Sunday, October 15, 2017

Opiates - A Public Health Crisis

Opiate abuse is on the rise and we are not just talking about heroin.  Prescription opiate abuse has grown over a 50% rate increase since even two months ago in some parts of the country, 50%!  Doctors, nurses, and other health care professionals are trained to give pain medicine when it is appropriate for the patient.  Many of such cases are post surgery or post injury.  Sadly, even taking these medications for as little as one week can leave a person "hooked".

Hospitals get rated and with ratings, which is mainly patient satisfaction, comes either fines or money to put into their operating budget.  When a patient is at the hospital, the biggest score to watch is the patients "pain scale".  So, if a patient says my pain is at an 8, the staff is REQUIRED to do something, which means either an oral pain pill or even an IV injection of say, Fentanyl.  The patient can do this as many times as they want and within the time limits of each medication, the hospital is required to respond and give the medication.  This means the patient can lie and yet, medication must be given and therefore, the patient can be discharged and hooked on pain medicine.

Checks and balances have been put into place.  Many states have a pain medication monitoring system, that allows doctors and nurses to see a patients prescription history and therefore, can refuse to give a patient pain medication knowing they had a fill from another doctor and pharmacy just last week.  However, if that same patient comes into the hospital ER and talks about pain, medicine will have to be given and cannot be refused.  Therefore, some patients are able to get their fix with oral pills and skip around pharmacies knowing the loop holes and others skip around hospitals getting an IV fixation of medicine. 

The sad thing is that many, in fact, almost all of these patients never wanted to get "hooked".  In fact, most had an actual injury or surgery that lead them to becoming introduced to the medicine and with say a surgical complication or really bad injury, the patient was on pain medication for several months, maybe even having multiple hospitals stays and surgeries and thus, they were on the medicine for long periods of time.  When it came time to get off, they were not able to do so and experienced horrible withdraw which only lead the patients to get back onto the medicine. 

Withdraw is a horrible experience for anyone.  Sweating, nausea, diarrhea, insomnia, increased pain, lack of energy, depression, and much more will take the patients full focus leaving him or her to not be able to work or even function around family.  It can last a few days to several weeks and destroy home relationships and friendships.  It can also cause patients to loose time at work and even get fired.  Therefore, in order for the patients body to function naturally, they must get back on the medicine.  Many patients are not getting the medication to get "high", but to at least not have chronic pain and to be able to function normally.  It is like someone who has diabetes and has to have insulin injections.  Those injections allow the patient to live normal, control their diabetes and thus, focus on other things and not just their diabetic problem.  Same goes for the patient who is hooked on pain pills.  They must be able to get back to a normal "level" of function within their nervous system, thus taking at least one or two pills does this.  However, it leaves the patient hooked and not knowing what to do other than to continue to take the pills.  The sad thing is that over time, the patient has to take more and more to get to that same "level" of normal functioning, which is called building a tolerance to the medicine and can lead to more and more issues such as taking stronger and stronger medicine. 

This particular post, which is the 1st of a 4 part series, isn't focused on the many issues and questions just coming from the above overview of this complex topic.  Rather, it is about the lack of help for these patients once they do become hooked, which is a huge part of driving this public health issue deeper and deeper into the dark and leaving many to wonder if they will ever get off of these pain medications. 

Doctors and other health care providers do not have the time to deal with patients above after they have become a "problem" patient.  In fact, when a doctor feels the patient may be more or less addicted, many doctors send a letter to the patient advising them they will no longer see them as a patient, in fact this is the doctors way of "breaking up" with the patient.  That same patient will end up then finding a new doctor who will help them, but then could end up in the same boat.  For some patients, when they feel they have reached the end of the line with doctors, some will turn to illegal ways of getting the medication or perhaps, go to a more dangerous and stronger type of opiate, such as heroin.  This is what leads to the sharp increase of patients from a low dose of pain medication to the more dangerous opiate and causing more health problems and also death by accidental overdose. 

While our society has put pressure on hospitals to ensure patients are "happy" and that pain is bad and must be "blocked" by the brain, we came up with a simple answer.  Give them a pill and that is all they need.  What we need to do is to look at other ways to treat pain, including massage therapy, therapy itself of the mind, other medication that isn't an opiate, and many other such types of pain management.  However, this isn't ever really talked about, as many of us have been patients and have had surgery, think about what you were told and given options as when you had pain.  Think about the simple visit to your doctor when you got pain medication given to you, if you have been down that road.  Much of this goes back to the education at medical school and how medical students are not taught about pain, all the issues surrounding pain, and how many different types of therapy exists for pain treatment.  Doctors are busy, taking time to discuss issues such as this could cause them to lag behind in their daily schedule and get a penalty.  All of this comes back to the ratings that hospitals and doctors get when dong their job.

The sad thing is that much of this is totally preventable, even by having a short simple, but frank discussion, when patients are given or will be given a pain medication.  Even giving them other options should be verbalized to them.  However, many times it is not.  More needs to be done in this area, which will be the focus of our next blog.  Finally, when a patient is "cut-off" instead of throwing them into the cold ocean, as many doctors offices do (they break up and turn their backs knowing the patient may have an addiction problem), they forget about that patient and say; "It isn't my problem".  Sure, say that to the family that just had their loved one overdose with a problem that was small at best, yet grew into a huge problem and therefore, they died because they were ignored.  This is the FAILURE of our system.  Would a doctors office or ER ignore a patient who came in with half their finger cut off?  No way.  So why do they do just this?  Is it because we still see a "mental illness" as not a real illness, when it really is no different than someone who has heart disease?  Addiction is a disease of the mind, but don't be scared of it, rather refer that patient out to get help just like you would if they had a heart problem.  Failing to help these patients by cutting them off and turning your back is cold, wrong, and honestly goes against the Hippocratic oath that EVERY doctor takes when graduating from medical school; "I shall do NO harm".  Yet, they do when they send that letter as their last correspondence to the patient saying they won't see them anymore and that is it.  What needs to be done is learning how to really approach these patients, softly describing to them that addiction may be of concern and thus, WE CAN HELP.  Many patients would welcome the help as many of them are scared not knowing how to get off of the pills, because many of these patients WANT to get off of the medication.  But when they are looking into the deep blue ocean, it is easier to go and get that life boat or life jacket then to jump in on their own for fear of drowning. 

As a public health expert, I must say that we are FAILING to give any patient help when they see that deep blue ocean.  It is causing patients to move to illegal ways of obtaining the medication and then leading to getting onto stronger forms of an opiate all the way to death.  Patients who had shoulder surgery didn't plan to get addicted, they wanted their pain in the shoulder to stop and thus had surgery done.  They didn't ask for another COMPLICATION of the surgery, opiate addiction.  But when that did occur, they need help.  Would we ignore a patient with a bleeding complication from surgery?  No we wouldn't, so why are we ignoring this complication?  Because the attitudes of many health care professionals is it is not their problem or they didn't create this problem or the patient needs to find help on their own as psychiatry isn't part of my job as a surgeon.  If we do not start to retrain medical education on this subject, how pain management includes MANY options other than opiates all the way down to doctors knowing how to recognize a patient who "might" be addicted and knowing what path to take for that particular patient, it could change the lives of many patients ONE PATIENT AT A TIME.  And if we do that, then our stats get better and thus, public health gets better.  Therefore, we need to implement PUBLIC HEALTH POLICIES that change the way we not only think about this, but the way we ACT about this....because at the end of the day, one life taken back by getting off the pain medication successfully without relapse, means one life saved which means the world is a better place.

Saturday, February 20, 2016

Confusion surrounding the death of Justice Scalia

The death of Justice Scalia has brought much attention to our current death investigation system.  When Justice Scalia was discovered dead, there was much confusion surrounding his death.  Initially, when the Justice of the Peace in the remote area of Texas where he passed, was contacted, it was discovered both Justice of the Peace were out of town which lead to finding one who agreed to pronounce Justice Scalia dead over the phone.  The death scene was not investigated well nor did any official who is considered the coroner in Texas (Justice of the Peace) actually visit his death scene.  

In Texas the coroners are not physicians, rather they are Justice of the Peace and I am not even sure that any of them get much formal training in actual death investigation.  The same can be said for other states like Missouri where they are coroners, most are funeral directors and are elected and again, they don't have much formal training in death investigation.  This differs from other jurisdictions where they have formally trained death investigators that work for the medical examiner.  I worked in such an office while training in forensic medicine in Kansas City.  We had forensic pathologists (doctors) who did the autopsy work and death investigators who worked for the office and went out to all death scenes and reported their findings back to the doctor.  If the doctor was ever needed at the scene, they were always available.  Some states are entirely medical examiner systems, like New Mexico where the Office of the Chief Medical Investigator covers the whole state and they have trained field death investigators covering all parts of the state.  If Justice Scalia had died, say in Nevada or Oklahoma (both state ME systems) a trained death investigator would have gone to the scene.  They would have conducted a good investigation and reported it back to the main office where a decision would have been made to do or not do an autopsy.  Maybe they would have at least transported his body in to look at it externally and determine if an autopsy was needed, but at least an external exam could have been done in conjunction with the scene investigation.  In reality, with all the pre-existing conditions Justice Scalia had, there really is no need to do an autopsy.  But with his high profile, at least a death investigator should have gone to the scene and perhaps followed by an external exam by a forensic pathologist should have been conducted.  That would calm many worries and misunderstandings that has now lead to rumors throughout the country and DC.  

Our death investigation system is way behind the times and I see it all the time with families I consult with who hire us to look into their loved ones death.  Sadly, I don't see it being fixed anytime soon or even in my lifetime. 

Monday, June 15, 2015

Neurological Research

Our company is dedicated to helping researchers find answers to many difficult to understand neurological disorders.  In order to advance our understanding, we have to have access to actual human neurological tissue.  Families who are gracious enough to fulfill a family members request of donating their brain, spinal cord, and other neurological tissue for research is the ultimate gift.

Once this occurs, these families are directed to brain banks throughout the country and in turn, we are contacted to streamline this process by responding to the decadents location within a 24 hour period to do the tissue recovery.  We are against the clock, as once death occurs, the biochemistry that is so delicate can often times be lost quickly if these tissues are not removed within 24 hours.  It is within the neuro-biochemistry that many researchers find their answers and it is these answers that can not only help us understand these disease processes more then we do now....but it is from these answers that new treatments are developed to help fight these neurological diseases and perhaps, find a cure.

Discuss with your family donating your brain, spinal cord, and other neurological tissue upon your death.  It could be the way we find out how to treat and cure a neurological disease.

*You do not have to be diagnosed with a neurological disease in order to donate.  We also need tissue from decedents who have not neurological disease and their tissue is considered "non-diseased or normal" tissue.  Contact us today to learn more.

Wednesday, April 29, 2015

Decrease Overdose Deaths with Expanded EMS Use of Naloxone

CDC: Centers for Disease Control and Prevention, Your Online Source for Credible Health Information
Photo: EMS workers moving a patient from an ambulanceStudy results published in the April issue of the American Journal of Public Health indicate that expanding naloxone training and use among emergency medical service (EMS) staff could reduce overdose deaths caused by a type of prescription painkiller called opioids. Naloxone is a prescription drug that reverses the effects of opioids. It can be life-saving during a potentially fatal opioid overdose if administered in time.
Study Findings
Study researchers analyzed National Emergency Medicine Service Information System data to consider factors associated with naloxone use among EMS staff. According to the published study, "Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in Rural Communities," key findings include:
  • Naloxone is underutilized in rural areas.
    • Rural areas have 45% more prescription opioid overdose deaths compared to urban areas, but naloxone use is only 22.5% greater in rural areas compared to urban naloxone use.
  • Males are less likely to receive naloxone than females.
  • Young people are more likely to receive naloxone.
    • Adults age 20 – 29 years were most likely to receive naloxone, while adults age 60 and over were least likely to receive naloxone.
  • Advanced EMS are more than five times as likely to administer naloxone compared to basic EMS.
Why This Is Important
The United States is in the midst of a prescription opioid overdose epidemic. Each day, 44 people in the United States die from overdose of prescription opioids. Many more become addicted. Expanding naloxone training and capabilities among EMS staff can help to reduce deaths from prescription opioid overdose. Additionally, cities and states across the country can take steps to reverse this epidemic by improving opioid prescribing practices through use of prescription drug monitoring programs.

Learn More

Wednesday, March 11, 2015

Study reveals how genetic changes lead to familial Alzheimer’s disease

Study reveals how genetic changes lead to familial Alzheimer’s disease

NIH-funded research suggests novel approach for developing drugs for inherited Alzheimer’s
Mutations in the presenilin-1 gene are the most common cause of inherited, early-onset forms of Alzheimer’s disease. In a new study, published in Neuron, scientists replaced the normal mouse presenilin-1 gene with Alzheimer’s-causing forms of the human gene to discover how these genetic changes may lead to the disorder. Their surprising results may transform the way scientists design drugs that target these mutations to treat inherited or familial Alzheimer’s, a rare form of the disease that affects approximately 1 percent of people with the disorder. The study was partially funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health.
For decades, it has been unclear exactly how the presenilin mutations cause Alzheimer’s disease. Presenilin is a component of an important enzyme, gamma secretase, which cuts up amyloid precursor protein into two protein fragments, Abeta40 and Abeta42.  Abeta42 is found in plaques, the abnormal accumulations of protein in the brain which are a hallmark of Alzheimer’s. Numerous studies suggested that presenilin-1 mutations increased activity of gamma-secretase. Investigators have developed drugs that block gamma-secretase, but they have so far failed in clinical trials to halt the disease.
Image showing the effects on mouse cortex of an Alzheimer’s-causing mutation
A new mouse model of neurodegeneration. This image compares sections of cortex from a control mouse (left) to a mouse with a presenilin-1 mutation (right). The dashed line indicates the surface of the brain. Presenilin-1 mutations decrease gamma-secretase activity and cause features of neurodegeneration, including shrinkage of the cortex, as shown above. Image courtesy of Raymond Kelleher and Jie Shen, Harvard Medical School.
The study led by Raymond Kelleher, M.D., Ph.D. and Jie Shen, Ph.D., professors of neurology at Harvard Medical School, Boston, provides a plot twist in the association of presenilin-1 mutations and inherited Alzheimer’s disease. Using mice with altered forms of the presenilin gene, Drs. Kelleher and Shen discovered that the mutations may cause the disease by decreasing, rather than increasing, the activity of gamma-secretase.
One of the presenilin mutations also caused impairment of memory circuits in the mouse brain and age-dependent death of neurons.
“The findings by Drs. Shen and Kelleher are a significant departure from conventional thinking that should open up exciting and creative new possibilities at all levels of research, from basic molecular mechanisms all the way to clinical intervention,” said Roderick Corriveau, Ph.D., program director at NINDS.
“This is a very striking example where we have mutations that inactivate gamma-secretase function and yet they trigger an array of features that resemble Alzheimer’s disease, notably synaptic and cognitive deficits as well as neurodegeneration,” said Dr. Kelleher.
Although plaques are the main biological indicator of Alzheimer’s, neurodegenerative changes are also an important feature of the disease. These changes include loss of brain cells, cognitive deficits such as problems with memory, changes in the brain’s electrical activity and inflammation. Commonly used mouse models of the disease exhibit excessive plaque deposition, but do not show symptoms of neurodegeneration. According to Dr. Kelleher, this may be one reason that treatments developed in mice have not been successful in patients. 
“This study is the first example of a mouse model in which a familial Alzheimer’s mutation is sufficient to cause neurodegeneration. The new model provides an opportunity that we hope will help with the development of therapies focusing on the devastating neurodegenerative changes that occur in the disease,” Dr. Kelleher said.
Dr. Shen’s previous work demonstrated that presenilins and gamma-secretase play an important role in learning and memory, communication between brain cells and neuronal survival, and cautioned against the use of gamma-secretase inhibitors for Alzheimer’s disease therapy. Later, a large phase III trial was stopped because treatment with a gamma-secretase inhibitor worsened the cognitive ability of patients.
Although the majority of cases are not inherited, familial Alzheimer’s disease is associated with early onset of the disorder, with symptoms often appearing before age 60. Drs. Shen and Kelleher hope that the mechanisms uncovered in this study may provide insight into the common forms of the disorder that affect more than five million people in the United States.
The results in this paper suggest a new approach for drug development. “We believe that restoring gamma-secretase would be a better, more effective therapeutic strategy for Alzheimer’s patients,” said Dr. Shen.
This work was supported by grants from the NINDS (NS041783, NS042818, NS075346), the Alzheimer’s Association, and the Pew Scholars Program in the Biomedical Sciences.
For more information on Alzheimer’s Disease, visit:http://www.ninds.nih.gov/disorders/alzheimersdisease/alzheimersdisease.htm.
The NINDS is the nation’s leading funder of research on the brain and nervous system. The mission of NINDS is to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.
About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

Thursday, January 22, 2015

Forensic Entomology discovering new science.

http://www.forensicmag.com/news/2015/01/new-insects-revealed-entomological-decomposition?et_cid=4377201&et_rid=585244410&type=headline