National Strategy to Reduce Prescription Drug Abuse

Nearly 500 people have taken our Attitudes about Psychiatry survey so far. If you haven't yet, [please do.]

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The White House released its plan last week entitled "Epidemic: Responding to America's Prescription Drug Abuse Crisis" [LINK to pdf of this 10-page plan]. Below are some of the elements in this plan that is part of the National Drug Control Strategy (like that has worked so well :-/).

The areas of this plan involve education of prescribers and users, monitoring programs, making it easy to dispose of controlled dangerous substances (CDS for short), and enhancing enforcement. The plan establishes thirteen goals for the next five years, and also creates a coordinating body, the Federal Council on Prescription Drug Abuse, to oversee and coordinate it all.

If any of our readers have comments on specific items (I've numbered them for ease of reference), including unintended (or even intended) consequences, please chime in.

1. EDUCATION
1. require training on responsible opiate prescribing
2. require Pharma to develop education materials for providers and patients
3. require professional schools and organizations to include instruction on balancing use of opiates for pain while reducing abuse
4. require state licensing boards to include relevant ongoing education in their licensure requirements
5. help ACEP develop guidelines for opiate prescribing in the Emergency Department [this should be a big help]
6. increased use of written patient-provider agreements
7. facilitate public education campaigns, especially targeting parents
8. encourage research on low-abuse potential treatments, epidemiology of substance abuse, and abuse-deterrent formulations
   
2. TRACKING AND MONITORING
1. encourage effective PDMP (Prescription Drug Monitoring Programs) in every state, including use of HIEs and connecting with federal health care systems (VA, DOD, IHS, DOJ), and expanding interstate operability of PDMPs
2. support reauthorization of NASPER, which funds PDMPs
3. explore provider insurance reimbursement for checking the PDMP database before writing CDS prescriptions [interesting...might work]
4. reduce "doctor shopping"
5. issue Final Rule on electronic CDS prescribing [finally!]
6. increase use of SBIRT programs, including via EHRs (Electronic Health Records)
   
3. DISPOSAL
1. expand on "take-back" programs (eg, allowing pharmacies to accept unwanted pills for disposal)
2. develop DEA regs on CDS disposal and educate public on it
3. get Pharma involved
   
4. ENFORCEMENT
1. increase training for law enforcement personnel and prosecutors
2. aggressive action against "pill mills" and inappropriate prescribers
3. establish a Model Pain Clinic Regulation Law for states to use
4. increase surveillance of prescription drug trafficking
5. use PDMP data to identify "doctor shoppers" and do something about it

This is long enough, so I won't list the plan's thirteen goals; these begin on page 9.

While I am concerned that the enforcement aspects will continue to criminalize actions against people with addictions (which should be viewed more as a health problem rather than a criminal problem, IMO), the increased use of Prescription Drug Monitoring Programs to increase identification of and assistance for people with prescription drug abuse problems should be helpful. Recent articles about the diversion of opiates, even by elderly folks who are supplementing their fixed income by selling their Percocets to neighbors, make it clear how deep this problem is. Some of these interventions have a decidedly Big Brother feel to them. But people are dying, so something must be done.

More Happiness, More Suicide?

On Tara Parker-Pope's NY Time Well Blog, she tells us that in places where people are the happiest, for example Denmark & Sweden, for example, have the highest happiness ranks, and the highest suicide rates. This is perplexing.

And apparently, the various United States are also ranked. New Jersey, where I grew up, is the 47th happiest state-- surprising given Full Serve gasoline, good pizza, and beaches. You were looking for something more out of life? Also it has the 47th suicide rate, so the miserable apparently tough it out.

Ms. Parker-Pope writes:

After analyzing the data, the researchers found a relationship between overall happiness and risk of suicide. In general, states with high levels of life satisfaction had higher suicide rates, according to the report, which has been accepted for publication in The Journal of Economic Behavior and Organization.
“Perhaps for those at the bottom end, in a way their situation may seem worse in relative terms, when compared with people who are close to them or their neighbors,’’ said Stephen Wu, associate professor of economics at Hamilton College. “For someone who is quite unhappy, the relative comparison may lead to more unhappiness and depression.”
Dr. Wu noted that other studies have found that people react differently to low income or unemployment depending on how common it is in their community. “If a lot more other people around them are unemployed, it doesn’t seem so devastating,’’ he said.

I'm not sure one idea leads to another. Could there be another factor here? How do suicide rates correlate with the availability of mental health professionals, for example? Or with the price of chocolate in a give region? And how happy is my state?

If you haven't taken our Shrink Rap survey on Attitudes Towards Psychiatry, Please do -- you can get to it by clicking HERE

Aspirin and Aspirin Related Medication NSAID May Reduce Risk of Colon and Rectal Cancer

What the Heck are NSAIDs Anyway?

It's not a done deal but aspirin and aspirin related medication called non steroidal anti-inflammatory (NSAID) drugs have been targeted repeatedly for the potential to lower some kinds of cancer especially cancer of the large intestine(colon and rectum).

Several reports have alluded to cancer reduction by aspirin.







NSAIDs are non steroidal anti inflammation drugs versus corticosteroids which are medications which are also anti inflammatory but obviously are steroids. The studies we are discussing were of NON steroidal meds such as aspirin. Other NSAIDs include medications such as ibuprofen, naproxen, etc. The putative protective effect of aspirin against some heart attacks is probably better documented than the cancer effect which is much more up in the air.



And of course like everything in the world of medicine there are also bad effects of aspirin and NSAIDs such as gastrointestinal bleeding and asthma exacerbation.









The latest evidence pointing in that direction comes from the American Journal of Gastroenterology, the authors of the study with the zippy title,
Non-Steroidal Anti-Inflammatory Drugs and Colorectal Cancer Risk in a Large, Prospective Cohort conclude that "NSAID use was associated with a reduced colorectal cancer risk; the magnitude of this association differed between aspirin and non-aspirin NSAIDs. Daily aspirin and non-aspirin NSAID use by individuals with a family history of colon cancer significantly reduced the risk of rectal and colon cancer, respectively".





Several reports have alluded to cancer reduction by aspirin such as a previous study by Harvard scientists. "Regular, long-term aspirin use reduces risk of colorectal (colon and rectum large intestine) cancer among men. However, the benefit of aspirin necessitates at least 6 years of consistent use. The potential hazards associated with long-term use of such doses of aspirin should be considered". The "results provide additional proof that a simple drug like aspirin can help prevent colon cancer,” said Dr. Andrew T. Chan, the study’s lead author and an assistant professor of medicine at Harvard. Still, he said, “I wouldn’t recommend it to all patients, because of the side effects,” which can range from upset stomach to gastrointestinal bleeding".

Aspirin Dose and Duration of Use and Risk of Colorectal Cancer in Men

Aspirin Prevents Bowel Cancer.


Similarly a previous Oxford University study said taking a dose of aspirin of 300mg a day for five years offered protection against colorectal cancer. "Long-term aspirin use is generally not backed because of the risk of stomach problems,(the main problem with chronic aspirin use is internal bleeding) but the team said it could benefit those at high-risk of cancer. Problems with aspirin use include stomach bleeding and ulcers, worsening asthma in some, as well as allergy.





The Harvard study of aspirin found that "After adjusting for age, smoking, diet, physical activity and other risk factors, they found that men who took more than two standard 325 mg aspirins a week reduced their risk for colon cancer by about 21 percent compared with those who took less. Men who took 6 to 14 a week reduced their risk by 28 percent, and those who took more than 14 pills a week had a 70 percent decreased risk.The longer the men took aspirin, the more they reduced risk, but taking it for less than five years, or taking the equivalent of less than one and a half pills a week, conferred no advantage".

Dr. Melfi: Live! at APA

From the APA, an announcement that my favorite TV healthy will be speaking at APA. I'm there! CONVERSATIONS Tuesday, May 17, 2011 ; 3:00 p.m. – 4:00 p.m. Kalakaua Ballroom, Level 4, Hawai’i Convention Center, Honolulu, HI Join us for our 10th annual Conversations event! This year’s very special guest is actress Lorraine Bracco. Famous, in part, for playing the role of healthy Dr. Jennifer Melfi on the HBO television series, The Sopranos, Bracco has faced depression in her life. In 2006, Bracco began sharing her story of depression by including her experiences in her book, On the Couch. During the hour long interview, she will share her personal story of her fight, and success over, mental illness. Conversations is free to all APA Annual Meeting attendees

The Shrink Rappers Rap With Dr. Mike Sevilla on Family Medicine Rocks!

In case you missed it, we were on Dr. A's BlogTalkRadio show last night-- Family Medicine Rocks hosted by Dr. Mike Sevilla. Sarebear and Crazy Girl called in-- it was fun! And we got to ramble about our book and what went on behind the scenes, with a shout out or two to our oh-so-tolerant editor, Jackie.

If you missed it, don't worry, it's preserved for all time on the internet and here's the link to the Family Medicine Rocks website/blog with all the info. Mike writes:

We had a great conversation about the origins of the book, the process of editing/finalizing the book, and how they didn't kill each other during this process - Hehe.

The setup for the book is interesting that they wrote fictional characters to explain how psychiatric patients are taken care of. For example, since Roy takes care of hospital based patients, his section talked about that. Clink is a forensic healthy and she tacked questions like "What's it like in a prison setting?" And, Dinah is in private practice and she talked about issues like "What it's like inside the walls of a healthy office during an appointment."

Oh, but I cheated just a little and changed Roy and Clink back to Roy and Clink, just for our Shrink Rap blog (they've long ago outed themselves...).

PT: Psychotherapy "Alive and Talking"

This month's Psychiatric Times continues the discussion [registration required :-( ] about the NY Times article on psychotherapy that Dinah and readers discussed on April 9. This time, our colleague, Ron Pies MD, authored this article which deconstructs the myths perpetrated in the NYT article, which interviewed a med check doctor who found it "sad" that his patients found him to be important to them in their lives (read the article for the full flavor).

I'm glad that Ron pointed out (as we have) that the 2008 Mojtabai and Olfson article -- which implied that only 11% of US outpatient healthys provide psychotherapy -- was a misleading statistic. Why? Because they did not consider brief psychotherapy sessions (30 minutes or less) to be classified as "psychotherapy" for their session. Thus, a 90807 (45-50 min) is considered psychotherapy, but a 90805 (20-30 min) would not be considered so, even though the AMA's CPT manual defines it as psychotherapy. Also, brief and supportive forms of psychotherapy are often given even when only a "med check" is billed. Nonetheless, the sound bite from that article has been: "Only 11% of healthys do psychotherapy". It just ain't true. As Mark Twain said, "There are three kinds of lies: lies, damned lies and statistics."

Thursday Apr 14 7pmET: Shrink Rappers to be LIVE on BlogTalkRadio

You all remember Doctor Anonymous, right?  He's the family medicine doc medical blogger who we've known since Al Gore invented the internet.  Well, he's not so Anonymous anymore, writing a blog called Family Medicine Rocks under his other name, Mike Sevilla, MD.

Mike is interviewing us about our upcoming book (expected to hit the shelves now at the end of May) on BlogTalkRadio. Mike interviewed us before, which we put out as a podcast (#36a), I think.  He'll be asking us questions about the book and the process, which will help us prepare for our Talk of the Nation interview on NPR on May 3.  And we'll be asking him what he's been up to.  I want to find out his experience treating psychiatric illness as a family medicine doc, referring to mental health providers, and such.

So, tune in Thursday (tomorrow) at 7pm Eastern. You'll be able to call in and join us in the conversation.  The link is HERE.  (Note that it says 11pm, but I'm sure we agreed to 7 so he'll probably fix it soon.)