July 6th, 2007 by Dr. Val Jones in Expert Interviews
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An important new study related to Americans’ use (and abuse) of alcohol was recently published in the Archives of General Psychiatry. I caught up with Revolution Health’s addictions specialist, Bruce Phariss, MD to get his perspective on this very common, yet often disabling addiction.
Dr. Val: Is there anything surprising or new
presented in this study? If so, what is it?
Dr. Phariss: It
isn’t necessarily surprising, but it is striking that 30% of Ameicans have an
alcohol problem at some point in their lives. Alcohol problems often develop
slowly and no one “notices” that it has become a problem until well after the
fact. That’s why it takes 10 years on average for those that get treatment to
actually get the treatment. The study also highlights the fact that a huge gap
exists between those needing treatment and those receiving treatment. We’re
still not doing a very good job in the treatment community of getting the word
out there that treatment is available and that treatment
works.
Dr. Val: Why do you think that only 25% of
people with alcohol abuse problems get treatment?
Dr. Phariss: Three things: First, denial and stigma keep many “unaware” that they have a
problem. The first step in the stages of how people change behaviors is
awareness. If you don’t know you have a problem, you can’t change it. Along
this same line, if alcoholism is viewed as a moral failing instead of as a
medical condition, then good, moral people don’t think they can be alcoholics.
That’s good logic, but unfortunately, alcohol is non-discriminatory and even
good, moral people develop alcohol problems. Fighting through that
generalization of stigma is too tough for many people and they never seek
treatment or attempt to change their behavior.
Second, our cultural still
galmorizes drinking and drugging. Although the hype surrounding the many young
starlets currently in rehab centers appears to say how tough these addictions
are to kick, the overall slant is to add cache to the celebrity. It’s cool to
need rehab, it’s cool to be that out of control with alcohol and substances,
it’s almost synonymous with celebrity of a certain type. Sadly, this message
influences the behavior of many Americans, especially the under 25 crowd, who
are the most venerable to developing addictive behaviors.
Third, many people stop on their
own without treatment. Almost anyone who does find their way into treatment of
any kind (AA, treatment programs, etc.) has tried to stop on their own at least
once, maybe a hundred times. Just think of the many times you’ve heard someone
say “New Year’s Eve is my last day of drinking” or “I’m going to give up booze
for Lent and not pick it up again” or, my favorite, “I can give it up any time I
want….” In fact, some of the 75% of the people who need to deal with their
drinking do deal with it on their own. But many others need help of some kind.
Breaking down barriers to treatment — access and psychological and financial
barriers — remains the goal of the treatment community.
Dr. Val: What sorts of interventions might be
most useful (on a personal and on a national scale) to reduce alcohol abuse and
dependence?
The debate on a national level as to how to intervene to reduce alcohol
abuse and dependence is ongoing and heated at times. However, many intervention
and prevention programs focus on underage, college age and the under 25-year-old
drinkers. If you don’t a drink until age 21 you are four or five times less
likely to develop an alcohol problem than someone who drinks before the age of
21. But underage and college age drinkers are becoming more numerous, not less,
so we must be doing something wrong. A few colleges have taken an approach I
like: in addition to providing counseling, supporting AA meetings by providing
space, a few colleges have taken to trying to change the “perceived norm” about
drinking on campus. Although in fact most kids on campus do not binge drink on
a regular basis, the perception by incoming freshman is that everyone drinks
more than they do. This holds true for the guy who drinks two six packs a day
(clearly way too much)….he actually thinks that the majority of students drink
more than he does. What is a motivating emotional factor for college students:
they want to be accepted, to be a regular, normal guy or girl. If the
perception is that normal is to drink a bucket, then as a group they will be
more likely to drink heavily. A few colleges have taken the simple step of
making the student body aware that, in fact, most students do not drink to
excess. That simple step has helped to curb the trend of more and more alcohol
on campus.
Dr. Val: What’s the take-home message to be
gleaned from this study?
Dr. Phariss: The take-home message is that the medical profession has a long way to go in
de-stimatizing treatment for alcohol use disorders and that the substance abuse
treatment community remains too distant, too inaccessible and too timid in
announcing that treatment works. As the AA slogan says: “It works if you work
it, so work it, you’re worth it.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 2nd, 2007 by Dr. Val Jones in News
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New research suggests that people with allergies to molds, pollen, and dust mites but NOT cat dander, may have heightened asthmatic reactions to their usual triggers in the presence of cats. This is unfortunate news for cat owners or anyone who is fond of kitties but has environmental allergens. Researchers note that :
Avoidance of cat exposure would be beneficial to a much wider
population than previously expected. Furthermore, cat allergen levels
were ubiquitous in cat-owning communities, and their results showed
effects of cat allergen exposure at lower levels than generally
regarded necessary to produce a measurable result.
So basically, if you live in a “cat-owning community,” their airborne fluff will probably make your pollen and mold-induced asthma worse. Aside from declining to pet and/or play with them, I doubt that there’s much you can do to completely avoid their dander. But there is some cause for all allergy sufferers to eye cats with suspicion… time to trade in Tiger for Fido?
[View cat allergy cartoon]This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2007 by Dr. Val Jones in News
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There’s a new trend in the pharmaceutical industry: repurposing old drugs for new indications and/or combining current drugs to create brand new effects. Recent studies suggest that two drugs (Lyrica and Neurontin) approved for the treatment of neuropathic (nerve) pain may also be helpful for improving sleep quality. And since disordered sleep is also at the root of conditions like fibromyalgia, there seems to be reason for enthusiasm. Another study suggests that Wellbutrin (an anti-depressant often used as a smoking cessation aid) could be useful for enhancing libido. Again, some cause for celebration – quit smoking AND improve your sex life with one pill? Not bad.
The New York Times describes the new trend in drug combination research – robots combine random drugs to see if together they have stronger effects on tissue cultures than they do alone. Sounds like low-brow trial and error, but companies such as CombinatoRx are betting that this approach will turn up potential therapeutic benefits at a faster rate (and at much lower costs) than the old-fashioned process of original drug research and development.
This should be handled with a healthy dose of skepticism – is combining nexium (a stomach acid reducer) and naproxen (pain medicine that can harm the stomach lining) anything more than a commercial gimmick? What about the chance finding that anticoagulants enhance the effects of inflammation-reducing steroids? Perhaps that is indeed relevant and helpful?
It’s clear that testing drug combinations has the potential to create a financial windfall for pharmaceutical companies – so the FDA will need to make sure that these new combo drugs offer real benefits over taking them separately.
Still, if you asked me where I’d rather put my research dollars – testing unusual drug combinations in Petri dishes or analyzing whether or not water has memory (a foundational principle of homeopathy), I think you know where I’d place my bet.
Go ahead and shuffle and re-deal, Big Pharma. Maybe you and the FDA will uncover something useful after all? We’ll be watching with interest and a critical eye.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2007 by Dr. Val Jones in Health Policy, Opinion
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There were a series of amusing anecdotes presented at the
very beginning of Sicko. Various people
were denied coverage by health plans for things that didn’t have the right
coding or were submitted incorrectly.
One woman received a message that her ambulance transportation to the
hospital from the scene of a car accident (where she was knocked unconscious)
was not covered by her health insurance because she did not obtain pre-approval
for the ambulance ride. She asks, “When
could I have called for pre-approval?
It’s hard to get permission when you’re unconscious.”
Another person was declined coverage because he was too thin
(he was six feet tall and only 130 pounds), and one young woman was
denied because she was overweight (5’1” and 175 pounds).
While these denials are laughable, they are ridiculous
specifically because they are decisions that appear to be made by a computer –
or perhaps by applying inflexible rules to real life scenarios without the
benefit of human interpretation. [See my cartoon on the subject.]
And as we consider Mr. Moore’s proposed solution to the apparent
capriciousness of health insurance company coverage policies – we see that his
single-payer solution is really no different.
He is trading one impersonal decision maker for another. Big government is no more capable of
delivering personally relevant care than is the health insurance industry. The problem with both is that they take
decision-making away from the patient and those closest to their situation – the providers who have a
much better sense of what is needed and appropriate.
As a physician it really upsets me when a third party payer denies coverage of an important treatment to my patient. I understand that we have to have some broad, population-based rules for medical coverage as a means for cost containment – but a one-size-fits-all system will always fail some people. We physicians are regularly on the phone on their behalf, explaining to appeals associates why our patient needs X, Y, or Z… and then have to re-explain the medical necessity up the chain of command until a Medical Director is finally reached, who then has no incentive (other than basic human decency) to give in to the pleading physician’s request on behalf of her patient. We (and our staff) spend uncompensated hours upon hours doing this every week.
And Medicare creates rules to deny coverage to people too (and it probably doesn’t save on administrative costs over health insurance plans anyway, notes Charlie Baker at Harvard Pilgrim Healthcare, Inc.). So from a physician’s perspective it feels as if we’ve had our clinical judgment usurped by bureaucracy and for-profit health insurance companies. We have been reduced to claims advocates rather than clinicians. It is exhausting and infuriating – and I don’t see this improving any time soon (and neither does Paul Levy at Harvard).
Healthcare is not free, as Dr. Leap points out, and unfortunately it’s also not personal. And that’s what I am lamenting – the depersonalization of medical care. My patients will not be able to make a full range of informed choices with my help – they will be given a very limited menu of options from their third party payer – who will argue that they are not limiting care because the patient can always pay out-of-pocket for anything their physician believes is necessary, but is not covered under their plan. And so where does that leave the patient on a modest income? Effectively, they are indeed limited to the options covered by their third-party payer. And this is so ironic, given the new push for personalized medicine (optimizing individual treatment via genetic testing, etc.) In the end it seems that we’re aiming for personalized medicine and an impersonal healthcare system. And maybe that’s part of what’s “sicko” about all of this.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 29th, 2007 by Dr. Val Jones in Health Policy, Humor
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Alright, I can’t help it – I just watched the new movie
Sicko, so I have to write about it. Labeled a propagandist
by some, self-contradictory by others, the value of Michael Moore’s
work is in its ability to get the public talking about a critically important
subject. And I must agree with the New York Times reviewer on this point – Sicko was the best
edited and most entertaining of Mr. Moore’s documentaries.
Why
Socialized Medicine Won’t Work in the US (In My Humble Opinion)
Sicko
was interesting for me because it compared the healthcare systems of the US, Canada,
France and Britain. Moore’s whole thrust is that socialized medicine is the
potential cure for America’s
healthcare crisis. I grew up in Canada,
spent summers in France,
trained in medicine in the US,
and my mom’s British – so I have a unique and very deep appreciation for the
cultural differences of these 4 countries. And here’s what I see: the way
a country cares for the sick is a reflection of their shared cultural
values. Each healthcare system has its own personality – like wine made
from grapes grown in the unique soil and climate of a specific region.
Even if you export the same vines to another place, the wine will never taste
the same. Let’s take a look at a few of these cultures (and yes I am
using somewhat stereotypical language to clarify the differences):
Americans
are fiercely individualistic. They are passionate, driven, and believe
that success is proportional to how hard you work. They believe in
survival of the fittest – if you’re not doing well, it’s probably your own
fault. Everything’s a competition, and capitalism spurs on a constant
parade of advertising, marketing, sales and consumerism, all orbiting the
almighty dollar and personal convenience. It’s critical to them that
anyone can attain the American dream – if they work hard enough. Fabulous
riches are within the grasp of any average Joe if he concocts a really good,
money-making business plan. Americans don’t have time for health prevention,
long vacations, taking care of others – no, they’re so busy working that only a
medical emergency will jar them out of their usual pursuits.
What
sort of healthcare system would grow out of this cultural milieu? A
hurried, high stakes, emergency intervention focused, technology driven
grab-all ruled by any stakeholder who can outsmart the competition.
Forget the poor, they’re not productive and don’t deserve equal care
really. But that financially successful “average Joe” will receive mind-blowing
technologically advanced care that costs hundreds of thousands of dollars and
can keep him alive long beyond any reasonable need to do so. Joe has a
shot at immortality, and somehow that makes all the work worthwhile. Yep,
that’s pretty much what the US
healthcare system is like.
Canadians
are good natured and tolerant. They put the needs of others first.
They will pull over in a snow storm to help you change a tire, and then they’ll
have a beer with you and talk about hockey at a local pub after towing your
vehicle out of the ditch. They will also wait patiently and without
complaint for hours on end in a line for tickets or groceries, or whatever the
line is for. There are so few people in Canada (compared to the land mass)
that nothing feels crowded or busy. Their socio-political views lean
strongly toward socialism –almost no one is really rich or very poor in Canada.
Everyone is treated with the same friendly respect, living comfortably, no real
crime or racial tensions. What sort of healthcare system would these
people invent?
A
socialized, government-run system that offers “free medical care” for all, with
insanely high taxes to cover it all. There are long lines, competent
doctors, and moderately satisfied patients.
The
French are argumentative and political. They tend to value
leisure above work, they don’t like rules imposed on themselves, and believe
that their government’s purpose is to serve their needs at all times.
They protest regularly, everything is unionized and everyone is focused
on personal rights and liberties. Employers are at the mercy of
government rules and employee whims. They work very little and expect
extensive social services, smoking cigarettes and drinking coffee, watching the
world walk by from neighborhood cafes. What sort of healthcare system
would these people want?
A
government-run, heavily social service oriented system that caters to a
leisurely lifestyle. Spa treatments, alternative medicines, herbalism all
thrive, but in order to keep people from overburdening the spas, copays for
many basic services run as high as 40% of the total bill.
So
the question is this: how would Americans respond to these other brands of
healthcare? If they were served up the Canadian system, they’d
scream at the tax rates, and become hysterical at the inability to trade up to
a platinum level of care for those who have “earned it.” They would not
accept the long lines for care and would immediately start a scheme for
off-shoring medicine to circumvent the lines.
If
Americans were offered the French system, they’d be immediately annoyed by the
inconvenience of the office hours (months of vacation are taken at a time by
all members of society, including doctors), they’d never use the preventive
health measures (they don’t have time for that stuff), and although they’d be
glad to receive home health aides for no more excuse than – “I just had a
baby and I’d like a government worker to clean my house” – when they saw the
tax rates it would take to make this available to all, they’d find it
unacceptable, especially with such high copays and out of pocket expenses..
So
socialized medicine will never work in the United States – not because it’s a
fundamentally flawed system, but because the American culture will not tolerate
it. Healthcare solutions are not globally applicable – (though I’d say
that from an IT perspective, there is an information sharing system that is
needed equally badly by all countries). Instead, systemic changes should
be personalized to the culture. Looking to other countries for magical
fixes to healthcare woes is like expecting that all cancers will respond to the
same chemotherapy regimen. Medical care is most effective when it is
customized to the individual, and healthcare reform will be most effective when
it takes into account the unique cultural values held by a country’s people.
In my next post, I’ll explain why health insurance companies
and big government health plans (Michael Moore’s solution to US healthcare
woes) share a common flaw.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
