Tuesday, March 26, 2019

Life changing or a disappointment?

Jet lag is a big topic of conversation here this week as faculty and students return to the campus after a long holiday. It’s understandable. When we travel long distances across several time zones, few of us can survive the trip without feeling a little out of whack. Those flying back from the west coast or overseas may be dogged by the symptoms of jet lag — fatigue, insomnia, digestive upsets, and headaches — for several days as they get back to work. According to Dr. Charles A. Czeisler, director of the Division of Sleep Medicine at Harvard Medical School, jet lag is due to a misalignment between the external environment and the internal clock in the brain that drives our daily performance, alertness, and ability to sleep.
What happens during jet lag

An internal master clock — a cluster of 20,000 neurons in the brain just above the optic nerve — controls our circadian rhythms. In response to light and other cues from the environment, it coordinates the functions of different body systems over a 24-hour period and regulates when we sleep and wake. As the environment changes, our internal clock uses environmental cues to gradually reset itself, at an average rate of an hour a day. If you cross several time zones within a matter of hours, there isn’t enough time for your internal clock to synchronize your body with the new time zone.

Say you take an 11-hour flight from New York City to Honolulu. Your plane leaves at 6:00 a.m. and lands at 11:00 a.m. Honolulu time. You may have gained half a day to spend on the beach but you may not have the energy to enjoy it. Your body is still on New York time, where it’s 5:00 p.m., so it’s beginning the wind-down to bedtime. It will be five or six days before your body is on Honolulu time.
Minimizing jet lag

If you have a few business trips or winter getaways on your calendar, you may be able to minimize the effects of crossing time zones by giving your internal clock some helpful cues. If your destination is only a zone or two away, you may just need to make minor adjustments, like eating meals, going to bed, and awakening a little earlier than usual (if you’re traveling east) or a little later (if you’re heading west). If you’re crossing several time zones, you may want to try the following:

    Gradually switch before the trip. For several days before you leave, move mealtimes and bedtime incrementally closer to the schedule of your destination. Even a partial switch may help.
    Stay hydrated. During the flight, drink plenty of fluids, but not caffeine or alcohol. Caffeine and alcohol promote dehydration, which worsens the symptoms of jet lag. They can also disturb sleep.
    Switch your bedtime as rapidly as possible upon arrival. Don’t turn in until it is bedtime in the new time zone.
    Use the sun to help you readjust. If you need to wake up earlier at your destination, get out in the early morning sun. If you need to wake up later, expose yourself to late afternoon sunlight.

A quick fix for jet lag?

In 2009, Dr. Clifford Saper and colleagues at Harvard-affiliated Beth Israel Deaconess Medical Center identified a second “master clock” in mice that can regulate circadian rhythms when food is scarce. In essence, the body’s circadian rhythms are suspended to conserve energy.

It’s been theorized that humans may have a similar mechanism and that a brief fast may trigger a quick reset of circadian rhythms. Dr. Saper has suggested a 12-to-16-hour fast the day before and during travel. For example, if you were to take a flight from New York City to Honolulu, you would refrain from eating for a couple of hours before takeoff and during the flight, but would have a good meal as soon as convenient after landing. This technique hasn’t been tested in clinical trials, but there are many testimonials to its effectiveness in the media.

If you want to try this, it’s a good idea to check with your health care team to see if fasting is advisable for you. And you will still need to drink water — not caffeinated beverages, juice, or alcohol — during your flight. The American Congress of Obstetricians and Gynecologists (ACOG) recently put out a new Committee Opinion, “Immediate Postpartum Long-Acting Reversible Contraception.” I counsel all my pregnant patients about the option of immediate postpartum birth control in the form of IUDs and implants, both of which are long-acting, reversible contraceptives (LARC). The contraceptive implant goes in your arm, and IUD is placed inside your uterus. Immediate postpartum contraception refers to placement of LARC in the period between delivery of a baby and the time a new mother leaves the hospital.

Many women are aware that IUDs and implants are highly effective, safe, and forgettable methods of birth control, including for adolescents. What is less well known is that they are also a convenient and effective option for immediate postpartum contraception. Placing them right after the birth of a baby in the hospital streamlines women’s access to contraception, reduces the hassles of appointments in the weeks and months following birth, and lowers the risk of unintended pregnancy and pregnancies that occur sooner than planned. ACOG has long supported efforts to promote education around, access to, and actual use of LARC. However, this is ACOG’s first clinical opinion specifically dedicated to immediate postpartum LARC.

Unfortunately, in Massachusetts, where I practice, hospitals take a financial loss whenever we provide immediate postpartum LARC, because insurance payments for the birth of a baby are bundled, which means we get one fee regardless of how many services are provided. The device and procedure are covered by most insurers, public and private, in an outpatient clinic, but are not reimbursed in addition to the global fee for delivery of a baby, if provided while the mom is in the hospital for delivery. We need to lead the way with payment reform for immediate postpartum birth control to change this.

While many women may plan to start using birth control at their six-week postpartum checkup, up to 40% of women do not attend a follow-up appointment, and so never obtain a reliable birth control method. But even for women who do go to the routine six-week postpartum follow-up visit, ovulation can occur as early as three weeks after birth and can result in pregnancy. The early days with a new baby are a busy, exhausting, and often stressful time. Having LARC inserted before leaving the hospital takes one thing off the list. There is no worry about scheduling an appointment or getting to the doctor’s office. The one downside is that IUDs placed right after birth are slightly more likely to be expelled compared to those placed at the six-week visit. Yet many women still find that the advantages of insertion before leaving the hospital outweigh the disadvantages.

Access to and effective use of contraception is the critical foundation for empowering women, improving health outcomes, and saving money. Advocating for expansion of immediate postpartum contraception is essential to reduce unintended pregnancy and rapid, repeat pregnancy rates. Several states have changed their insurance reimbursement policies, but Massachusetts is not one of them. Massachusetts is the state that led the way in health care reform, and we need to join other states that are already taking the lead in further improving reproductive health care by adding insurance coverage for immediate postpartum contraception. It makes no difference that effective depression treatments exist if you don’t have access to them. Increasing the availability of behavioral treatments is a key challenge for the field of mental health care. A recent study has just suggested a way to do this. The research was published in The Lancet.
Cognitive behavioral therapy (CBT) and behavioral activation (BA)

Cognitive behavioral therapy (CBT) is the most researched non-medication treatment for depression. It’s been shown to be effective, yet access to CBT is limited. One reason is that there are not enough well-trained clinicians (usually psychologists, social workers, and psychiatrists) to meet demand. And, training clinicians well is expensive. The upshot is that if you do have access to CBT, it is costly — either to you or your insurance company. Is there an alternative to CBT that could be more available and less costly to the system and individuals?

Researchers at the University of Exeter in Great Britain examined the effectiveness and cost of just such an alternative. It’s called behavioral activation (BA) and its focus is on actions — getting back to doing enjoyable activities as well as those that offer the opportunity to achieve a goal or improve a skill. BA also addresses the avoidance of certain activities (read: procrastination) that, when a person can actually do them, have an upside — for example, meeting new people or trying new activities. CBT involves changing behaviors, too (the “B” part). But, part of the process includes evaluating our thoughts, or cognitions (the “C” part), to see if we’re viewing ourselves, other people, our future, and the world around us accurately. Patients learn to challenge negative thinking — not to fool themselves into thinking everything’s okay, but to look at things more objectively.

A big difference between CBT and BA is that it’s easier to provide BA. Paraprofessionals can offer BA, whereas you need clinicians with more — and therefore more expensive — training to provide CBT.
Comparing behavioral activation and cognitive behavioral therapy

In this study, BA worked equally well as CBT (it was “non-inferior” to CBT), and was 21% less expensive because the providers were less expensive. The good news is that this form of depression treatment works as well as CBT, and is more affordable; therefore it should become available more broadly.

Here’s how the study worked. In just five days, the research team trained junior mental health workers to deliver BA. These workers had no prior training in mental health interventions. They also recruited therapists with extensive training in CBT and gave them a five-day workshop to ensure they would all follow the same CBT approach to depression treatment. (In this study, the CBT approach emphasized the “C” — cognitive therapy.) Investigators went on to ensure that all the providers (BA and CBT) were delivering the therapies correctly.

Study participants included 440 patients with major depressive disorder (that’s a large sample). Half received BA and half received CBT — 67% of the BA and 72% of the CBT patients completed at least eight sessions (a good completion rate). Twelve months after they started treatment, approximately 80% of patients in both groups no longer met the criteria for having major depressive disorder. That’s an encouraging success rate for both forms of therapy.

One caveat about this study was that there wasn’t a “no treatment” comparison group, so we don’t know how many patients would have improved on their own. But what’s especially interesting is that 78% of the participants were taking antidepressant mediOpioid drugs help relieve pain by sticking to opioid receptors in the body, which in turn, helps block “pain signals.” The umbrella term “opioids” includes prescription painkillers, such as hydrocodone (in Vicodin) or oxycodone (in Percocet), as well as heroin. These drugs not only ease pain and cause pleasurable feelings, but also can depress breathing — take too much and a person can stop breathing altogether and will die without quick treatment.

Unintentional overdose is now the leading cause of accidental death in the United States. As more Americans are prescribed opioids for chronic pain, these medications increasingly find their way into the community. This has led to a rise in the non-medical use of these drugs.  In 2014, 10.3 million people reported taking prescription opioids that were not prescribed for them, or for reasons other than the condition the medication was intended to treat. As a result, emergency department visits related to the misuse of prescription opioids have tripled, and deaths related to prescription opioids have quadrupled since the early 2000s.

We desperately need ways to prevent these accidental deaths.
What is naloxone?

Naloxone, also called Narcan, is a medication that immediately reverses the effects of opioids in the brain. As a result, it can rescue someone from an overdose instantly. It can be given as a nasal spray or a muscular injection (like an Epi-pen used for severe allergic reactions). Its use among people who use illegal opioids has reduced the number of deaths due to overdose. Anyone with a minimal amount of training can give the naloxone, and it won’t cause harm if given to someone who has not taken opioids. Early on, there were concerns that the availability of naloxone might increase opioid use. That has not turned out to be the case, in part because the drug causes an unpleasant sensation of withdrawal when given to someone who has used opioids. Naloxone programs have proved successful, but they typically are intended for people who use non-prescribed opioids.
Can naloxone help protect people taking prescribed opioids?

But people who use opioids prescribed by their doctors are also at risk of overdose. Is there a role for naloxone serve as a safeguard for these patients?

A recent study in the Annals of Internal Medicine explored the potential benefits of prescribing naloxone along with opioids — an approach called “co-prescribing.” Here’s how it works. Providers educate patients who take opioids for chronic pain about the risks of overdose and teach them how to use naloxone. And then prescribe both drugs at the same time.

In this study, researchers trained staff at six clinics in the San Francisco area on how to co-prescribe opioids and naloxone. They then looked at how often naloxone was actually prescribed, whether co-prescribing translated in fewer emergency department visits related to opioids, and whether the dose of prescribed opioids changed. Here’s what the study found:

    When providers were trained in this approach, the number of naloxone prescriptions increased. So doctors seemed willing to co-prescribe.
    Patients who were on higher dosages of opioids or had been to the emergency department in the past year because of opioids were more likely to get prescribed naloxone.
    Compared to the people who did not receive a naloxone prescription, those who did had 47% fewer emergency department visits per month in the subsequent six months.
    Receiving naloxone had no effect on the dose of prescribed opioids.

Putting the results into action

The results of this study suggest that naloxone may help curb the potentially devastating risks of opioid misuse — and that doctors are willing to prescribe it along with opioids.

There’s more encouraging news. Co-prescribing seems like a viable option. A relatively brief training for providers was enough to result in a third of patients on opioids for chronic pain receiving a naloxone prescription. The fact that those on higher dosages and with previous ER visits were more likely to get a prescription likely means that providers were particularly willing to co-prescribe to patients they perceived to be at high risk. However, doctors appeared less likely to co-prescribe for their elderly or black patients. Given that overdoses occur among all ages and ethnicities, this is a concern and highlights the need for more uniform protocols to ensure naloxone is made available to all patients at risk. The reduction in emergency visits is particularly interesting and may be due to the positive effects of simply talking explicitly about overdose and medication risks. It could also be because having naloxone on hand meant patients didn’t need to go to the emergency department for an overdose.

Given the relative safety of naloxone and the death toll from opioids across this country, co-prescription of naloxone with opioid pain medication makes a lot of practical sense. Any opportunity to discuss the risks of opioids, how to identify and respond to an overdose, and how to use naloxone is beneficial. These discussions are important not just for patients taking opioids for chronic pain, but also for their friends, family, and community members.

With greater availability of naloxone, anyone can save a life.cations and were still depressed before the study. These volunteers also averaged six to seven prior episodes of depression. That suggests that they probably would not have improved much without the BA or CBT.

Overall, this study is exciting because it suggests ways to treat depression that can reach the many people who need treatment but are having trouble getting it. While there are more than 100 types of arthritis, osteoarthritis is by far the most common. It’s the age-related, “wear-and-tear” type of arthritis that affects almost everyone fortunate enough to live a long life, affecting up to 80% of older adults. Fortunately, symptoms may be mild. But for those in whom symptoms are severe, treatment can make a big difference.
So what can be done for osteoarthritis?

The available treatments for osteoarthritis include:

    Non-medication approaches, such as physical therapy, loss of excess weight, or use of braces or a cane
    Complementary and alternative treatments, such as acupuncture, massage, or tai chi
    Medications, such as pain relievers, anti-inflammatory medications, or cortisone injections
    Surgery, such as knee or hip replacement.

Surgery is usually a last resort. But for severe osteoarthritis, it’s often the only option likely to make much difference. In the United States alone, more than 600,000 knee replacements and 300,000 hip replacements are performed each year; and predictions are that these numbers will rise dramatically in the coming decades.
And just how good is joint-replacement surgery?

Most articles about joint replacement surgery (and the surgeons who perform them) make statements such as: “The vast majority of patients who have their knees replaced are markedly improved” or “More than 80% of people who have their hip replaced are glad they had it done.” While these statements are generally quite true, there is still a significant number of people who get less than they expected from the surgery. Part of the disappointment may be because their expectations were too high.

Two recent studies analyzed the question of how good knee replacement surgery is — but not from the surgeon’s perspective. These studies surveyed patients directly. After all, joint replacement surgery is intended to reduce pain and improve function, so it’s the patient’s perspective that counts! Here’s what they found:

    A 2014 study enlisted an independent survey center to interview individuals after knee replacement surgery. While 90% were satisfied with the function of their new knee, about one-third reported that their knee did not feel “normal.” Up to one half reported at least some continued symptoms or trouble with function. The authors noted that some of the “cutting edge” advances in knee replacement surgery — such as the use of computers to more accurately align the new joint — did not seem to improve these numbers much.
    A 2015 study compared people who had knee replacement surgery with those who were also good candidates for surgery but had not yet had it. Those having surgery reported better pain control and better function after one year than those treated non-operatively; however, those having surgery had far more complications, such as blood clots in the leg veins.

Is joint replacement right for you?

These studies show that we still have a way to go when it comes to the treatment of osteoarthritis. Even the most “definitive” treatment — surgical joint replacement — has significant limitations. But I think another message in these studies is that if you are considering joint replacement surgery it’s important to know what to expect:

    It’s a big operation with a significant recovery time.
    There are some important risks.
    There’s a reasonable chance your knee will not feel completely “normal” afterwards.

Still, for many, having a severely arthritic joint replaced allows them to walk with far less (or no) pain and to have a dramatically improved quality of life. No, it’s not perfect. But for most people who need it, joint replacement is far better than the alternatives.

No comments:

Leave a comment