August 14th, 2008 by Dr. Val Jones in Health Policy, News
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Methamphetamine (also known as “speed” or “meth”) is a fairly common drug of abuse in this country. The National Institute on Drug Abuse estimates that as many as 3% of 12th graders have tried the drug, and about 0.3% of the population actively abuses it. Meth stimulates the release of dopamine in the brain, which produces a feeling of intense well being, as well as increases in wakefulness, respiration, heart rate, blood pressure, and hyperthermia. It is very addictive, and its tragic, long-term effects include permanent brain damage, personality changes, psychosis, hallucinations, and impaired learning and memory.
While most meth is produced by “superlabs” in foreign countries, there are a substantial number of small, illegal labs in the US that produce it. Meth can be created by extracting pseudoephedrine (found in many cold and allergy medicines like Sudafed) and transforming it into meth via a chemical process that creates toxic environmental waste.
In order to clamp down on local production of meth, it is critical to control the diversion of pseudoephedrine from local pharmacies into illegal labs. The US government introduced a “Combat Meth Act” to improve the tracking of pseudoephedrine purchases, but some believe that this approach doesn’t go far enough. One successful anti-meth program in Australia (called the MethShield) is now being piloted in Kansas. I spoke with Shaun Singleton, the creator of MethShield, to learn more about how we can reduce meth production and sales in the US.
Dr. Val: Tell me about the Combat Meth Act and why it dovetails nicely with MethShield.
Singleton: The Combat Meth Act was introduced in 2005 and it has substantially reduced the number of meth labs in the US. The Act limits consumer purchase of pseudoephedrine to 3600mg of active ingredient per day (or 9000mg in a 30 day period). In order to purchase pseudoephedrine, you have to present a form of government-issued I.D. (like a driver’s license) and the pharmacist records that information and keeps it in a log book. However, since this information is not electronic, pharmacies don’t share information with other pharmacies, and so meth producers are able to present fake I.D.s and travel from one pharmacy to the next without anyone realizing that they’re over their legal limit. So unfortunately, people found a way to circumvent the Combat Meth Act and local production of meth continues to be a problem.
The MethShield is a real-time tracking program for pseudoephedrine sales. Instead of keeping paper records, it allows pharmacists to enter information into a secure online database. This makes it much more difficult for people to travel from pharmacy to pharmacy, purchasing their maximum allowed dose at each one. With MethShield the pharmacist knows exactly how much product the client has purchased in the past (from any participating pharmacy), and whether they’re eligible to purchase more or not. The information in the database is aggregated and made available for law enforcement to review.
Dr. Val: How do you protect patient privacy?
Singleton: First of all, you have to realize that we’re not interested in people who have a sinus infection, or use 50 Sudafed tablets per year. We’re talking about the 1% of people who are purchasing 20 packs of Sudafed in a day. Those people are the ones who are flagged by the MethShield system and are investigated by law enforcement.
The MethShield database offers superior privacy to current methods – which basically involve hand-writing peoples’ names in a binder and keeping it open on the counter top at the pharmacy (not very secure at all). MethShield was originally conceived and developed by the Pharmacy Guild of Australia and took great care to engineer the database in the most secure way possible. We ask for informed consent from clients and train pharmacy staff in how to maintain the database. In Australia we processed several million transactions during our pilot and did not receive a single privacy complaint. Most people are quite willing to give their driver’s license number to their pharmacist, understanding that the process might help to catch meth lab criminals.
Dr. Val: Can’t people just use fake I.D.s?
Singleton: We can’t stop people from using fake I.D.s, but the system renders them useless very quickly. Once you’ve entered one I.D. in the system to purchase 9000mg of pseudoephedrine, you generally can’t use it to buy more for another 60 days.
Dr. Val: Couldn’t the MethShield check the I.D.s against the DMV records to identify fake I.D.s more rapidly?
Singleton: Law enforcement officers can do this manually, but for privacy reasons the MethShield database does not connect to any other databases. Also, MethShield was designed to support pharmacists – so they can sell pseudoephedrine products safely – and it’s not really their role to be checking peoples’ I.D.s against a DMV database.
Dr. Val: What inspired you to create the MethShield?
Singleton: I’m married to a pharmacist and we live in Queensland, the once meth capital of Australia. I head a team that has devoted itself to creating IT solutions that make life easier for pharmacists, since they spend a lot of their time filling out forms to comply with government and insurance regulations instead of dispensing drugs and counseling people. We wanted to try to automate some of those processes to help pharmacists like my wife do what they’re really skilled at. We applied innovative thinking to kill two birds with one stone – to address the meth problem and free up pharmacists from some of their overly burdensome administrative tasks.
MethShield launched in November, 2005 and within the first 6 months of the program we were able to reduce the number of illegal meth labs detected by law enforcement by 23%. After 18 months we reduced the number of meth lab detections by 37%, and also had an increase in arrests and a number of charges raised. It’s really exciting to see such a visible impact.
Dr. Val: How are you planning to quantify the success of the program in Kansas?
Singleton: There will be 128 pharmacies in the pilot (as opposed to the 950 that we had in our Australian pilot program) and the success of the program really depends on the participation rate of the pharmacies. If they are careful to process all their transactions through the database we’ll get some meaningful data. Ideally we’d like to establish clear patterns of use and help the law enforcement agents to discern where the products are being abused. Law enforcement detected 97 illegal meth labs last year in Kansas, and we hope that the MethShield will further assist in the crackdown. If we can demonstrate the cost effectiveness of the program, we hope that Kansas will implement it state-wide.
*More about the MethShield*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 10th, 2008 by Dr. Val Jones in True Stories, Uncategorized
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A psychiatrist friend of mine (we’ll call him “Dr. X”) treats urban patients who have substance abuse problems and often live in homeless shelters. Here are some recent conversations that had me scratching my head:
Mr. P: [recovering from crack cocaine, alchohol, and heroin abuse] Doc, I’ve been feeling really depressed lately and the therapy sessions aren’t helping.
Dr. X: I know that we’ve done all we can to manage your depression conservatively. You may want to consider trying a small dose of an anti-depressant medication. It could really help.
Mr. P: [Eyes bulging, jaw dropped] But, Dr. X, those anti-depressant medications might affect my MIND!
***
Dr. X: Ms. P, why aren’t you taking your prenatal vitamins?
Ms. P: [actively smoking crack while pregnant] I don’t trust that stuff. I think it could harm my baby.
***
Dr. X: Ms Y, I know you’ve been struggling with pain related to your broken leg. Why not let me prescribe some pain medications for you?
Ms. Y: Oh, no – I don’t want any prescription medicines. I don’t trust those.
Dr. X: Well how are you going to manage your pain, then?
Ms. Y: My sister has some pills that I take.
Dr. X: What pills?
Ms. Y: Darvocet and Vicodin.
***This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 8th, 2008 by Dr. Val Jones in News
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Thanks to Dr. Deb for highlighting two interesting psychology research studies which offer new insight into lie detection. The first was conducted at my undergraduate alma mater, Dalhousie University, in Nova Scotia. After analyzing 697 videos of people reacting to emotion-evoking photos, researchers concluded that study subjects who tried to modify the natural response to a cute or alarming photo still retained flickers of the real emotion in their facial expressions. These “microexpressions” were identifiable by computer analysis of facial muscles, and may support the development of a new type of lie detector – a digital, facial expression analyzer.
The second research study found that people are less accurate in recounting false stories backwards than they are at describing a reverse chronology of true events. In other words, discerning truth from error may be as simple as asking someone to tell you what happened beginning at the end and working backwards. If they have a really difficult time keeping the facts straight – they are more likely be falsifying the information.
I don’t know if either of these lie detecting approaches (analyzing microexpressions or backwards story telling) will work on sociopaths and exceptionally good liars. But for the garden-variety fibber, they may just work.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 18th, 2008 by Dr. Val Jones in True Stories
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This alarming story (h/t KevinMD) of a physician attacked by a drug-seeker reminded me of my intern year. I worked in an inner city hospital in New York, and was scheduled to work in the “detox unit” for a full month. We interns had mixed feelings about our “detox month” – on the one hand, the patients were generally healthy and were unlikely to need blood draws, procedures, spinal taps, intubations, and such. This meant less work to do during our shifts. On the other hand, the patients were hardened drug users, often with a history of violence — and let’s just say that depleting the system of all the heroin, crack, alcohol, and various other substances didn’t tend to put them in the best mood.
I personally did not enjoy my detox month. I’d prefer a “crashing” ICU patient any day over a beligerant, hep C positive man trying to threaten me into giving him an additional dose of colace. And frankly, as a woman it was kind of scary to be around these guys. I never knew if they were going to snap, and no matter how many security guards are around, a lot of damage can happen in the 60 seconds or so it takes them to get to you.
One night the “detox resident” appeared for duty. His shift started at 11pm and the day shift nurses were eager to get home. The security guards were changing shift as well, and had not entered the lock-down area inside the unit. The resident went in alone. Suddenly, one of the patients snapped, and grabbed the unsuspecting doctor by the throat. The patient threw him up against the wall and punched him in the face, breaking his nose and fracturing his eye socket. Blood flew everywhere and the resident tried to fight back to defend himself. Unfortunately he was no match for the 250 pound patient, and sustained a few kicks to the ribs before the security guards were able to subdue the man. The resident was transferred off the detox unit rotation and given an extra week of vacation. I was the intern who was asked to fill in for him.
I felt somewhat paranoid that month, and refused to be inside the lock down area without a security guard within 15 feet of me. Fortunately, I was not physically attacked – I only experienced verbal abuse and the occasional very awkward conversation about genital deformities.
But it was a real wake up call for me – medicine can be a risky business, and white coats do not protect against psychotic aggression. I guess it’s just one of the risks we take in caring for all-comers.
***
Addendum: here’s another example of doctors being abused by narcotic-seekers.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 8th, 2008 by Dr. Val Jones in Expert Interviews
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With the recent news about the high prevalence of Post Traumatic Stress Disorder (PTSD) in military veterans returning from Iraq and Afghanistan, I decided to interview Revolution Health’s expert psychiatrist, Dr. Ned Hallowell, to find out more about PTSD and what to do about it.
*Listen To The Podcast*
Dr. Val: What is post traumatic stress disorder (PTSD)?
Dr. Hallowell: As the name implies, it is the response a person has to any traumatic experience or event. The brain really changes in response to trauma, and people can be quite crippled by it. Some will actively avoid people and situations that remind them of the event, others experience “triggers” that set them off into a panicky or dissociated state. PTSD can cause “flashbacks” where people feel as if they’re right back at the scene of the incident, they may also have nightmares or problems with relationships, job function, substance abuse, major anxiety or depression and even suicide.
PTSD exists on a spectrum. You can get fired from your job and experience mild trauma, but if the firing was really unfair and unexpected it can change you fundamentally for years to come. It isn’t the actual event that determines whether or not a person develops PTSD, it’s how you –given your particular neurochemistry and genetics – are able or not able to assimilate, accommodate, and deal with the traumatic event.
Dr. Val: How does a person know if they have PTSD?
Dr. Hallowell: If something terrible has happened to you and you’re not able to calm down, put things into perspective or get back to your old self – then you may have PTSD. Instead of getting your equilibrium back you’re rattled, anxious, and sleeping poorly. Fear builds on fear and you can even become afraid of life itself and begin withdrawing, avoiding, and shutting down, and self-medicating.
What you want to do is “name it” – in other words allow yourself to consider that you may have PTSD, and then get professional help. A mental health professional who specializes in PTSD is ideal. Dr. Bessel van der Kolk has written several excellent books on the subject.
It’s also worth noting that people can get vicarious PTSD. There have been cases where practitioners have developed PTSD simply by listening to accounts of trauma.
Dr. Val: Is early intervention important?
Dr. Hallowell: This is controversial. Some people believe that it’s important to talk about the event right away, but I’m of the belief that people should remain connected to others but not be required to talk about it until they’re ready. I could see someone after a mugging or car accident and never talk about the event – my role is just to create a “safe place” for them to be. Later on we might talk about it, or we might not. Discussing the details of a traumatic event can retraumatize you – and in a funny way you can develop a habit of reliving the trauma, almost the way that people become addicted to worry. However if the patient wants to talk about the trauma, that suggests to me that they need to – and I let them be the guide.
Dr. Val: What happens if PTSD is not treated?
Dr. Hallowell: It can wreak havoc on people. “Avoidance” as a lifestyle is very incapacitating. If you can’t go places and do things, you’re feeling anxious all the time, and having nightmares and flashbacks, you can’t enjoy life.
Dr. Val: Can PTSD be prevented? In the case of soldiers, for example, who are likely to experience horrible things in times of war – can they be mentally prepared for this kind of thing?
Dr. Hallowell: Part of what makes trauma traumatizing is that it’s unexpected. So it makes intuitive sense to me that if you’re prepared for what you’re going to see or experience that you will find it less traumatic when it happens. The surprise and lack of control are what’s overpowering about trauma. Having a plan (knowing what to do in case of a traumatic event) and knowing what to expect afterwards (and how to get help) will go a long way in reducing the damage of trauma. You can still be traumatized, however, even if you’re “ready” for it.
Dr. Val: Tell me a little bit about kids and PTSD. Do they express PTSD differently?
Dr. Hallowell: In children, the dissociative state is pretty common – they become vacant and unreachable. Sometimes the opposite happens and they are inconsolable, experiencing night terrors, crying, and temper tantrums. However, kids are remarkably resilient and I’ve seen play therapy work wonders for them after traumatic events.
For example, four-year-olds might sit on the floor and not talk to me at all about the trauma they’ve been through, and the next thing you know they’re reenacting the scene with their toys and dolls. They have no idea that they’re replaying the event this way (a form of “displacement”) – and may do it over and over again for a period of six weeks… and the next thing you know they’re over it. It’s remarkable. They use their imagination to heal themselves. It’s the greatest therapy in the world. No medication is used, and it’s a permanent fix. It’s almost like doing psychoanalysis at the point of the childhood trauma. When you’re 40 you try to relive these experiences in analysis to resolve the conflict – but as a child you’re actually doing the work near the time of the incident.
Dr. Val: What’s the most important thing for families to do for loved ones who have PTSD?
Dr. Hallowell: Connect with them. Understand them, listen to them, and don’t let them get isolated. Take their concerns seriously, and don’t judge them. Then find out what they need and get them to a mental health professional who understands PTSD.
*Listen To The Full Conversation Here*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
