www.nytimes.com

For Bad Backs, It May Be Time to Rethink Biases About Chiropractors

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Spinal manipulation or physical therapy such as heat and stretches (above) seem as effective as traditional approaches to help lower back pain. 

About two of every three people will probably experience significant low back pain at some point. A physician like me might suggest any number of potential treatments and therapies. But one I never considered was a referral for spinal manipulation.

It appears I may have been mistaken. For initial treatment of lower back pain, it may be time for me (and other physicians) to rethink our biases.

Spinal manipulation — along with other less traditional therapies like heat, meditation and acupuncture — seems to be as effective as many other more medical therapies we prescribe, and as safe, if not safer.

Most back pain resolves over time, so interventions that focus on relief of symptoms and allow the body to heal are ideal. Many of these can be nonpharmacological in nature, like the work done by chiropractors or physical therapists.

Physicians are traditionally wary of spinal manipulation (applying pressure on bones and joints), in part because the practitioners are often not doctors and also because a few chiropractors have claimed they can address conditions that have little to do with the spine. Patients with back pain haven’t seemed as skeptical. A large survey of them from 2002 through 2008 found that more than 30 percent sought chiropractic care, significantly more than those who sought massage, acupuncture or homeopathy.

Researchers have been looking at the evidence supporting spinal manipulation for some time. Almost 35 years ago, a systematic review evaluated the available research, most of which was judged to be low in quality, and found that there might be some short-term benefits from the procedure. Two reviews from 2003 agreed for the most part, finding that spinal manipulation worked better than a “sham procedure”, or placebo, but no better or worse than other options.

Almost a decade later, a Cochrane review assessed the literature once more, and found 12 new trials had been conducted. This review was more damning. It found that spinal manipulation was no better than sham interventions.

But since then, data have accumulated, as more higher-quality studies have been performed. Recently, in The Journal of the American Medical Association, researchers looked for new studies since 2011, as well as those that had been performed before.

The evidence from 15 randomized controlled trials, which included more than 1,700 patients, showed that spinal manipulation caused an improvement in pain of about 10 points on a 100-point scale. The evidence from 12 randomized controlled trials — which overlapped, but not completely with the other trials — of almost 1,400 patients showed that spinal manipulation also resulted in improvements in function.

In February, in Annals of Internal Medicine, another systematic review of nonpharmacologic therapies generally agreed with the other recent trials. Based upon this review, and other evidence, the American College of Physicians released new clinical practice guidelines for the noninvasive treatment of subacute back pain. They recommended that patients should try heat, massage, acupuncture or spinal manipulation as first-line therapies.

The only things that might detract from the use of spinal manipulation in this situation would be its cost and potential harms.

Because they fear those potential harms, some physicians are hesitant to refer patients to chiropractors or physical therapists for care. But in all the studies summarized above, there were really no serious adverse events reported. It’s possible to find anecdotes of harm to the spinal cord from improper manipulations, but these are rare, and almost never involve the lower spine.

Some physicians are concerned about the cost of spinal manipulation, especially since most insurance carriers don’t cover it. Visiting a chiropractor costs more than taking many non-narcotic pain medications. But more invasive interventions can cost a lot of money. In addition, studies have shown that, in general, users of complementary and alternative medicine spend less over all for back pain than users of only traditional medicine.

Medication and surgery can also lead to harms. We shouldn’t forget that prescription pain medications, like opioids, can lead to huge costs, especially when they’re misused.

Some physicians are uncomfortable that we don’t have a clear picture of how spinal manipulation actually works to reduce pain. It’s also possible that some chiropractors do it “better” than others, and we can’t tell. This concern should be tempered by the fact that we don’t have a great understanding of why many other therapies work either. Some of the more traditional things we recommend don’t even work consistently.

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Still, there is no merit to many other claims about spinal manipulation — that it has been proved to work for things like infantile colic, painful periods, asthma, gastrointestinal problems, and more. For most conditions, the therapy lacks a good evidence base.

But given the natural course of back pain — that most of it goes away no matter what you do — the ideal approach is to treat the symptoms and let the body heal. Noninvasive therapies seem to do that well enough.

Source:www.nytimes.com

Clues to Zika Damage Might Lie in Cases of Twins

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While identical twins often share a fate, fraternal twins
typically don’t, a divergence that offers clues to researchers.
But one case is confounding these expectations.

On the bed next to her brother, Ana Vitória da Silva Araújo acted like the 1-year-old she was. She smiled and babbled. She played with a stuffed whale. She plucked the pacifier from her brother’s mouth and the burp cloth from his shoulder.

Her brother, João Lucas, seemed unaware of her, his eyes closed, his mouth making sucking motions. It was typical behavior for a newborn. But João Lucas is the exact same age as Ana Vitória — they are twins.

João Lucas was born with microcephaly and other serious problems, the result of his mother being bitten by a Zika infected mosquito during pregnancy. But the virus that attacked his brain in the womb apparently spared his sister.

The siblings are one of nine sets of twins identified in Brazil’s Zika crisis, and scientists hope they can shed light on how the virus works generally and why it inflicts ruthless damage on some babies and not others.

Twins often yield clues to medical mysteries because their biological similarities allow scientists to identify relevant differences. Determining why one twin became infected in the womb while the other did not may illuminate how Zika crosses the placenta, how it enters the brain, and whether any genetic mutations make a fetus more resistant or susceptible to Zika infection.

Until recently, Brazil’s Zika twins seemed to follow a pattern, said Mayana Zatz, a geneticist and molecular biologist at the University of São Paulo. The cases include two sets of identical twins, and both babies in each pair have microcephaly, she said. There are also six sets of fraternal twins, in which one twin has microcephaly, while the other appears unaffected.

Since identical twins share one placenta while fraternal twins almost always have separate placentas, Dr. Zatz and other experts suggested that the Zika virus may have penetrated one placenta and not the other.

Walking home after their two-hour bus ride to attend medical appointments.Adriana Zehbrauskas for The New York Times

Perhaps the virus entered through a weak spot in one placenta’s membrane, said Dr. Ernesto Marques, an infectious disease expert at the University of Pittsburgh and the Oswaldo Cruz Foundation in Recife, Brazil. Or if one fetus “kicked the placenta,” he said, inflammation from that bruise on the membrane could become a portal.

But one set of twins has broken the pattern. Those twins are fraternal and had separate placentas — but both have microcephaly and other Zika complications. “The boy is more affected than the girl, but both are severe,” Dr. Zatz said.

That case complicates the theory. Dr. Vanessa van der Linden, who helped discover that Zika causes microcephaly and has treated some of the twins, said one explanation might be that in some fraternal cases Zika crossed both placentas, but the twins had genetic differences that influenced why only one became infected or “why the babies reacted differently to the virus.”

Dr. Marques suggested another possibility: that an impaired twin was exposed to Zika before the mother’s body or the placenta developed immune responses against the virus and that the second fetus was infected slightly later.

Ms. Ribeiro took João Lucas for a hearing test. Adriana Zehbrauskas for The New York Times

“It should reach both at an equal time,” he said. “However, if the virus hit one of the babies before the mother actually had developed protective immune responses, you have a problem.”

Dr. Zatz’s lab has drawn blood from affected and unaffected twins, and is growing brain cells from their stem cells. She is testing to see which of those cells are susceptible to Zika infection. That could show whether some twins have genetic predispositions that make Zika infection more likely. Ultimately, Dr. Zatz expects to find an interplay of factors that can vary in each twin pregnancy. “I believe,” she said, “the explanation will be complex.”

For now, why João Lucas is devastated by the virus and his sister is not remains a mystery.

When João Lucas and his twin sister were born in August 2015, their mother, Neide Maria Ferreira da Silva, was unaware he had microcephaly or brain damage, she said. He was born first and was temporarily placed in an oxygen chamber because of breathing problems. And the maternity hospital’s “deformation doctor,” a physician specializing in newborns with deficiencies, recommended he see a geneticist. But Ms. da Silva thought any problems would be mild, she said.

She had already given birth to 10 children, starting when she was 17. It took a month before she brought João Lucas to the geneticist, who said “his brain, it wasn’t like ours,” Ms. da Silva, 42, recalled. “It was going to be always very small.”

Ms. da Silva holding Ana Vitória, right, and Ms. Ribeiro with Joao Lucas, left. Ms. Ribeiro is the boy’s guardian. Adriana Zehbrauskas for The New York Times

She was shocked. “I didn’t feel sad or upset,” she said. “I thought about how it was going to be when he grows up” and realized “I will have to take care of him more than the other kids.”

But his symptoms began overwhelming her. “He would fall asleep, and five minutes later he would start screaming,” she said.

Ms. da Silva was especially alarmed by João Lucas’s seizures, which made him “get purple” and look “like his eyes were going to jump out.”

Sometimes he became so agitated, he would scratch himself in the face, Ms. da Silva said. “Blood would come out.”

Ms. Ribeiro giving João Lucas a massage. The boy sometimes became so agitated, he would scratch himself in the face.Adriana Zehbrauskas for The New York Times

Unable to cope with his care, Ms. da Silva started bringing him to a neighbor’s cousin, who began caring for him. The caregiver, Valéria Gomes Ribeiro, 46, brought the baby to his first appointment with a neurologist. The doctor prescribed clonazepam, an anti-anxiety drug, to calm him, but Ms. Ferreira still found that when João Lucas was home, something often went wrong. He developed pneumonia and eating problems, even what she called “an emotional fever” because he seemed to miss Ms. Ribeiro, Ms. da Silva said.

Ms. da Silva’s 11-year-old daughter became pregnant and had an abortion, prompting a child protection agency visit. After Ms. da Silva told the caseworker that a friend was caring for her Zika baby, the agency investigated and initiated proceedings to remove João Lucas from her home. To keep him from being placed in a shelter, both women and the state agreed that João Lucas would live with Ms. Ribeiro, while Ana Vitória stayed with Ms. da Silva. Under court order, João Lucas spends Sundays at his biological mother’s house.

Ms. Ribeiro, who has adorned João Lucas with a bracelet and necklace hung with a good-luck charm called a “figa,” tries to keep up with his many appointments. They include visits with a psychologist who shows João Lucas a panel of black and white squares to stimulate vision and rubs him with a sponge studded with Popsicle sticks to stimulate touch.

On a visit last fall to Ms. Ribeiro’s emerald green house on a dirt street, where the 23rd psalm hangs on a yellow wall, Ana Vitória toddled around, clutching a piece of spongy cake with one hand, thumping a table with the other. Reaching for her brother’s mouth, she touched the green tape that therapists apply around his lips, fingers, back and chin to relax tight muscles. Ms. da Silva waved a rattle before João Lucas, but he did not respond.

So far, his sister — like the other fraternal twins without obvious brain damage — appears unimpaired, but doctors are monitoring her and the others. At Ana Vitória’s one-year exam, she was slightly behind developmentally. Her vocabulary was limited and she was slow to point to her mother when the doctor asked, Ms. da Silva said.

That could be unrelated to Zika, but, she noted, “The doctor never said it’s 100 percent sure that she doesn’t have a problem.”

Source:www.nytimes.com

A Transgender Learning Gap in the Emergency Room

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After a skiing accident, Beck Bailey, featured in Transgender Patients Face Challenges at the Hospital, encountered doctors who were unsure how to treat transgender patients. 

As an emergency physician, I’m always engaging in a fast-tempo, often awkward, all too stressful dance with strangers. Lately, though, I’ve noticed a particular gap in my own medical education and training, as well as in that of my colleagues, that’s further tripping up our steps: how to provide optimal health care for transgender patients.

The gap is amplified in the emergency room, where even under the best of circumstances the interaction we have with patients is typically rushed and never entirely comfortable — and where I’m usually meeting a patient for the first time and don’t have the patient’s medical history at my fingertips. Because transgender people are less likely to have health insurance and are four times more likely to live in poverty compared to the general population, the emergency room serves as a particularly important safety net for these patients.

Sometimes the patient is registered as the wrong gender immediately from triage, resulting in a strained communication from the get-go. Other times, a staff member lets out a surprised gasp as a patient undresses for a physical exam. Then there are the moments when providers call a patient a “he/she” or “they” on rounds. Private rooms are also hard to come by in busy, overcrowded emergency rooms, and patients may be inappropriately clustered by gender.

None of this, for the most part, is out of malice. Instead it’s because of our own ignorance — and stems from our lack of education and training on providing sensitive and evidence-based care for transgender patients.Currently, American medical schools’ curriculums are not sufficiently addressing the health needs and concerns of the lesbian, gay, bisexual and transgender community. A comprehensive survey of schools in the United States and Canada revealed that less than five hours in medical schools are devoted to L.G.B.T. health over all; some medical schools reported zero hours of training. While I did learn about providing health care for lesbian, gay and bisexual patients when I went to medical school over a decade ago, I didn’t receive any special education on the particular health needs and concerns of the estimated 1.4 million adults living in the United States who identify as transgender.

In one study, half of these patients had to teach their doctors about transgender health issues at some point. A Twitter hashtag #transhealthfail started trending in August of 2015, when transgender patients shared stories about their negative experiences with the health care system. Patients continue to use the hashtag today.

These holes in medical education and training can cost lives. Over 70 percent of transgender people nationwide say they have experienced serious discrimination in a health care setting. A third of transgender people postpone — or completely avoid — seeking health care because of the fear of discrimination. One in five have yet to disclose their transgender status to any medical provider.

Though still in the nascent stages, our medical education system may be on the cusp of changing. The Association of American Medical Colleges released its first medical education guidelines for L.G.B.T. health in November 2014. The University of Louisville School of Medicine became the national pilot site to implement a new model of physician training. The initiative, called the eQuality Project, was fully integrated into the curriculum this academic year.

Dr. Amy Holthouser, the associate dean for medical education at Louisville, explained that one way the program is unique is that instead of having an isolated module designated for learning about L.G.B.T. health, the issues pertinent to L.G.B.T. patients are integrated into the entire curriculum. In the pharmacology block, for instance, students may learn about hormone therapies used for transitioning, in the same way that they might learn about medications to treat high blood pressure. When students are educated about routine pap smears, the importance of screening transgender men is also taught; the same goes for prostate exams and transgender women.

Some schools make the commendable effort of allocating hours to L.G.B.T. health, but often they focus too narrowly on subjects like sexually transmitted infections and H.I.V., Dr. Holthouser explained, which can further stigmatize patients. “Instead, we want to teach students how to provide all aspects of patient care,” she said.

All in all, the school now has revised about 50 hours of its curriculum to include L.G.B.T. health — which puts it far ahead of the curve. The medical colleges’ association’s standards are not mandatory. But Dr. Holthouser predicts that “once they start putting questions specific to L.G.B.T. health on board exams and require them in reports for accrediting bodies, schools will quickly catch up.”

At New York University School of Medicine, Richard Greene, the director of gender health education, is working on incorporating L.G.B.T. education into both undergraduate medical education and residency training. For all medical students and those residents training to become primary-care physicians, he has already implemented standardized patient exams — simulated clinical scenarios in which actors play patients — that test candidates’ competency with transgender health issues. He is working on expanding this across all residency training programs, regardless of the specialty.

Dr. Greene’s efforts have been met with enthusiasm. “I find young learners, like new medical students and new residents, are really excited to learn about transgender health. I’m really optimistic about the next generation,” he told me. “Senior providers don’t know what they know.”

For doctors like me who didn’t get the training in our earlier years, there are easily accessible learning resources. The National LGBT Health Education Center, a part of the Fenway Institute, provides free web-based interactive modules, which I recently took. The University of California-San Franciscoand the World Professional Association for Transgender Health also have extensive online resources and learning modules. Conferences and webinars are routinely available for physicians to attend and learn more about providing health care to the L.G.B.T. community.

But the first step is simply recognizing our own deficiencies — and realizing that learning about transgender health is as pressing as mastering dosages of the newest cholesterol-lowering drug or memorizing the latest protocol for resuscitating a patient from cardiac arrest. “This is something that’s not going away,” Dr. Greene said. “In fact, it’s becoming more urgent.”

Source:www.nytimes.com

How Behavioral Economics Can Produce Better Health Care

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Handwashing is important for doctors, and sometimes they need nudges to do it.

Consider the following.

I’m a physician at the end of more than a decade of training. I’ve dissected cadavers in anatomy lab. I’ve pored over tomes on the physiology of disease. I’ve treated thousands of patients with ailments as varied as hemorrhoidsand cancer.

And yet the way I care for patients often has less to do with the medical science I’ve spent my career absorbing than with habits, environmental cues and other subtle nudges that I think little about.

I’ll sometimes prescribe a particular brand of medication not because it has proved to be better, but because it happens to be the default option in my hospital’s electronic ordering system. I’m more likely to wash my hands — an activity so essential for safe medical care that it’s arguably malpractice not to do so — if a poster outside your room prompts me to think of your health instead of mine. I’ll more readily change my practice if I’m shown data that my colleagues do something differently than if I’m shown data that a treatment does or doesn’t work.

These confessions can be explained by the field of behavioral economics, which holds that human decision-making departs frequently, significantly and predictably from what would be expected if we acted in purely “rational” ways. People don’t always make decisions — even hugely important ones about physical or financial well-being — based on careful calculations of risks and benefits. Rather, our behavior is powerfully influenced by our emotions, identity and environment, as well as by how options are presented to us.

People overwhelmingly tend to stick with default options when given a choice (organ donation rates are over 90 percent in countries where citizens need to override a default and opt out of donation compared with 4 to 27 percent where they much choose to opt in). People are more sensitive to losses than commensurate gains (losing $100 feels twice as bad as winning $100 feels good). We tend to overvalue the present (most of us prefer one free coffee now to two free coffees next week). And more choice isn’t always good (people are less likely to buy a product if they’re given dozens of options instead of just a few).

We in the medical community have only recently started to explore how behavioral economics can improve health. As with any hot field, there’s always the possibility of hype. But these insights might be particularly valuable in health care because medical decision-making is permeated with uncertainty, complexity and emotion — all of which make it hard to weigh our options.

A leader of this movement is Dr. Kevin Volpp, a physician at the University of Pennsylvania and founding director of the Center for Health Incentives and Behavioral Economics. He designs randomized trials around some of health care’s most important challenges: nudging doctors to provide evidence-based care; ensuring patients take their medications; and helping consumers choose better health plans.

“There’s starting to be a broad recognition that decision-making environments in health care could better reflect how doctors and patients actually make decisions,” he said.

Dr. Volpp, whose work is used by both the public and private sector, recently collaborated with CVS Caremark to test which financial incentives are most effective for getting employees to quit smoking. Employees were randomly assigned to one of three groups. The first was “usual care,” in which they received educational materials and free smoking cessation aids. The second was a reward program: Employees could receive up to $800 over six months if they quit. The third was a deposit program, in which smokers initially forked over $150 of their money, but if they quit, they got their deposit back along with a $650 bonus.

Compared with the usual care group, employees in both incentive groups were substantially more likely to be smoke-free at six months. But the nature of the incentives mattered. Those offered the reward program were far more likely to accept the challenge than those offered the deposit program. But the deposit program was twice as effective at getting people to quit — and five times as effective as just pamphlets and Nicorette gum.

Getting the incentives right is important in helping people quit smoking. 

Parting with your own money is painful. But it is effective.

That’s also a lesson in Volpp-led research on getting people to lose weight and exercise more. One recent study gave incentives to patients by entering them into lotteries or into deposit contracts for meeting weight loss goals. Those in the lottery group were eligible for a daily lottery prize with frequent small payouts and occasional large rewards — but only if they clocked in at or below their weight loss goal. People in the deposit group invested their own money (generally a few dollars a day), which was then matched by researchers. They’d get their money back — and then some — if they met their goal at the end of the month.

At four months, both incentive groups had lost more than three times as much weight as the control group (about 14 pounds versus four pounds), but the deposit group lost slightly more than the lottery group. A similar study found that patients were more likely to walk 7,000 steps a day if they were given an upfront payment — part of which had to be returned each day that they didn’t meet their exercise goal — compared with lotteries, rewards or old-fashioned encouragement.

Other work has highlighted the power of defaults — which in health care can have life-or-death consequences. And perhaps nowhere is doctors’ default tendency more apparent than in our bias toward aggressive end-of-life care that favors quantity over quality of life.

With this in mind, researchers studied whether the type of end-of-life care patients choose is influenced by how we present the options. Terminally ill patients were randomly assigned to complete one of three advance directives: The first group received a form with the comfort-oriented approach preselected; the second had the aggressive care box checked; the third had both options left blank. Patients were free to override the default and select any option they preferred.

Nearly 80 percent of patients in the comfort default group chose comfort, while only 43 percent in the aggressive care default group did. (Sixty-one percent of patients without an embedded default opted for comfort.) It seems, then, that even critically important decisions about how we want to live our final days are affected by what comes pre-ordered on the menu we’re given.

Health insurers are also betting that behavioral economics can improve quality and lower costs. Blue Cross Blue Shield (B.C.B.S.) of Massachusetts is using a variety of behavioral economics concepts to pay its doctors — including peer comparisons and bonus payments for continuous improvement instead of absolute thresholds. In Hawaii, B.C.B.S. is experimenting with joint incentives for doctors and patients to meet diabetes care goals.

Start-ups are jumping into the nudge game, too.

The Brooklyn-based start-up Wellth, for example, has developed an app to reward patients for taking their medications. Nearly a third of prescriptions in the United States are never filled, and about half of all patients don’t take their medications as prescribed — even after life-threatening illnesses like heart attacks. Every year, medication nonadherence causes 125,000 deaths and costs the health system up to $289 billion.

Wellth thinks it can help patients manage themselves.

“We want to give them immediate, tangible rewards for healthy behavior,” said Matthew Loper, the company’s C.E.O. and co-founder. “But ultimately, we’re in the business of habit formation. We want behaviors to stick.”

Say a patient is discharged from the hospital after a heart attack. She downloads the Wellth app, and the company deposits $150 into her account, which she gets to keep if she takes all her medications for three months. Every morning, Wellth sends her a reminder to take her pills. If she snaps a selfie while taking her medicine, she keeps the money.

If she forgets, she gets additional notifications over the course of the day, and maybe a text or two. If she misses the day’s assignment altogether, she loses $2. If she misses several days in a row, she loses $2 for each day and gets a phone call in addition.

A more complete view of human behavior seems necessary for more effective medicine. Health is fundamentally the product of myriad daily decisions made by doctors and patients, and by uncovering what truly motivates us, we may be able to nudge one another toward wiser decisions and healthier lives.

Source:www.nytimes.com

In School Nurse’s Room: Tylenol, Bandages and an Antidote to Heroin

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A naloxone kit at Washingtonville High School in Orange County, N.Y. 

At every school in New Rochelle, just north of the Bronx, in Westchester, there is a locked medicine cabinet in the nurse’s office, stocked with things like EpiPens for allergic reactions, inhalers for asthma, Tylenol for aches and pains.

Now, those cabinets also include naloxone, an antidote for people who are overdosing on opioids like heroin. Given as an injection or a nasal spray, naloxone can quickly revive someone who is not breathing. The city keeps it in every nurse’s office, including in its elementary schools.

“We have it the same way we have defibrillators and EpiPens, the way we have oxygen in our schools,” said Dr. Adrienne Weiss-Harrison, the school district’s medical director. “Rarely do we pull a defibrillator off the wall, but it’s there if we need it, and that’s how we approach this opportunity to have naloxone.”

There is no comprehensive data on how often students overdose while at school, but it happens. Renee Rider, assistant commissioner at the New York State Education Department, said the department has heard anecdotally of two schools where a student overdosed and was saved by E.M.S. workers using naloxone

But the numbers of young people dying from overdoses around the country is striking. According to the Centers for Disease Control and Prevention, in 2015, opioids killed 7,163 people between the ages of 15 and 29, more than 20 percent of total deaths.

And as communities across the country face this swell of death from heroin and pills, schools see the epidemic lapping at their doorsteps — killing friends, neighbors, recent graduates. Educators are increasingly deciding that they should have naloxone on hand.

New Jersey Assemblyman Vincent Mazzeo, a Democrat, in the fall sponsored a bill in the state legislature that would require all high schools to stock naloxone. In talking to parents and students in his district, Mr. Mazzeo said, “It came out that kids were coming into school on opiates, perhaps on heroin.”

Without the antidote, “If a kid comes into school and he overdoses, they don’t have the proper tools. They’d have to wait for E.M.S. first responders to come.”

Now, in Massachusetts and Kentucky, Connecticut and New Mexico, schools have the drug for emergency use. New York State has a program that provides it free to schools, with 64 districts participating so far. In Pennsylvania, nearly 250 public and charter schools have received a free supply. In Rhode Island, every middle school, junior high and high school is required to have naloxone on the premises. And scattered around the country, there are schools and districts that have bought the medication on their own.

“It is absolutely a sad sign of the times,” said Roy Reese, superintendent of Washingtonville Central School District in Orange County, N.Y. “I say this not reluctantly, but sadly: it is only a matter of time.”

Naloxone has been available for more than 40 years, and for much of that time, it was largely found in hospitals. But it has become increasingly common outside of them as the opioid epidemic has spread, and is now often found at the fingertips of law enforcement officers. In recent years, laws have changed to allow schools to keep it on hand and administer it to whoever needs it. In New York, for example, public health law was amended in 2015 to authorize school employees to administer naloxone.

Brian Connolly, principal of Washingtonville High School. The school keeps naloxone in the nurse’s office and with Mr. Connolly’s secretary. 

Through the state’s program, New York schools can now receive two doses of generic intranasal naloxone in a little nylon bag; the kits cost about $66, the State Health Department said, though schools get them for free. The drug is also available under the brand name Narcan, which is a nasal spray, and Evzio, which is an auto-injector like an EpiPen. Evzio is the most expensive, with a list price of $4,100, according to Kaléo, the company that makes it.

New York City schools are not stocking it because, officials said, they “have not seen the need.”

Many schools have chosen to stock Narcan because they can get it for free. A partnership between Narcan’s producer, Adapt Pharma, and the Clinton Foundation, offers any high school in the country two free doses of Narcan. Adapt Pharma covers the cost of the medication, and the Clinton Foundation does outreach to schools and districts. In an indication of the reach of the epidemic, President Clinton said last year that three of his friends had lost children to opioid overdoses.

An Adapt Pharma spokesman said about 1,300 units have been distributed so far to schools in 15 states, including Pennsylvania, Massachusetts, Kentucky, Delaware and New Hampshire. After the free supply runs out, schools can buy more for $75 a carton, which contains two doses. The list price for that amount is $125, Adapt said.

“I don’t see this as a big land-grab for market share,” said Daniel Raymond the deputy director of policy and planning at the Harm Reduction Coalition, which provides trainings on health issues related to drug use. “Ultimately, schools are going to be a niche market compared to other purchasers of naloxone.”

Kathleen Neelon, the nursing coordinator for the Wallingford, Conn., schools, said that in recent years, there has been an alarming numbers of overdoses among young adults in the area, so the district decided to stock Narcan for its high schools. They keep it in an emergency kit, which is filled with things like quick-clotting gauze and a blood pressure cuff.

“We instituted it in December, and I hope we never have to use it” Ms. Neelon said. The school sent out a notice to parents about the decision, and there were stories on the local news, she said, but she knew of no pushback from the community. “Most people said, it’s a sad statement, but it’s better to be prepared than not.”

Some observers wonder if the reaction would be different if schools were stocking an antidote to a different drug, like crack cocaine. The crack epidemic was particularly acute among black people, while the opioid epidemic has hit white people especially hard. Much has been written about how race has impacted the nation’s reaction to the opioid epidemic.

“If there was an antidote to crack, the argument would be we should just kick these people out of school, rather than trying to deal with them in the school system,” said Mr. Raymond of the Harm Reduction Coalition. “It would be about getting tough, cracking down, kicking them off of sports teams and expelling them.”

In many school districts, educators say the severity of opioid problem has overwhelmed any concerns they might have about the optics of naloxone.

Mark Marrone, superintendent of Mainland Regional High School in southern New Jersey, said he knows of several Mainland graduates who overdosed and died in their 20s, and one who overdosed and survived after being given naloxone. If the worst happens at his school, he said, he plans to be prepared.

“Some people worry that this says, ‘Oh, there are drugs in the schools,’” Mr. Marrone said. “No, there are drugs everywhere. We want to teach kids the right way to respond.” And maybe, he continued, “you’ll save a life.”

Source:www.nytimes.com

How Long Have I Got Left?

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AS soon as the CT scan was done, I began reviewing the images. The diagnosis was immediate: Masses matting the lungs and deforming the spine. Cancer. In my neurosurgical training, I had reviewed hundreds of scans for fellow doctors to see if surgery offered any hope. I’d scribble in the chart “Widely metastatic disease — no role for surgery,” and move on. But this scan was different: It was my own.

I have sat with countless patients and families to discuss grim prognoses: It’s one of the most important jobs physicians have. It’s easier when the patient is 94, in the last stages of dementia and has a severe brain bleed. For young people like me — I am 36 — given a diagnosis of cancer, there aren’t many words. My standard pieces include “it’s a marathon, not a sprint, so get your daily rest” and “illness can drive a family apart or bring it together — be aware of each other’s needs and find extra support.”

I learned a few basic rules. Be honest about the prognosis but always leave some room for hope. Be vague but accurate: “days to a few weeks,” “weeks to a few months,” “months to a few years,” “a few years to a decade or more.” We never cite detailed statistics, and usually advise against Googling survival numbers, assuming the average patient doesn’t possess a nuanced understanding of statistics.

People react differently to hearing “Procedure X has a 70 percent chance of survival” and “Procedure Y has a 30 percent chance of death.” Phrased that way, people flock to Procedure X, even though the numbers are the same. When a close friend developed pancreatic cancer, I became the medical maven to a group of people who were sophisticated statisticians. I still dissuaded them from looking up the statistics, saying five-year survival curves are at least five years out of date. Somehow I felt that the numbers alone were too dry, or that a physician’s daily experience with illness was needed for context. Mostly, I felt that impulse: Keep a measure of hope.

These survival curves, called Kaplan-Meier curves, are one way we measure progress in cancer treatment, plotting the number of patients surviving over time. For some diseases, the line looks like an airplane gently beginning its descent; for others, like a dive bomber. Physicians think a lot about these curves, their shape, and what they mean. In brain-cancer research, for example, while the numbers for average survival time haven’t changed much, there’s an increasingly long tail on the curve, indicating a few patients are living for years. The problem is that you can’t tell an individual patient where she is on the curve. It’s impossible, irresponsible even, to be more precise than you can be accurate.

One would think, then, that when my oncologist sat by my bedside to meet me, I would not immediately demand information on survival statistics. But now that I had traversed the line from doctor to patient, I had the same yearning for the numbers all patients ask for. I hoped she would see me as someone who both understood statistics and the medical reality of illness, that she would give me certainty, the straight dope. I could take it. She flatly refused: “No. Absolutely not.” She knew very well I could — and did — look up all the research on the topic. But lung cancer wasn’t my specialty, and she was a world expert. At each appointment, a wrestling match began, and she always avoided being pinned down to any sort of number.

Now, instead of wondering why some patients persist in asking statistics questions, I began to wonder why physicians obfuscate when they have so much knowledge and experience. Initially when I saw my CT scan, I figured I had only a few months to live. The scan looked bad. I looked bad. I’d lost 30 pounds, developed excruciating back pain and felt more fatigued every day. My tests revealed severely low protein levels and low blood counts consistent with the body overwhelmed, failing in its basic drive to sustain itself.

For a few months, I’d suspected I had cancer. I had seen a lot of young patients with cancer. So I wasn’t taken aback. In fact, there was a certain relief. The next steps were clear: Prepare to die. Cry. Tell my wife that she should remarry, and refinance the mortgage. Write overdue letters to dear friends. Yes, there were lots of things I had meant to do in life, but sometimes this happens: Nothing could be more obvious when your day’s work includes treating head trauma and brain cancer.

But on my first visit with my oncologist, she mentioned my going back to work someday. Wasn’t I a ghost? No. But then how long did I have? Silence.

Of course, she could not stop my intense reading. Poring over studies, I kept trying to find the one that would tell me when my number would be up. The large general studies said that between 70 and 80 percent of lung cancer patients would die within two years. They did not allow for much hope. But then again, most of those patients were older and heavy smokers. Where was the study of nonsmoking 36-year-old neurosurgeons? Maybe my youth and health mattered? Or maybe my disease was found so late, had spread so far, and I was already so far gone that I was worse off than those 65-year-old smokers.

Many friends and family members provided anecdotes along the lines of my-friend’s-friend’s-mom’s-friend or my-uncle’s-barber’s-son’s-tennis-partner has this same kind of lung cancer and has been living for 10 years. Initially I wondered if all the stories referred to the same person, connected through the proverbial six degrees. I disregarded them as wishful thinking, baseless delusion. Eventually, though, enough of those stories seeped in through the cracks of my studied realism.

And then my health began to improve, thanks to a pill that targets a specific genetic mutation tied to my cancer. I began to walk without a cane and to say things like, “Well, it’s pretty unlikely that I’ll be lucky enough to live for a decade, but it’s possible.” A tiny drop of hope.

In a way, though, the certainty of death was easier than this uncertain life. Didn’t those in purgatory prefer to go to hell, and just be done with it? Was I supposed to be making funeral arrangements? Devoting myself to my wife, my parents, my brothers, my friends, my adorable niece? Writing the book I had always wanted to write? Or was I supposed to go back to negotiating my multiyear job offers?

The path forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d just spend time with family. Tell me one year, I’d have a plan (write that book). Give me 10 years, I’d get back to treating diseases. The pedestrian truth that you live one day at a time didn’t help: What was I supposed to do with that day? My oncologist would say only: “I can’t tell you a time. You’ve got to find what matters most to you.”

I began to realize that coming face to face with my own mortality, in a sense, had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn’t know when. After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely. The problem wasn’t really a scientific one. The fact of death is unsettling. Yet there is no other way to live.

The reason doctors don’t give patients specific prognoses is not merely because they cannot. Certainly, if a patient’s expectations are way out of the bounds of probability — someone expecting to live to 130, or someone thinking his benign skin spots are signs of impending death — doctors are entrusted to bring that person’s expectations into the realm of reasonable possibility.

But the range of what is reasonably possible is just so wide. Based on today’s therapies, I might die within two years, or I might make it to 10. If you add in the uncertainty based on new therapies available in two or three years, that range may be completely different. Faced with mortality, scientific knowledge can provide only an ounce of certainty: Yes, you will die. But one wants a full pound of certainty, and that is not on offer.

What patients seek is not scientific knowledge doctors hide, but existential authenticity each must find on her own. Getting too deep into statistics is like trying to quench a thirst with salty water. The angst of facing mortality has no remedy in probability.

I remember the moment when my overwhelming uneasiness yielded. Seven words from Samuel Beckett, a writer I’ve not even read that well, learned long ago as an undergraduate, began to repeat in my head, and the seemingly impassable sea of uncertainty parted: “I can’t go on. I’ll go on.” I took a step forward, repeating the phrase over and over: “I can’t go on. I’ll go on.” And then, at some point, I was through.

I am now almost exactly eight months from my diagnosis. My strength has recovered substantially. In treatment, the cancer is retreating. I have gradually returned to work. I’m knocking the dust off scientific manuscripts. I’m writing more, seeing more, feeling more. Every morning at 5:30, as the alarm clock goes off, and my dead body awakes, my wife asleep next to me, I think again to myself: “I can’t go on.” And a minute later, I am in my scrubs, heading to the operating room, alive: “I’ll go on.”

Source:www.nytimes.com