There's a prescription drug abuse problem sweeping the U.S., but fixing it will require a systematic change focused on how most health professionals prescribe drugs, rather than changing the practices of a few bad apples. At least, that's the recommendation put forth in a research letter published in JAMA Internal Medicine. Researchers examined Medicare claims from 2013 to see which doctors prescribed opioids - a class of drug that includes OxyContin, morphine, and codeine - and how many prescriptions they filled. They found that the drugs are prescribed by a broad cross-section of medical professionals -- including doctors, nurse practitioners, physicians' assistants, and dentists -- rather than concentrated among a small group of practitioners. That means overprescribing opioids, they suggested, is a problem to which a majority of health professionals are contributing, not the work of a small minority.
"You need to address everyone, or at least a larger amount of prescribers than a few deviants," said study author Jonathan Chen, MD, who is also an instructor at the Stanford University School of Medicine. "If you want to come up with a solution, you need to take that into account, or nothing will be effective."
Abuse of prescription painkillers has become a national concern - raising alarms among public health experts, policymakers, and law enforcement officials. According to theFederal Centers for Disease Control and Prevention, almost 19,000 people died from prescription painkiller overdoses in 2014, the most recent year for which data are available.Previous research suggested that as much as 80% of opioids are prescribed by a small subset of medical professionals. But the authors of this research letter provide a nuanced assessment. They found that 57% of these prescriptions are filed by 10% of doctors, nurse practitioners, physician assistants, and dentists. That figure demonstrates that patterns for opioid prescriptions are consistent with those for other medications, even ones that aren't commonly abused. Generally, 10% of doctors are responsible for 63% of medical prescriptions overall. That's noteworthy, Chen said. It suggests that there aren't a few errant or villainous doctors single-handedly fueling the opioid crisis. Instead, the frequency of doctors who prescribe these painkillers is almost the same as that of doctors who recommend any kind of medicine.
Whenever you look at any medication trend, the top prescribers will account for more than other people, he said. But if a few doctors were driving the opioid crisis, he said, you'd see a smaller proportion of them responsible for a larger amount of drugs compared to other medication." What this told us is opioids aren't special in any way," Chen said. That's why public health initiatives intending to address prescription drug abuse need to account for all doctors, he said. That kind of systematic approach is essential, said Caleb Alexander, MD, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, who was not affiliated with the study. "We're taking our eye off the ball if we're focusing on a very small subset of doctors alone," he said.
And the proportion of opioids prescribed by the top few is still a worry, he said. "Opioid prescriptions are skewed. It's a little bit immaterial -- it's a second-order question how skewed prescribing is."The study also doesn't account for the length of individual prescriptions or their strength: whether, for instance, the prescription is for 2 weeks or 30 days; or 30 milligrams of a drug versus 60 milligrams. It's possible and even likely, he said, that the 10% of prescribers highlighted in the JAMA study could be writing longer prescriptions and consequently fueling the drug abuse.Alexander's research, which isn't yet published, analyzed pharmacy claims in Florida over a single year, finding there that 4% of providers made 40% of opioid prescriptions -- a proportion that translated to 67% of all the drugs when accounting for the prescriptions' sizes.
Some differences between studies are probably the result of the people being studied, Chen said. Medicare beneficiaries have diverse backgrounds in a number of ways, for instance, but skew older. What matters, he said, is recognizing the role a number of doctors may play in getting patients easy access to opioids."Going after deviants, 'pill mills' or bogus pain clinics - it feels good to do that, because you have a villain. You feel that if you get rid of them, the problem is solved, and what we're trying to say is, 'I don't think that's going to be enough,'" Chen said. "Maybe all of us are contributing to this problem, even if we don't realize it."
Of the 10 people treated for Ebola in the U.S., eight survived and all had some symptoms in the weeks and months after they recovered, CDC researchers said. Their experience might help illuminate the challenges being faced in West Africa, where more than 17,000 people have survived the international Ebola outbreak, according to Lauren Epstein, MD, and colleagues at the agency's Atlanta headquarters.
Reports from the region, where most of the cases have occurred during the continuing outbreak, suggest survivors might face joint pain, hearing loss, eye disease, and fatigue, Epstein and colleagues reported in the New England Journal of Medicine. But little is known definitively about the clinical consequences of Ebola, they noted. To try to understand the issue, and illuminate the challenges faced in West Africa, they turned to the people successfully treated in the U.S., asking them to respond to a detailed questionnaire about the experience.Of the 10 people treated in the U.S., only two died - Thomas Eric Duncan, the first person to be diagnosed with Ebola on U.S. soil, and Martin Salia, MD, a Sierra Leone surgeon who was a U.S. resident. Two nurses who treated Duncan came down with Ebola, while the remaining six patients were U.S. physicians and missionaries who had been working in West Africa to battle the outbreak. The eight had a range of symptoms after recovery, Epstein said, some of which were severe enough to require re-admission to hospital. Most improved or went away over time, but only one survivor said all symptoms had completely resolved.
Six of the eight said they were able to return to normal daily activities within 8 weeks of discharge. Nonetheless, Epstein and colleagues argued, the findings suggest that survivors might need psychological and subspecialty assessments (such as rheumatologic, musculoskeletal, or neurologic evaluation) as well as their primary care.Some signs and symptoms started during the acute care hospital stay, some at discharge, and some later during the recovery period, Epstein and colleagues noted. The median recovery period - defined as the interval between hospital discharge and the survey, conducted in March - was 5 months, they reported. During that time, all survivors reported at least one symptom, Epstein and colleagues found.
The most frequently reported symptoms were:
As well, five participants had ocular symptoms, including pain, discomfort, or blurriness, and four had an ophthalmologic evaluation. Two survivors had treatment for unilateral uveitis.Six people reported psychological or cognitive symptoms, including short-term memory loss, insomnia, and depression or anxiety, and fewer than half said those symptoms had resolved by the time of the survey. Three reported paresthesia or dysesthesia soon after discharge, one of whom was treated for peripheral neuropathy; two said the symptoms had resolved by the time of the survey. Two patients were admitted to hospital briefly for a non-Ebola febrile illness, they found. The investigators cautioned they did not review medical records or assess whether the reported symptoms were directly caused by Ebola.
The World Health Organization reported that no new cases of Ebola had been reported in West Africa since Nov. 22, 2015. The nation of Guinea could be declared free of active Ebola on Dec. 28, 2015 if no new cases develop; Liberia’s corresponding target date is Jan. 14. The third country involved in the outbreak, Sierra Leone, was declared Ebola-free in early November 2015.
The flu vaccine last season was almost completely ineffective at preventing the disease, but it might have helped some people stay out of hospital, researchers reported. Overall, the vaccine failed to match the main circulating strain of influenza A, which in 2014-15 was an H3N2 virus, according to Alicia Fry, MD, of the CDC's influenza division in Atlanta.The genetics of circulating H3N2 began to drift away from the vaccine strain almost as soon as experts decided in late February of 2014 what should go into the vaccine. The vaccine strain of H3N2 was dubbed 3C.1, but starting in March it became clear that more than half of the circulating virus was of the types known as 3C.2a and 3C.3a -- variants that were "low reactors" to the vaccine. And it was the H3N2 virus that was causing disease. There was very little influenza (A) H1N1 (unlike 2013-14, when it predominated) and not much influenza B. The problem with flu is that it is highly variable genetically; when experts pick the vaccine strains -- based essentially on highly educated guesswork -- it takes several months to make the vaccine and get it into the clinic. In the meantime, the pathogen can and often does change.
Boston based non-profit, NICHQ, aims
to reduce unbearable episodes of pain for patients in the ER and other clinical
settings with “Sickle Cell Pain inthe Emergency Department: A Guide to Improving Care,” a step-by-step manual
for anyone on the front lines of acute care, from emergency room (ER)
doctors and nurses, to hematology specialists. Dr. Suzette Oyeku, NICHQ’s
strategic project director said, “Sickle cell disease patients wait in
excruciating pain longer than they have to for treatment. Guidelines do
exist, but many providers are unclear about how to carry them out, particularly
in acute care settings. Our guide was designed to help providers bridge
SCD work, funded by The U.S. Health Resources and Services Administration
(HRSA), yielded many results in improving care. These included a
reduction in the wait time for evaluation by 69 percent and a 29 percent
improvement in the time between triage and receiving pain medication. One
of the most significant outputs of the teams’ extensive work is “Sickle Cell
Pain in the Emergency Department: A Guide to Improving Care.” The online
publication offers best practice findings such as standardized order sets, a
recommendation to consider using intranasal fentanyl and a color-coded, full
body chart, reviewed by patients and doctors, as a standard pain assessment
Project Officer Dr. E. Donnell Ivy, said, “Having just recognized World Sickle
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People receiving this year's seasonal influenza vaccine are 23% less
likely to seek medical treatment for flu-type symptoms relative to
unvaccinated individuals, according to an interim CDC estimate based on
reports submitted so far for the current season.
That's less than half the "vaccine effectiveness" calculated for the vaccines deployed in recent seasons:
The CDC had previously acknowledged that the current flu vaccine cocktail appeared less effective than usual,
because the most common influenza A strain being detected in
circulation, dubbed A/Switzerland/9715293/2013, was not among those
selected for the 2014-2015 Northern Hemisphere vaccine. The
A/Switzerland strain is included in the vaccines to be used in the
upcoming Southern Hemisphere season, which begins in a few months. But
those stocks are neither ready yet nor would they be large enough to
cover the much more heavily populated Northern Hemisphere.
But the new estimate, published online in Morbidity and Mortality Weekly Report, is the first time the agency has put a number to the reduced effectiveness.
Authors of the report noted that their interim estimate came earlier
than in previous years, because of the early onset of significant flu
cases last fall.
"These early vaccine effectiveness estimates underscore the need for
additional influenza prevention and treatment measures, especially among
persons aged ≥65 years, young children, and other persons at higher
risk for serious influenza associated complications," they wrote.
Last week, the CDC called for immediate treatment with influenza antiviral drugs in all high-risk patients presenting with possible flu, without waiting for confirmatory testing.
A single dose of an investigational influenza drug was able to reduce
the duration of fever and viral shedding, researchers said. In a combined analysis of two randomized placebo-controlled trials, the
neuraminidase inhibitor peramivir (Rapivab), given by injection within
48 hours of symptom onset, also lowered the amount of virus in the
blood, according to Rich Whitley, MD, of the University of Alabama at Birmingham. But while the drug reduced the time to resolution of symptoms - the
primary endpoint of the trials - the difference from placebo was not
Is oral zinc associated with a shorter duration, decreased
severity, and reduced incidence of the common cold compared with placebo?
When initiated within 24 hours of symptom onset, oral zinc is
associated with a shorter duration of the common cold in healthy people.
However, there is no association between oral zinc and symptom
severity, and the prevalence of adverse effects with zinc lozenges is
high. Given the high heterogeneity of data, these results should be
interpreted with caution. Used prophylactically, oral zinc is associated
with a reduced cold incidence in children. Prophylactic use has not
been studied in adults.
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