending was $3.5 trillion and constituted 17.8% of the U.S. economy.

The biggest health care costs in medicine

  Diabetes, low back pain, and neck pain were the reason for the most increases in annual spending followed by hypertension and hyperlipidemia (fats) treatment. Falls fell out of the top ten conditions for the first time.

One area of saving

  Because of the changes from inpatient care to 24 hour admission and outpatient treatments, the number of in-hospital days have decreased and dropped spending by 45.9%.

Pharmaceutical expenses

  Drug costs rose by 67.1%, which is no surprise with Medicare spending outrageous. When is our government going to put the brakes on Big Pharma?? When the lobbyists get their hands out the Congressmen’s pockets!

Ambulatory Care Costs

  Because of the decrease in in-patient care, ambulatory care (outpatient) rose primarily because of population growth. Emergency department spending and intensity of services rose considerably which is disappointing since Obamacare was touted to free up the emergency rooms and did not.

Health factors

  If you factor obesity as a significant association with diabetes and low back pain, I have been reporting that these factors are causing the greatest rise in healthcare costs. Not addressing the obesity crisis as energetically as the opioid crisis would be a mistake, if we are to get a handle of healthcare costs.

  Neck pain spending was a surprise to me, but with the use of computers, this may be a factor.

  Cholesterol problems again correlate with diabetes and obesity, which rose as well.

  Depression increases correlated with increased spending for ambulatory and pharmaceutical costs and yet the mental health of our country is sad with poor coverage for mental illness.

Age and Nursing home costs

  When age is analyzed, people over 65 are creating the greatest spending which correlates with everything we have reported on over the past few years. And increased spending in nursing home facilities follows the age related spending, whereas increased utilization by younger groups correlated with increased spending in the emergency departments and dental care.

Price for services

  The cost for provider care, testing, hospital facilities are all factors that should be controllable but are not. Standardization of cost, transparency for patients to shop costs by different providers, and bundling of services all could help.

  We must look to the Congress to finally negotiate prices with Big Pharma. The cost of drugs today is obscene. Also increasing visits to the doctor correlates with more people having insurance.

The cost of Preventative Care

  Physicians trying to prevent cardiovascular and other diseases causes doctors to grab their prescription pads more frequently trying to curtail cholesterol alone has the majority of adults on anti-lipid drugs. Hopefully we will see a drop in costs when these preventative measures pay off. Increase in in-patient care (although less spending overall) was a large factor in medication increases especially in the top three conditions cited above (diabetes, low back pain, and neck pain and others).

  Essentially, the cost for each condition has risen across the board. Spending on cardiovascular disease was down perhaps because of the preventative services provided (anti-lipid drugs, better management of diabetes, etc.).

The cost of cancer care in the last few months of life

  Many pharmaceutical companies are spending all their research dollars on life-extending cancer drugs. This is the race to provide extremely expensive cancer drugs to extend life for 1-3 months in terminal patients when the treatment cost $300-400,000. It is happening in every cancer center in an attempt to find new cures, which is admirable but is costing billions of dollars and making cancer centers rich. Since the newer forms of cancer therapy came into existence, the costs have skyrocketed. I can tell you of several instances I personally know where patients have cancer all over their bodies, and their doctors are still treating them until their death…a very serious ethical question. 

Unnecessary testing, treatments, etc. and the Malpractice Factor

  A recent study cited some alarming yet not surprising statistics:

  20% of medical care, 25% of laboratory tests, 20% of prescriptions, and 1 out of 10 procedures are unnecessary. The number one reason for performing these medical tasks was fear of malpractice, patients insisted on the tasks, and some point to overscreening for disease especially cancer. False positives create unnecessary biopsies, tests, complications, and in some cases unnecessary treatments.

Big Pharma not playing ball!

  President Trump is working hard to reduce drug prices and one of the stumbling blocks is access to generic drugs. The FTC is investigating many of the pharmaceutical companies for refusing to supply samples to generic companies for production of the generic equivalent. There is bipartisan support for a bill to ensure access to these samples. Over 150 complaints by generic companies to the FDA is being investigated. Access to more generics will save the federal government over $3.8 billion over the next 10 years and patient will save because of it.

Conclusion

  If we are ever to get healthcare costs under control, the risk/benefit discussion must be part of the equation of medical care hard as it may be. Cost has got to be a consideration!! The Institutes of Medicine estimates that unnecessary medical services added $210 billion to the cost of healthcare. Healthcare costs are rising primarily because of increased utilization of services and do correlate with the rising population, which could be curtailed if our government comes to their senses (unlikely).

  There is no way healthcare costs will ever be controlled without the cooperation of the government, the public, the medical profession, healthcare facilities, and common sense as the overarching principle  There will come a time in the next decade when we will face a single payer system unless we all face the realities of our country’s challenges and deal with them. With the opposite polarity of our 2 party system, I am not optimistic. 

JAMA Forum Nov. 14, 2017

6) Low level Lead Exposure responsible for the deaths of 400,000 Americans each year!

  Surprised? According to the Journal Lancet Public Health, of the 2.3 million deaths annually in the U.S, low level lead exposure is responsible for 400,000 cardiovascular deaths per year. They stated that lead exposure is one of the leading causes of premature death in the U.S.

  From the Third National Health and Examination Survey, researchers tested blood lead levels on 14,000 adults from 1984-1994 and followed them for 19 years. At the levels of blood lead (6.7ug/dL)*, these people had increased risks of all-cause mortality rates from heart disease and strokes compared to those that had low levels of lead (<1.0ug/dL). These researchers estimated that if these levels were as low as the controls, it would have reduced the all-cause mortality from cardiovascular disease by 18% or 412,000 deaths. 

(*ug means micrograms of weight and dL means deciliter which is 100 milliliters. They are just different measurements and very small quantities compared to using milligrams per milliliter, which most are accustomed to). It takes very little lead in the system to create toxicity to the cardiovascular cells.

  Why is the number of deaths so much larger than previously reported?

  Previously researchers only looked at deaths related to lead levels above 5ug/dL. It has been discovered that lower levels are toxic as well. Older Americans have the highest levels because they have had more years of exposure and lived in times when leaded products were still legal. The authors from Vancouver, British Columbia, stated that about 1/3 of cardiovascular deaths are attributable to lead exposure.

  How are people exposed to lead?

  The soil (contaminated by leaded gasoline or paint), copper piping (soldered with lead), household dust, pottery, old and cheap toys, and cosmetics are the main sources.

  If your home was built before 1978, have your home tested for lead. If you are renovating, there may be exposure to lead. Vegetables grown in leaded soil will contain lead.

  10-20% of lead poisoning occurs from contaminated water. Even new homes have been found to have copper piping soldered with lead. According to the EPA, if you live in a house built in the last 5 years or less, assume the water is contaminated with lead. Private wells should be tested.

  This information is a surprise to me and probably you.

  Lead in our water, soil, and products are killing as many people as tobacco. We must become proactive about our environment and be more aware that unhealthy food, lack of exercise, and smoking kills the most, but lead contamination is a real factor in affecting our health.

  Cleaning of contaminated soil, removing older housing, phasing out leaded fuel, replacing any lead used in plumbing, reducing emissions from smelters, and strict rules on discarding lead batteries at facilities, and soil cleaning of any location which sold gasoline (leaded) according to laws.

  The U.S. has now stated that action should be taken in those who have blood levels above 1.0ug/dL

  How can patients be tested?

  A recent study stated that only a finger prick should be used to test for lead in the blood. Drawing blood in a rubber stoppered tube will interfere with the test, because the rubber stoppers excrete a chemical that interferes with lead in the blood, so be sure the test is performed properly. Pediatricians are aware of it.

  Lead exposure causes more all-cause deaths than cigarette smoking. Put that in your pipe and smoke it!! The good news is because of environmental regulations currently in the U.S., younger people should have lower levels of blood lead and experience less cardiovascular disease in the future.

Reference—Lancet Public Health

7. Seasonal Allergies-new guidelines—Awful seasons ahead!

  There are precious few of us who do not have seasonal allergies. Suffering can be mild but in my practice, I dealt with those that had the most complications from allergies.

  Over 30-60 million Americans are affected by allergies annually. That is 10-30% of adults and 40% of children.

  And there is bad news!! Allergy seasons are lengthening and getting worse thanks to global warming, experts say. As seasons getting warmer, the growing season for plants is lengthening. That gives those plants longer to spread their pollen into the wind for longer periods of time. In areas seeing more rain, that will encourage more mold. 

  Allergic rhinitis causes nasal congestion, sinus pressure, sneezing,  red itchy eyes,  headache, sleep disturbance, cognitive impairment, and fatigue.

  It seems the seasons tend to overlap and a great number of us have nasal congestion, post-nasal drip, cough at night, and ultimately sinusitis, ear blockage (eustachian tube swelling), eye allergy, progession of asthmatic bronchitis, allegic dermatitis, and even gastrointestinal upset. Add flu to the equation, and these patients are likely to suffer more than most.

  The American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology have developed new guidelines for the initial pharmacological treatment of seasonal rhinitis (nasal allergy) patients 12 years and older.

  The highlights are as follows:

1. Intranasal steroids (Rhinocort, Nasocort, Flonase, etc.) therapy is strongly recommended for the initial treatment of seasonal allergies rather than the nasal steroid combination with oral antihistamines.

2. Intranasal steroids are favored over leukotriene receptor antagonists (Accolate, Singulair, Zyflo) (over age 15).

3. A weaker recommendation was to recommend a nasal steroid in combination with a nasal antihistamine (age 12 and over).

  Some new information with improved research also has been reported regarding the benefit of oral probiotics. It is reported that it may help improve quality of life in these patients. In this study (American Journal of Clinical Nutrition, 2017), participants were given 2 capsules (1.5 billion colony-forming units per capsule) or a placebo. The bacterial strains were Lactobacillus gasseri, Bifidobacterium bifidum, and B. longum. These are common strains in many probiotics. The probiotic group felt their quality of life was improved based on specific questionnaires. Even though there is still subjectivity, there was a significant improvement over the controls (placebo group).

  If symptoms worsen, an allergy evaluation should be performed (skin tests and IgE blood tests). When certain allergens are positive, allergy shots are recommended.

  Oral steroids are not recommended except in special circumstances and for those who do not respond to the above regimens. Oral or intranasal antihistamines are recommended intermittently but not on a regular basis. Oral leukotriene receptor antagonists have some value but not as the primary therapy.

  Intranasal decongestants (oxymetazoline-Afrin) can be used intermittently when nasal congestion is worsens. Rebound nasal congestion after several day of Afrin can occur and lead to chronic addiction. I have seen patients using 2-3 bottles of Afrin per day. The only treatment at that point is oral corticosteroids and discipline to stay off the Afrin.

  Treating allergies is a long drawn out affair, and staying on chronic therapyis difficult, but starting therapy 2-3 weeks before a person knows they will be in trouble will allow for better results and even prevention of many of the symptoms.

This completes the May, 2018 Medical News Report

Next month the June, 2018 report will include:

1) Chronic pain series—part 3—Pain management specialists

2) Hip Fractures

3) Dry Eye syndrome

4) COPD—chronic obstructive lung disease

5) Which is better to lose weight—a low fat or sugar diet?

6) New medications to treat alcoholism

  Stay healthy and well, my friends, Dr. Sam