Dispelling Common Myths about Opioid Use Disorder in Pregnancy

By Sarah Bernstein, MD and Jessica Gray, MD
March 21, 2019

The opioid crisis and rise in overdose deaths in recent years has received a great deal of media attention. Though the media has helped to raise awareness, it has also contributed to stigmatization of individuals struggling with addiction. Pregnant and parenting women are among those who have been severely affected by the epidemic and perhaps most shamed by society for their use. Sadly, at a time when many women feel motivated to connect with the health care system and make healthy choices, women with addiction often avoid interacting with providers due to feelings of shame and mistrust. There are many misconceptions regarding the risks and benefits of medical treatment for women with substance use disorders as well as the treatment of neonatal withdrawal. We hope to dispel some of these myths and provide a better understanding of the evidence supporting the treatment of substance use disorders in the setting of pregnancy as well as neonatal withdrawal. Continue reading “Dispelling Common Myths about Opioid Use Disorder in Pregnancy”

Addressing the Urology Doctor Shortage: Implications For Patient Care

By Kevin R. Loughlin MD, MBA
February 14, 2018

Health care issues continue to receive extensive coverage in the lay press, however the current and future physician manpower issues which significantly impact patient care have been largely ignored. I would like to review the urologic workforce issues and their consequences. Continue reading “Addressing the Urology Doctor Shortage: Implications For Patient Care”

HMS Online CME Courses Approved for MAT Waiver Training

by The HMS CME Online Team
November 2018

NP and PA MAT Waiver Training

Through the Comprehensive Addiction and Recovery Act (CARA), nurse practitioners (NP) and physician assistants (PA) can become waivered to prescribe buprenorphine in the treatment of opioid use disorder (OUD) after completing 24 hours of specialized training.

We are pleased to announce that The Substance Abuse and Mental Health Services Administration (SAMHSA) has approved two of Harvard Medical School’s CME Online Opioid Use Disorder Education Program courses as fulfilling the 16-hour portion of the NP/PA 24-hour required training for waiver eligibility. These courses are: Continue reading “HMS Online CME Courses Approved for MAT Waiver Training”

Does Increasing Cigarette Prices Impact Consumption?

Ajay K. Singh
September 7, 2017

An interesting article by Nicholas Bakalar in the Aug 23, 2017 New York Times “Well” section caught my eye. It discusses a paper by Stephanie Mayne and colleagues accepted in Epidemiology that supports a relationship between the price of cigarettes and consumption. Quoting from the abstract:

$1 increase in price [of cigarettes] was associated with a 3% reduction in risk of current smoking (aRR: 0.97, 95% confidence interval [CI]: 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93, CI: 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR 1.2, CI: 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65, CI: 0.45%, 0.93%). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

A CDC Grand Rounds article titled Current Opportunities in Tobacco Control, which cites earlier work, supports the conclusions reached by Mayne et al. A 10% increase in the price reduces cigarette consumption by about 4%. The data from the chart below is pretty impressive. The progressive rise in the sales price of a pack of cigarette has resulted in a steady decline in cigarette sales.

The CDC article makes the following point: “Increasing the price of cigarettes discourages initiation among youths, prompts quit attempts, and reduces average cigarette consumption among those who continue to smoke.”

However, since early 2000 the price of cigarettes has remained relatively steady, but sales have continued to fall, suggesting that factors beyond price are also important.  These factors include tobacco control programs run by states, media campaigns, health warnings on tobacco packaging, changing attitudes about smoking and the tobacco industry, and reduced youth tobacco initiation.

An interesting article looking at the economics in the UK of increasing cigarette taxes makes two points:

  1. Nearly two-thirds of the price of a pack of cigarettes goes to taxes.
  2. Because people are addicted to cigarettes, demand price is inelastic and sales are unlikely to fall much.

The article also reaches some harsh observations: “Smokers already pay a lot of tax …[and] they do not cost the government much because they die early and save pension and health care spending. Higher taxes will increase inequality because the poor will pay a higher percentage of tax than the rich who are more likely to have given up. Higher taxes will encourage people to smuggle illegal cigarettes and avoid paying the tax.”

In the US, there is tremendous variability in the price of a pack of cigarettes. In New York State, the price currently is around $10.50 (and there is a proposal to raise it to $13 per pack). In contrast, price elsewhere is about half this amount (According to the website Fairreporters.net which lists the prices of cigarettes by state, $5.40 per pack in Kentucky and between $6 to $8 per pack in other states).

In summary, the jury is out on precisely how elastic demand is based on price, but it is a fair conclusion from published data that price does impact sales. Further, there seems to be ample room among many states in the US to increase cigarette taxes and, therefore, price.

But, at least one thing is indisputable: the benefits of not smoking.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Fake Medical News: When is Fake Really Fake?

By Ajay K. Singh, MBBS, FRCP, MBA
August 24, 2017

The use of the term “fake news” by President Trump and others raises the issue of whether medical news about disease and/or its treatment can be faked. Robert McNutt, in a provocative article in the Health Care Blog, asks the question: How Can I Tell if Medical News is Fake or Not?

Dr. McNutt recommends asking three questions in evaluating medical news:

  1. Is the item being reported measurable?
  2. What additional human traits or actions may cloud or confound the relationship between the item being studied and the outcome being touted?
  3. How was the study done?

McNutt uses the example of the purported health benefits of coffee. In a blog piece about one year ago, one of my Harvard colleagues, Dr. Sanjiv Chopra, wrote the following about the benefits of coffee drinking:

The facts are indisputable; coffee appears to offer a great variety of benefits, including substantial protection against liver cirrhosis, type 2 diabetes, heart disease, Parkinson’s disease, cognitive decline and dementia, gall stones, tooth decay and a host of common cancers, including prostate, colon, endometrial, and skin cancer. There also is a lower rate of suicide among coffee drinkers.”

Since I am not an expert on this, I will refrain from opining on the merits of coffee drinking, although I am very skeptical that the facts are “indisputable.” In McNutt’s example, he interrogates the benefit of coffee drinking using the three stated questions. More generally, he then states:

Observational comparison studies, rather than randomized studies, are nearly always fake, as observational studies cannot prove an independent contribution of the item being studied to the outcome of interest. In other words, if they happen to be true, we can’t prove it. Hence, they are fake.”

Of course, Dr. McNutt must realize that his statement goes too far. While confounding is an important issue in any association study, it is manifestly wrong to state that results from these studies are fake. Observational studies have limitations, but so do randomized trials.

Observational studies do not prove causation, but they can provide valuable data that, when examined by sophisticated statistical methods, might mimic randomized trials. Take the example of postmenopausal hormone therapy and coronary heart disease. Hernan and colleagues conceptualize observational data as a sequence of non-randomized trials to demonstrate the ability to arrive at conclusions that mimic those from a randomized trial on postmenopausal hormone therapy.

The early epidemiologic science around the association between smoking and lung cancer underscores the powerful impact that observational data can have in reducing the burden of disease and saving lives. Writing in Tobacco Control, Robert Proctor states:

“Scholars started noting the parallel rise in cigarette consumption and lung cancer, and by the 1930s had begun to investigate this relationship using the methods of case-control epidemiology. Franz Hermann Müller at Cologne Hospital in 1939 published the first such study, comparing 86 lung cancer ‘cases’ and a similar number of cancer-free controls. Müller was able to show that people with lung cancer were far more likely than non-cancer controls to have smoked, a fact confirmed by Eberhard Schairer and Eric Schöniger at the University of Jena in an even more ambitious study from 1943. These German results were subsequently verified and amplified by UK and American scholars: in 1950 alone, five separate epidemiological studies were published, including papers by Ernst Wynder and Evarts Graham in the USA and Richard Doll and A Bradford Hill in England. All confirmed this growing suspicion, that smokers of cigarettes were far more likely to contract lung cancer than non-smokers. Further confirmation came shortly thereafter from a series of prospective ‘cohort’ studies, conducted to eliminate the possibility of recall bias. The theory here was that by following two separate and initially healthy groups over time, one smoking and one non-smoking, matched by age, sex, occupation and other relevant traits, you could find out whether smoking was a factor in the genesis of lung disease. The results were unequivocal: Doll and Hill in 1954 concluded that smokers of 35 or more cigarettes per day increased their odds of dying from lung cancer by a factor of 40. Hammond and Horn, working with the American Cancer Society on another large cohort study, concluded that same year that the link had been proven ‘beyond a reasonable doubt’.

And, there are many other examples in the arena of public health and delivery science.

Dr. McNutt’s summary condemnation of the value of epidemiologic research, however well meaning, demonstrates a fundamental lack of understanding of the value of this science. Indeed, epidemiologic studies done well not only provide the foundation to develop hypotheses that can be tested in randomized trials, but have in themselves had tremendous impact on public health.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Dr. Singh teaches the online CME course: Developing Essential Skills in Clinical Research

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

 

Waiting for Addiction Treatment: A Deadly Proposition

By Sarah E. Wakeman, MD, FASAM
May 3, 2017

In a 2016 research letter to the New England Journal of Medicine, Dr. Sigmon and colleagues describe the results of a randomized pilot study of interim buprenorphine dosing for individuals with opioid use disorder.1 Interim buprenorphine dosing means offering medication alone to people on a waiting list to get into a buprenorphine treatment program, which generally involves medication plus counseling. This study randomized patients to either staying on the waiting list or getting just the buprenorphine administered at home by an automated and locked pill dispenser. The results were compelling. All of the participants who remained on the waiting list continued to use illicit opioids. In contrast, the majority of those treated with buprenorphine stopped using opioids completely, with abstinence rates of 88%, 84%, and 68% at 4, 8, and 12 weeks (P<0.001 for all comparisons). Continue reading “Waiting for Addiction Treatment: A Deadly Proposition”

Kissing Bugs and Heart Disease: Identifying Chagas’ Patients

By Ajay K. Singh, MBBS, FRCP, MBA
April 18, 2017

In managing patients with heart disease, most of us do not think about the possibility of Chagas’ disease (CD). CD is estimated to affect 5 million people worldwide and according to CDC seroprevalence estimates, affects about 300,000 people. CD accounts for nearly five times as many disability-adjusted life years lost as malaria. CD is estimated to cause approximately 7000 deaths annually.

A recent study by Sheba and colleagues of a convenience cohort of 4,755 Latin American-born residents of Los Angeles County reports that 1.24% tested positive for CD.

Bern and colleagues provide a comprehensive review of CD.  The disease was discovered in 1909 and is named after the Brazilian physician Carlos Chagas; Chagas’ is also known as American trypanosomiasis.

The protozoan parasite Trypanosoma cruzi (T. cruzi) is the cause of CD. It is thought that immigrants from Latin American countries acquire the trypanosomal infection from transmission by insect vectors (carried in the gastrointestinal tract of triatomine bugs) found in impoverished rural areas of Latin America. Triatomine bugs are also known as “kissing bugs”  because they bite while a person is asleep around the thin skin of the face around the eyes and mouth. T. cruzi transmission occurs when infected bug feces contaminate the bite site or intact mucous membranes, but it can also be transmitted through transfusion, via a transplanted organ, and congenitally.

CD has both an acute and chronic phase of disease. The acute phase is either asymptomatic, or associated with fever in a subset of patients with a chagoma. These chagomas contain the parasite and present with swelling and inflammation at the site of inoculation. Acute CD can rarely also present with more severe myocardial and central nervous manifestations.

[Review HMS lectures on Current Trends in Cardiology.]

The chronic phase manifests either with cardiac or digestive disease. Cardiac CD is a cardiomyopathy characterized by a chronic inflammatory process involving all chambers, conduction system damage, and a progressive dilated cardiomyopathy with congestive heart failure. Patients may also present with thromboembolism due to thrombus formation in the dilated left ventricle or aneurysm. Gastrointestinal CD disease is less common than cardiac CD and geographically distinct (mostly detected in Argentina, Bolivia, Chile, Paraguay, Southern Peru, Uruguay, and parts of Brazil rather than northern Latin America, Central America, or Mexico) and usually affects the esophagus and/or colon, resulting from damage to intramural neurons.

So what are the implications from the Sheba study? Sheba and colleagues make several recommendations. First, the prevalence of CD in the US has been underestimated and more awareness is necessary. Indeed, the US Center of Disease Control (CDC) considers CD, along with as cysticercosis, toxocariasis, toxoplasmosis and trichomoniasis, as a neglected parasitic infection.  Second, earlier diagnosis and treatment of CD might significantly impact the morbidity and mortality of the disease. And, third screening strategies should be considered for individuals at high risk: Latin American immigrants from endemic areas would be at the top of the list for screening. Indeed, screening tests are available for CD. Besides these, while CD is more common among immigrants, it has been detected in native-born Americans underscoring the importance of considering CD in the differential diagnosis of a cardiomyopathy.

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.