Investigation delves into Wash.’s prescription drug problem

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.

Web outlet pumps out dozens of stories on prescription drug abuse

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

NYT series digs into overprescription and developmentally disabled adults

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.

Lopez columns on ailing dad spark discussions about end-of-life decisions

From his friendship with a cellist to his adventures with medical marijuana, Los Angeles Times columnist Steve Lopez often draws on highly personal material in his work. His latest series, surrounding the end of his father’s life, mines that vein even more deeply.  Lopez has initiated a community-wide conversation about death and dying through his columns, his profiles of several people confronting life’s end, and reader contributions, which have snowballed since the series began this summer.

Dec. 28: Open the discussion on dying
What I’ve learned along the way is that we have to get past the fears and cultural taboos that prevent us from discussing death with loved ones. We need to make our wishes known in advance healthcare directives, sparing friends and family the psychological trauma of impossibly difficult decisions. We need more information on end-of-life choices and broad reforms of Medicare, which gladly pays for the tools of slow suffering in terminal patients — feeding tubes, hip replacements, etc.— but is stingier about paying for palliative care despite lower costs and higher patient satisfaction.

Dec. 18: Wishing for the right to make that final exit
Since I began writing about these issues in July, when my father took ill, I’ve had readers argue that how and when we die is not for us to decide, but is in the hands of a higher authority. I respect that view, but I’ve heard from far more readers who make a humane argument for options to avoid lingering and painful deaths. Many say that once they reach the point where they are simply being kept alive - as opposed to living - they want to have the choice of ending their suffering.

Dec. 14: Having to think about the unthinkable
Most people don’t like to plan for dying, but in our state of denial, we leave ourselves vulnerable to conditions we would never want. Arrangements for the end of life are essential.

Dec. 11: A terrible choice to ponder
Medical advances now keep people like my father alive in severely debilitated states, at ever-soaring costs to the public. Is that a humane, compassionate approach?

One doctor told me that our fragmented healthcare system has a built-in incentive to give my dad a feeding tube. The surgeon and hospital would get paid, the nursing home would benefit because Medicare would cover 100 more days and my family would be spared that cost. The only losers would be taxpayers, and maybe even my father, who has already been cut open, probed and filled with buckets of medication, only to become sicker, angrier and more depressed.

Dec. 4: Not ready to die, but prepared
The cancer that started 11 years ago has now ravaged the body of Freddie Ramos. It attacked a kidney first, then a lung, and the 57-year-old family man knows that death waits in the near distance.

He’s not ready to go, he says, but he’s prepared.

Nov. 27: Geriatric doctor doesn’t shy from tough talk
Gene Dorio, an old-school practitioner in Santa Clarita, insists families - and physicians - have honest discussions about end-of-life issues with those in failing health. Too often the difficult conversations are put off for too long.

Nov. 11: When death is certain, but dignity is not
For a senior, those two dreaded words - “broken hip” - are often the beginning of the end. Doctors said that without surgery, my father would probably die within three months. But surgery itself could kill him, given his weak heart.

Because of the morphine and dementia, it wasn’t clear that my father understood his options.

Aug. 13: Waiting calmly to die
The email from a reader in Westwood was short, to the point and disturbing.

“My life has been very full,” wrote Polly Berger. “But now it is getting very bad, and I want to go to that other world.”

Berger also said she wished there were more Dr. Jack Kevorkians around. I responded immediately, worried it was a cry for help.

July 17: Waiting in the dark with Dad
And so it goes, the slow, inexorable march to the place we all must visit. Watching, I find myself wondering why we’re so ill-equipped to accommodate, accept and talk about the fate we all are guaranteed.

We’re not very good at dying, or even aging. We dye our hair unnatural colors, pin back our faces and pretend nobody knows. We’ve got an obsession with youth and a phobia about death.

Ongoing: Matters of life & death
As part of the series, the Times invited readers to share their own experiences. Many have.

Lopez, author of The Soloist, was the keynote speaker at AHCJ’s 2008 Urban Health Journalism Workshop.

Kidney disease kills thousands in sugar cane fields

In The Center for Public Integrity’s iWatch News, Sasha Chavkin and Ronnie Greene write that, “Little noticed by the rest of the world, chronic kidney disease (CKD) is cutting a swath through one of the world’s poorest populations, along a stretch of Central America’s Pacific Coast that spans six countries and nearly 700 miles. Its victims are manual laborers, mostly sugarcane workers.”

Each year from 2005 to 2009, kidney failure killed more than 2,800 men in Central America, according to the International Consortium of Investigative Journalists‘ analysis of the latest World Health Organization data. In El Salvador and Nicaragua alone over the last two decades, the number of men dying from kidney disease has risen fivefold. Now more men are dying from the ailment than from HIV/AIDS, diabetes and leukemia combined.

Unlike in more developed nations, neither diabetes nor hypertension can be blamed for the widespread kidney ailments. Instead, the duo found, scientists suspect possible environmental toxins and strenuous labor conditions, both linked to the cane fields, as well as alcohol abuse and anti-inflammatory drug use. At present, researchers seem to be focusing on heat stress as the most likely culprit, and plantation owners seem to concur

Internal studies by Nicaragua Sugar, owners of one of Central America’s largest sugar plantations, provided by the company to ICIJ, show that the company has long had evidence of an epidemic tied to heat stress and dehydration. In 2001, company doctor Felix Zelaya conducted an internal study on the causes of CKD among its workers. “Strenuous labor with exposure to high environmental temperatures without an adequate hydration program predisposes workers to heat stress syndrome [heat stroke], which is an important factor in the development of CKD,” Zelaya concluded.

Nicaragua Sugar and other companies say they have acted voluntarily to protect workers by improving hydration, reducing work hours, and strengthening oversight of labor contractors.

Chavkin and Greene dig deep into the economic and political factors underlying the global response to the epidemic, as well as the day-to-day impact it all has on workers’ lives. For more, read their full investigation.

Project looks at problems in how deaths are investigated

The results of a yearlong joint investigation of the American autopsy system by ProPublica, Frontline and NPR show that problems in the death investigation system throughout the country have led to innocent people being sent to prison, “allowed the guilty to go free and left some cases so muddled that prosecutors could do nothing.” When autopsies aren’t done, diagnostic errors go undetected and opportunities to learn more about medicine are lost.

One story of patient rights and legal wrangling sports the remarkable headline “Why Can’t Linda Carswell Get Her Husband’s Heart Back?” It hinges, among other things, on the simple fact that “Even though the Institute of Medicine has reported that medication errors affect an estimated 1.5 million patients per year, it is not typical to conduct toxicology tests as part of clinical autopsies. They are routine in forensic autopsies.”

Another piece takes a broader view, exploring the reasons behind and consequences of the fact that autopsies are performed on only about one in 20 patients who die in hospitals when, 50 years ago, the rate was one in two.

Hospitals aren’t required to perform autopsies – the Joint Commission hasn’t included autopsy rates in its accreditation process since 1971 – and neither Medicare nor private insurers reimburse hospitals for the procedures, which Allen found cost about $1,275 each. The implications of these financial disincentives, combined with related factors such as some physicians’ confidence that new diagnostic tools such as MRIs and CT scans provide such accurate results that they obviate the need for postmortem work, are far-reaching.

Diagnostic errors, which studies show are common, go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost to learn about the effectiveness of medical treatments and the progression of diseases. Inaccurate information winds up on death certificates, undermining the reliability of crucial health statistics.

Furthermore…

A 2002 review of academic studies by the federal Agency for Healthcare Research and Quality found that when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in one of four cases. In one of 10 cases, the error appeared severe enough to have led to the patient’s death.

Other stories in the project report that suspicious deaths of the elderly are rarely investigated and that the deaths of children “pose special technical challenges for forensic pathologists.”

Watch the full episode. See more FRONTLINE.

Tsouderos looks at federal funding of alternative medicine

In her latest series, Chicago Tribune reporter Trine Tsouderos, whose award-winning reporting has brought her hard-nosed approach to investigating less-proven areas of medicine, which will be familiar to many members, to bear upon the federal government.

This time, her target is the National Center for Complementary and Alternative Medicine, which she calls “a small, little-known branch of the National Institutes of Health … launched a dozen years ago to study alternative treatments used by the public but not accepted by mainstream medicine.” According to Tsouderos, the center has spent $1.4 since its inception, some of it on curious projects.

A Tribune examination of hundreds of NCCAM grants, dozens of scientific papers, 12 years of NCCAM documents and advisory council meeting minutes found that the center has spent millions of taxpayer dollars on studies with questionable grounding in science.

You’ll want to read it for yourself, but highlights include sentences such as “The cancer treatment involving coffee enemas was based on an idea from the early 1900s, and patients who chose to undergo the risky regimen lived an average of just four months” and “Thanks to a $374,000 taxpayer-funded grant, we now know that inhaling lemon and lavender scents doesn’t do a lot for our ability to heal a wound.”

It’s not all just cherry-picking wacky studies, of course. Tsouderos also looks deep into the powerful alternative medicine industry as well as the scientific rigor, or lack thereof, that sits at its core.

Reporter recounts fellowship visit to CDC

This is a guest post from Winnie Yu, a freelance journalist based in Voorheesville, N.Y. She was among this year’s class of AHCJ-CDC Health Journalism Fellows who spent last week studying public health issues at two Atlanta campuses of the Centers for Disease Control and Prevention.

Life can get lonely when you work as a freelance writer. So it was a real thrill for me last week when I got the chance to attend the AHCJ-CDC Health Journalism Fellowship and listen to experts from the Centers for Disease Control and Prevention discuss the most pressing health issues of our day.

Ten journalists from around the country came to Atlanta to hear presentations on topics as varied as motor vehicle safety, vaccines, patient safety and prescription drug abuse. It was quickly apparent that the CDC is much more than the authority on when to get your vaccines.

We heard from numerous experts, including Mike Bell, M.D., associate director for Infection Control for the Division of Healthcare Quality Promotion; William Dietz, M.D., Ph.D., director of the Division of Nutrition, Physical Activity and Obesity for the National Center for Chronic Disease Prevention & Health Promotion; and Ann Albright, Ph.D., R.D., director of the Division of Diabetes Translation for the National Center for Chronic Disease Prevention and Health Promotion. We also enjoyed a brief presentation from the CDC’s director Thomas R. Frieden, M.D., M.P.H.

Each day ended with a tour. We saw the CDC’s emergency operations center, walked through the tobacco lab and peered in at scientists probing for foodborne illnesses. We looked at viruses under a microscope, marveled at slides the size of a pinhead (used under an electron microscope) and winced at the amount of nicotine that smokers continue to inhale from cigarettes.

And while I couldn’t get the tour guide to tell us where the United States hides its stockpile of smallpox - Russia has the only other one - I was amazed by the challenges that researchers must endure in order to work in the pathogen labs, including chemical showers and protective suits that preclude regular visits to the bathroom. Not surprisingly, we learned that a calm and even temperament is a requirement for the job.

No doubt, some of the information we already knew: Americans weigh more than ever. Autism is on the rise. Diabetes is a major health issue. But we also learned that polio remains a persistent problem in some parts of the world, tuberculosis still afflicts some segments of our population and the United States takes its role as a world leader seriously when it comes to public health.

It was truly an honor to be part of this fellowship, to get an up-close glimpse of the CDC and to share my time with a great group of journalists who were smart, funny and great dinner companions. I have no doubt the experience will spawn story ideas, beef up our source lists and provide ample background for future articles.  I know it will for me.

Aging in place becoming more popular, possible

In the latest installment in The Associated Press series on growing old in America, David Crary explores how the health care system is evolving to accommodate “aging in place” and seniors’ preference to remain in their private homes, even at points when their health care situation might seem to suggest relocation is in order. As the population ages, this preference is starting to play a role in policy decisions.

There’s no question that aging in place has broad appeal. According to an Associated Press-LifeGoesStrong.com poll conducted in October, 52 percent of baby boomers said they were unlikely to move someplace new in retirement. In a 2005 survey by AARP, 89 percent of people age 50 and older said they would prefer to remain in their home indefinitely as they age.

Communities have explored a number of programs to better serve this population, and Crary profiled some of the more notable efforts, including:

• The Naturally Occurring Retirement Community (NORC)
  

  … can be either a specific housing complex or a larger neighborhood in which many of the residents have aged in place over a long period of time and need a range of support services in order to continue living in their homes.

• “Village” organizations
  

  Members of these nonprofit entities can access specialized programs and services, such as transportation to stores, home health care, or help with household chores, as well as a network of social activities with other members.

  About 65 village organizations have formed in the U.S. in recent years, offering varying services and charging membership fees that generally range between $500 and $700 a year.

• Aging-friendly homes
  

  AARP has teamed up with the National Association of Home Builders to create a designation for certified aging in place specialists trained in designing and modifying residences for the elderly. Several thousand builders, contractors, remodelers and architects have been certified. Building or remodeling homes can include such details as touchless faucets, trim kitchen drawers instead of cupboards, grab bars and nonslip floors in the bathrooms.

  Arizona’s Pima County, along with a few other local governments, has gone a step further, passing an ordinance requiring that all new homes in the unincorporated areas around Tucson offer a basic level of accessibility. They must have at least one entrance with no steps. Minimum heights and widths are set so that light switches can be easily reached and doorways are passable in a wheelchair.

• Medicaid changes
  

  In several states, there’s debate about whether to promote aging in place by shifting more Medicaid dollars to community-based programs and away from traditional nursing facilities. But budget problems may complicate such efforts as some financially struggling states cut back on home health services that help keep some elderly people out of nursing homes.

Calif. center, ethnic outlets partner to examine elderly day care’s demise

The California HealthCare Foundation’s Center for Health Reporting partnered with no fewer than nine different organizations to produce a sprawling story package examining the impact of the looming closure of many of California’s adult day health care centers. (Since the project launched, California reached a legal settlement that will allow adults most at risk of institutionalization to continue to receive services previously provided by adult day health centers. Existing centers will be able to provide services through the end of Feb. 2012. See this write-up in California Healthline.)

Jocelyn Wiener’s centerpiece stands alone, but the package really gains steam when you take the time to consider its full breadth and depth.

For those new to the issue, here’s Wiener’s primer and a hint as to why the package grew out of a collaboration with a kaleidoscope of ethnic media organizations.

Los Angeles County – especially its many ethnic minority communities –will be hit hardest by the closures. According to state data, the county is home to more than 60 percent of the program’s 38,000 enrollees statewide. One quarter have dementia. Forty percent are incontinent. Nearly half have a psychiatric diagnosis. More than 70 percent do not speak English.

The centers provide them with transportation, meals, exercise, medication management, physical and occupational therapy, as well as robust social programs that many participants say have renewed their will to live.

Health journalists will find Richard Kipling’s “how we did it” piece to be a natural entry point. Kipling unspools the narrative of how a brief suggestion became an anything-but-brief compendium of multilingual, multicultural, multigenerational reporting. Kipling’s blog also serves as a useful roadmap to the project.

Watch the AHCJ website for more about how this project was reported.

If the video doesn’t appear on your page, please click through to :Bibiana Viernes: Her Center, Her Life” from CAhealthReport on Vimeo.

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