Investigation delves into Wash.’s prescription drug problem
Filed under: Aging, Children, Europe, Government, Health care reform, Health data, Health policy, Hot Health Headline, Pharmaceuticals, Public health, Public records
Everything time we think prescription drug abuse stories have peaked, something comes along to push the story further. This time, InvestigateWest’s Carol Smith sets herself apart by starting from square one and clearly explaining the origins and dimensions of Washington’s particularly nasty drug issues, tracing back each facet of the problem to its source and spotlighting what makes the Evergreen State unique.
Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.
The backdrop for her work is an epidemic that shows no signs of abating, despite a recently implemented state law Smith calls “a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines.”
Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it. Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.
Why caused it to leap so quickly? Smith tracks down several key tipping points. “There’s plenty of blame to go around for what caused the epidemic,” she writes. “Aggressive marketing of opiates by drug companies, nonexistent tracking of overprescribing, lack of insurance coverage for alternative treatments for pain, and demand by patients for quick fixes, to name a few.”
She drills down into many of those causes, with my personal favorites being two key origin stories:
- How marketing by OxyContin maker Purdue Pharma led to relaxed guidelines for chronic pain treatment and a “1999 law specified ‘No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed,’” both of which helped cause a jump in prescriptions.
- How “the rise in the death rates of Medicaid patients tracks along with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: Methadone.”
See the upper right-hand sidebar for more stories from the six-month investigation.
Article looks at reform concepts put into practice
Filed under: Health care reform, Hot Health Headline
Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.
Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.
“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.
“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.
“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”
The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.
So what are those health reform themes?
Value-based purchasing – loosely translated – is paying for what works.
Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.
Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.
So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.
On balance: Lazar explains a little-discussed fundamental fact of aging
It’s not easy to write well about the nitty-gritty details of aging – the wear and tear on bones and joints, the deterioration of seeing and hearing, the gradual onset of frailty in barely observable increments.
But everyone encounters this when they’ve lived long enough; physical decline is a fundamental part of the aging experience.
Judith Graham (@judith_graham), AHCJ’s topic leader on aging, is writing blog posts, editing tip sheets and articles and gathering resources to help our members cover the many issues around our aging society.
If you have questions or suggestions for future resources on the topic, please send them to judith@healthjournalism.org.
That’s why Kay Lazar of The Boston Globe deserves kudos for her story on balance problems in older adults, a common, seemingly mundane condition that hasn’t received much attention.
The consequences can be serious: when balance is compromised, seniors become at risk of losing their mobility or falling, potentially precipitating a cascade of other medical problems.
Lazar’s explanation of why older people become unsteady on their feet is graceful and easy to understand:
“A person’s sense of balance relies on an exquisite interplay of three regions, your vision, a maze-like structure in the inner ear which includes microscopic cells that resemble little hairs, and the muscles and joints running from your feet, up through your spine, that sense your body’s position.
All three areas send signals to your brain, which processes the information, and helps give you a sense of spatial orientation - your balance.
As we age, eyesight fades, as do our muscles’ ability to sense surroundings. Meanwhile, the hair cells in the inner ear die off and do not regenerate. These declines combine to throw off the signals to your brain about your balance.”
Her description of “four flavors of dizzy” - the feeling of blacking out, unsteadiness, spinning, or lightheadness - almost surely will help older adults and their families recognize symptoms that may require medical assistance.
That’s why a story like this is valuable. By talking openly about a problem that usually passes under the radar screen, it expands our sense of alertness to older people and difficulties they may experience. It makes seniors visible, not invisible as they so often seem to others.
Next time I see an older person hesitate at a curb before stepping down or stand stiffly in a crowd, nervous about moving in tight, confined spaces, I’ll think about Lazar’s article.
With state funds gone, Okla. dental programs still serve needy
Writing for the local NPR StateImpact outlet, Logan Layden looks at how dental programs for the needy are coping in the absence of state funding. In the 2010 state budget crisis, Layden writes, “Funding for several programs, including Dentists for the Disabled and Elderly in Need of Treatment, was totally eliminated.”
Among those was Oklahoma’s D-Dent, which provides a sort of superstructure that takes care of logistics and tests in order to allow dentists to donate their work to the needy and elderly. Since the cuts, the statewide program has gone from supporting about 800 patients a year to about 600. They no longer get state funds, though they still rely on the health department for most of their referrals, as well as a little moral support.
“We here are entirely supportive of this program,” Jana Winfee, Chief of Dental Health Services the Department of Health, said. “They have our support, just no funds.”
For more on NPR’s StateImpact project and a list of current participants, check out their lab.
Survivor goes undercover in Tijuana cancer clinics
Filed under: Health journalism, Hot Health Headline
Reporting for Al Jazeera English’s People & Power, Sarah Macdonald tells how her own battle with breast cancer led her to shave her head, hide a camera and go undercover to investigate south-of-the-border clinics touting alternative cancer therapies.
The thriving sub-industry of alternative Tijuana cancer clinics relies primarily on palliative care licenses to operate, a end-of-life-care-focused designation that seems somewhat sinister when it’s hidden behind promises of miracle cures. In looking beyond those promises, MacDonald’s investigation finds an interesting mix of chicanery and genuine good intentions, but ends on a familiar, cautionary note.
I have been fortunate in that I have successfully emerged from my own treatment for breast cancer, so I completely understand the desperation that people will feel when they are told their condition is terminal. It is a death sentence. I understand why many patients or their families will begin to scour the internet in search of a cure and will seize on anything that offers hope. However, as our investigation has shown, at least some of the Tijuana clinics are offering nothing but false hope. There is little or no evidence to support their claims that their strange therapies actually work and there is plenty of evidence that vulnerable people have parted with large sums of money for no reason.
Share your thoughts on database design for tracking pharma payments to doctors
Filed under: Government, Health care reform, Health data
Curtis Brainard of Columbia Journalism Review reminds reporters that their input is needed on the design of a federal database that will track payments from drug and device makers to doctors.
Investigations and databases, such as Dollars for Docs by Propublica, have revealed payments to doctors who had been accused of professional misconduct, had been disciplined or lacked credentials. Researchers have found evidence that payments can influence doctors’ treatment decisions (PDF).
Provisions in the Affordable Care Act mean that companies will have to report such payments to the Centers for Medicare & Medicaid Services, which will post the data on a public website. CMS has asked for “comments on how to structure this Web site for ultimate usability.”
There are a number of ways to submit your comments, detailed in this Federal Register announcement. Comments must be received by 5 p.m. EST on Feb. 17.
PLoS Medicine article advocates using legal system to stem ghostwriting
An essay published by PLoS Medicine makes the case that the “guest” authors of ghostwritten articles – typically academic researchers who provide little or no input – in medical journals should be held legally liable for damages or deaths caused by the drug or device that is the subject of articles they sign their names to.
The article points out that ghostwriting “openly infringes academic standards and … contributes to fraud” but that journal editors have been ineffective at putting a stop to it.
We argue that when an injured patient’s physician directly or indirectly relied upon a journal article containing false/manipulated safety and efficacy data, then pursuant to the legal authority outlined above, the authors of that article, including guest authors, are legally liable for patient injuries and could be named as defendants.
Xavier Bosch, Bijan Esfandiari and Leemon McHenry, authors of the PLoS Medicine piece, even endorse the theory that the Racketeer Influenced and Corrupt Organizations Act (RICO) could be used, something that was mentioned in an article last year. Other recourses the authors recommend include the False Claims Act and the Anti-Kickback Statute.
Web outlet pumps out dozens of stories on prescription drug abuse
Filed under: Health journalism, Health policy, Hot Health Headline, Pharmaceuticals, Public health
In partnership with USC’s Annenberg School for Communication & Journalism and a number of other organizations, Santa Barbara online news outfit Noozhawk (about), put together “Prescription for Abuse,” an exploration of the misuse and abuse of prescription drugs in the Santa Barbara area.
In the extensive, online-only series, the reporters take a look at the problem and its underlying causes, then go a step further by exploring possible solutions as well.
In a uniquely meta twist, the series even looks at how journalism such is advancing public health goals and explains how the project came together. The series features at least 36 individual articles, by my count, and every health journalist who takes the time to browse the full catalog will come across at least a few easily localizable ideas, but in this space I’ll just highlight those stories that deal directly with the series itself:
- USC, California Endowment Unite to Support Health Journalism at the Source
- Bill Macfadyen: Prescription for Abuse Project Is a Series of Opportunities
- Santa Barbara Teen News Network Adds Another Dimension to Prescription Drug Abuse Series
- Annenberg Fellowships Take a Diverse Approach to Community Health Journalism
- Bill Macfadyen: Noozhawk Earns a USC Annenberg Health Journalism Fellowship
- Noozhawk Journalists Recount Lessons Learned from Prescription Drug Abuse Series
‘Every day is an improvisation’ when caring for aging relatives
How many of us have seen problems with older relatives that we’ve looked away from, not wanting to acknowledge their seriousness or fully face the consequences?
There’s a word for this: denial. And there’s a good example of how it can affect family decision making in the current issue of the Journal of the American Medical Association. [Note: AHCJ members have free access to JAMA.]
Judith Graham (@judith_graham), AHCJ’s topic leader on aging, is writing blog posts, editing tip sheets and articles and gathering resources to help our members cover the many issues around our aging society.
If you have questions or suggestions for future resources on the topic, please send them to judith@healthjournalism.org.
It’s a personal story written by Carolyn Cannuscio, a social epidemiologist who studies aging, about her beloved 96-year-old grandmother, Nana.
After a nasty fall, Cannuscio and her mother move Nana from Florida to a Pennsylvania assisted-living facility that they had visited often and checked out with some degree of thoughtfulness.
“We grilled the staff about their services, the environment, and the nature, costs and limits of care my grandmother would receive there,” Cannuscio writes. “We were assured by the credible marketing director on multiple occasions that this would be the last move Nana would ever have to make.”
What a reassuring promise. If only it were true.
Cannuscio and her mom soon find that the facility is unprepared for Nana’s arrival, with “no clear plan for her daily care, no bedroom door, and – most importantly – no grab bars in the bathroom.” What? They didn’t make sure these plans were in place before Nana stepped on the airplane that took her away from Florida?
It gets worse – right from the start.
We quickly learned that the facility was so understaffed that Nana would be neglected on the standard care plan. We saw residents stranded in wheelchairs in random spots in the hallway, hoping for a generous guest or a more able-bodied resident to guide them to dinner. We then accompanied Nana to dinner ourselves and saw residents waiting unattended and unfed for long stretches, until they were addressed rudely by the harried wait staff.
Where were these alarming signs when Cannuscio and family members visited the facility in advance of her grandmother’s move?
As it turns out, they were hiding in plain sight. Searching the Internet, Cannuscio had come across a report from the state health department that apparently showed problems with the facility’s sanitary practices. And during a visit, she’d been taken to an apartment reeking of “cat excrement” that was home to a “disoriented, disheveled man who clearly needed more help than he was getting.”
Yet, hope prevailed: hope that this squalid apartment was an aberration, that Nana would get the care she needed, that this difficult move would prove satisfactory in the end.
Hope such as this is entirely understandable. But in this case, it led to denial: a refusal to give adequate consideration to evidence that this assisted-living facility wasn’t what it was claiming to be. After Cannuscio acknowledged that, she was distressed to discover that no federal standards govern assisted-living facilities.
In the end, however, she lays blame on “my fantasy that all of our elder care problems would be solved” with the move to assisted living.
Indeed. As older people become frail, like Nana, problems abound and there is no foolproof solution. Not if the older person is cared for at home, not if they’re in assisted living, not if they’ve moved to a nursing home. Daily challenges exist in all these settings and, as Cannuscio notes at the beginning of her piece, “every day is an improvisation.”
It’s our job as journalists to bring these challenges into the public realm, where they can be seen clearly and understood in context. Our hope is that the material going up now and in the months ahead on AHCJ’s aging web resource – information about assisted living facilities and nursing homes, on long-term care and caregiving, on aging-in-place and home care – will help as you pursue these kinds of stories in your communities and make it harder to deny the very real problems that so many seniors face.
NYT series digs into overprescription and developmentally disabled adults
Filed under: Health journalism, Health policy, Hot Health Headline, Pharmaceuticals, Public health, Public records
In the series Abused and Used, New York Times reporter Danny Hakim and a host of his colleagues have been investigating how public resources are used to treat developmentally disabled New Yorkers. The series is ongoing, but hit an inflection point with the publication of Hakim’s piece on the few-strings-attached use of very powerful drugs to treat some of the state’s most vulnerable adult residents.
Developmental disabilities, Hakim writes, often manifest themselves in ways that are easily mistaken for mental illness, and these misdiagnoses can lead to unnecessary or improper medication. “In fact,” Hakim writes, “developmentally disabled residents of group homes in New York are more likely to be given Ativan, an anti-anxiety drug that has a tranquilizing effect, than multivitamins, the records show.”
Hakim’s reporting is rich with both anecdotes and data. These paragraphs from the series will give you an idea of how he approached the issue.
Tens of thousands of powerful pills created to treat serious mental illnesses like schizophrenia are given to developmentally disabled people in the care of New York State every day.
…a review by The Times of previously unreleased records, as well as interviews with state employees, clinicians, family members and outside experts, reveals that the psychotropic medications, which alter the brain’s chemistry, are often dispensed sloppily, without rigorous or regular review, by general practitioners with little expertise in the area.
And low-level workers at state group homes are frequently given discretion to increase the medication “as needed,” despite their lack of significant training.
Psychologists who have worked inside the system describe a culture in which the drugs are used to control the disruptive behavior of the developmentally disabled — people with conditions like autism, Down syndrome and cerebral palsy — an approach increasingly discredited in the field.
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