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The Puzzling Popularity of Back Surgery in Certain Regions

https://mobile.nytimes.com/2017/02/13/upshot/medical-mystery-why-is-back-surgery-so-popular-in-casper-wyo.html

You might think that once drugs, devices and medical procedures are shown to be effective, they quickly become available. You might also think that those shown not to work as well as alternatives are immediately discarded.

Reasonable assumptions both, but you’d be wrong.

Instead, innovations in health care diffuse unevenly across geographic regions — not unlike the spread of a contagious disease. And even when studies show a new technology is overused, retrenchment is very slow and seemingly haphazard.

Back surgery is a great example. In the early 1990s, when John Wennberg’s Dartmouth Atlas of Healthcare first started tracking treatment rates among older Medicare users, back surgery was relatively uncommon; 1992 rates were as low as one case per thousand in cities as diverse as New York and Johnson City, Tenn.

By 2006, average rates of back surgery had increased to 4.9 per thousand. The procedure had spread rapidly across the Northern Plains and Mountain States. Growth was especially significant in certain cities elsewhere — like Lubbock and Harlingen, Tex. Yet rates in New England and some parts of the Midwest had barely budged.

Even as back surgery’s popularity as a treatment for back pain began to rise in the 1990s, there was little solid evidence of its effectiveness. It wasn’t until 2006 that the first large randomized trial on the subject was published.

That study showed relatively modest benefits of surgery for many conditions that lead to back pain. While many patients felt better after a year, so did a nearly equal proportion of people in the control group who didn’t have surgery. However, years before that evidence was available, some regions had adopted back surgery at a high rate, while others had not.

The rates of back operations performed in hospitals began to flatten after 2006, but little was known about growth in the treatment in outpatient clinics, the same-day facilities with greater convenience and lower costs. Recently, Brook Martin and Sandra Sharp, two Dartmouth researchers funded by the National Institute of Aging, tracked outpatient as well as inpatient procedures through 2014. The finding: Rates of Medicare back surgery had grown 28 percent since 2006, with no decrease in regional variations; rates in 2014 ranged from 3 per 1,000 in the Bronx to 11.5 per 1,000 in Casper, Wyo.

The puzzling thing is why back surgery became more popular in certain broad regions, but not in others. Why, for example, did rates grow so rapidly in the Northern Plain states while rates in New England barely budged?

Our best guess comes from a study by Harvard and Dartmouth researchers, not on back surgery, but on cardiac treatments. It found that regional variation in Medicare spending is associated with variation in physician preferences for intensity of cardiac treatments, and to a greater degree when the evidence is ambiguous. Patient preferences exerted almost no influence. It’s likely that the pattern holds for back surgery, too, though it has not been studied in the United States.

It’s tempting to conclude that there are simply regions where the intensity of care of all types is higher — that some regions invest in all of the latest shiny technologies, while others don’t. This is too simple; Miami and McAllen, Tex., the two most expensive regions in the United States for overall Medicare spending, also clock in with among the lowest spine surgery rates. Instead, we see what Mr. Wennberg calls a surgical signature: Casper Wyo., has the highest back surgery rate in the country, but its cardiac bypass surgery is well below the national average.

This puzzling pattern once again points toward idiosyncratic physician beliefs. Orthopedic surgeons in a particular hospital may be more aggressive, while the cardiologists there are less so.

Though we can’t say this is the answer with 100 percent certainty, we can rule out some other explanations. One is how much surgeons are paid. Since Medicare pays the same price for the procedure (adjusted for cost of living) across the country, prices can’t explain the paradox. The high rates in Denver could also be explained by back pain sufferers who flock to star surgeons and well-known hospitals there, but this doesn’t hold water either. The way the statistics are compiled, if a medical tourist traveled from Des Moines to Denver, the Medicare record keepers would assign that operation back to the tourist’s home in Iowa.

Maybe it’s differences in health. Perhaps areas with rapid growth in back surgery were those where more people had back pain. Yet northern New England retirees had similar histories of hard physical labor in farming, lumbering and manufacturing, and were no more affluent than their counterparts in the Northern Plains states.

Another explanation might be that patients prefer surgery in some regions of the country. One study observed large variations in back surgery across small regions in Ontario, but these weren’t explained by patient preferences. That study, like others, found physician beliefs about the benefits of surgery were associated with surgical variations.

If physicians are driving back treatment choice, even for procedures not supported by evidence, what can be done? One approach is to provide patients with unbiased information about the potential benefits and risks of back surgery relative to nonsurgical therapy so they can make informed choices. But the concern remains that for people in intense pain, when the doctor says that “I get good results with surgery, and my patients generally feel much better,” the back surgery option, with little out-of-pocket cost, will be hard to resist.

Another option is for hospitals or insurance companies to audit outlier physicians, as in a recent example of a back surgeon with a pattern of unusually high billing. In his audit, nine of 10 procedures were deemed not medically necessary.

A third option is to push people toward high-quality back surgery centers. Walmart created a network of high-quality spine centers for its employees that includes Virginia Mason Hospital in Seattle and the Mayo Clinic. It charged hefty co-payments to anyone getting surgery outside the network. The company found about a third of referrals didn’t need back surgery.

Often discussed, the big challenge in health care is to reduce spending by cutting wasteful care. It seems just as important, though, not to let more waste creep in as it did with back surgery. Once it spreads widely, it’s very hard to undo.

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The Walgreen’s employees/ pharm. tech at plank rd.

https://www.complaintsboard.com/complaints/walgreens-the-employees-pharm-tech-at-plank-rd-c847315.html

I am extremely upset and embarrassed with the way the pharmacy tech has treated me this has been a second time she has discriminated against me due to my mental health med I’m on . She 2 months ago gave me a hard time about billING my insurance for 2 pills a day for a 30 day period. She tried to tell me I had to pay cash for the whole amount because she wouldn’t bill it for part of prescription she tried to say that’s frauding the imsurance. So I contacted my insurance company and the lady said she had never heard of such a thing and that medicaid or VA premiere have limits on what they cover for many and all pharmacists and techs. should know that they have to bill it for whatever portion is covered she called in and demanded they stop trying to make me pay out of pocket for the whole prescription when I am covered and approved for 60 a month at 2 a day. so she ran it through and I got my medicine. then 2 months later the same tech that humiliatese and talks to me as if below the rest of the customers decided to pull the same trick again and told me they cant bill it for 2 a day. I explained that they have been billing it for 2 a day for last 4 months and why can’t they look into history where evenu insurance called and forced them to do a partial bill. for what’s approved. She then tried to tell me she did it and when I left it was only 2 in the bottle so me and my 2 year old returned after waiting an hour already and went through drive through and was explaining to them they were supposed to fill 60 and bill it for 2 a day. The same tech came back and said no we can’t and won’t bill them for 2 a day I said then why did u sat okay and give me 2. Then a very young looking kid that was an assistant mangager came to the window and said very rudely we aren’t going to bill it for 2 a day and now that u got 2 you have to come back tomorrow to get the reat I asked nicely if they can cancel it or call the insurance company and let them know they made a mistake he said hold on so I sat there with my 2 year old crying at this point after all this time and he had me waiting at the window with people mad behind me I Was about to pull off to go inside but he saw me and cane back to the window and said just wait sorry it’s taking so long it’s almost done so I said fine. then 5 minutes later a police officer pulls up beside me and says I was Called because u were holding up the line I said areally u kidding me I was told to stay here that he was checking on something and they never once asked me to come in. I tried to pull off to come in but he stopped me and said wait were almost done and apologized for taking so long. so the officer could see they weren’t making sense he walked me inside and I said not one person asked me to come in and not one person spoke up and said yes I did so he said he could see I was telling the truth sense not one person could say they did. I was humiliated and treated cruel. as they were laughing after he said just wait I’m almost done because they knew he was trying to keep me there for the officer he called. and after 30 min there with officer my doctors office was furious they were treating me like this yey once agsin. so she called the pharmacy and spoke to tech and said this is ridiculous your shift is treating her wrong and it is just because the medicine she is on. She said I should be treated the same as an old lady picking up her blood pressure medicine. She told her she made the mistake why doesn’t she call the insurance and fix. it. well she acted as though she would to her and the officer and then once the officer left she made me wait 45 minutes while on phone with the pharmacy side of insurance trying to find any way out of filling this medicine.trying to find a loop hole to get out of filling it. so I finally saw she wasn’t going to fill it and left with my baby. The next day I called in and it was a different shift but one tech was there that was there the day before and he apologized for how they treated me he said it was wrong and he said yes I will run it through for 2 a day as we are supposed to and I walked in and got my medicine and left well I went back to the store and was told by the assistant manager that was laughing and tricking me to wait in line for police . that I was banned from store I asked why he said because your doctors office was to our staff and u we had to call the police on. I said for no reason and the officer left because he could see were being. ridiculous and u had no right to call the officer when u made me WA it in line and never asked me to come inside . so I asked to speak to general manager he said yes are banned because the tech said they asked u to come inside I said are u kidding me they all agreed and Noone said to the officer that because it isn’t true. but they lie to you to ban me . I asked if he’d listen to the recording or speak to tell officer to prove none asked me to come in and he said no our decision i’s made we are banning u so I left with tears in my eyes hurt that they would treat me this poorly because of my medicine I take and my disabilities. my number is 5403889271. my email is charitylbrown7899@gmail.com. please do something about this it’s not right and extremely prejudice against the ones with disabilities.

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Noninvasive treatment for low back pain: a new clinical guideline from ACP

http://www.clinicaladvisor.com/pain-management-information-center/acp-guideline-for-noninvasive-treatment-of-low-back-pain/article/638322/

The American College of Physicians (ACP) has released 3 recommendations regarding the noninvasive treatment of acute, subacute, and chronic low back pain in a clinical practice guideline published in the Annals of Internal Medicine.

The ACP developed the guideline from randomized, controlled trials and systematic reviews published through April 2015 that focused on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. The agency evaluated outcomes including reduction or elimination of back pain, improvement in back-specific function, improvement in health-related quality of life, reduction in work disability, number of back pain episodes, patient satisfaction, and adverse events.

Recommendation 1

The ACP recommends that clinicians and patients should select nonpharmacologic treatment with superficial heat to treat acute or subacute low back pain, given that this pain usually improves over time. Clinicians can also treat acute or subacute pain with massage, acupuncture, or spinal manipulation. Nonsteroidal anti-inflammatory drugs or muscle relaxants should be selected if pharmacologic treatment is required (Grade: strong recommendation).

“Clinicians should reassure patients that acute or subacute low back pain usually improves over time, regardless of treatment,” the study authors wrote. “Thus, clinicians should avoid prescribing costly and potentially harmful treatments for these patients, especially narcotics. In addition, systemic steroids were not shown to provide benefit and should not be prescribed for patients with acute or subacute low back pain, even with radicular symptoms.”

Recommendation 2

For patients with chronic low back pain, the ACP recommends that patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction. Other treatments include tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (Grade: strong recommendation).

Recommendation 3

The ACP states that clinicians should consider pharmacologic treatment in patients with chronic low back pain who have an inadequate response to nonpharmacologic therapy, using nonsteroidal anti-inflammatory drugs as a first-line therapy or tramadol or duloxetine as a second-line therapy.

The agency notes that opioids should only be considered as an option in patients who have failed the other treatments, and only if the potential benefits outweigh the risks. Clinicians should discuss the known risks and realistic benefits of opioid use with their patients (Grade: weak recommendation, moderate-quality evidence).

“Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as TCAs [tricyclic antidepressants] and SSRIs [selective serotonin reuptake inhibitors],” the authors concluded.

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https://www.facebook.com/12news/

Sent to me from a chronic painer !!!

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UnitedHealth Sued By U.S. Government Over Medicare Charges

http://www.foxbusiness.com/features/2017/02/16/unitedhealth-sued-by-u-s-government-over-medicare-charges.html

The U.S. Justice Department has joined a whistleblower lawsuit against UnitedHealth Group Inc that claims the country’s largest health insurer and its units and affiliates overcharged Medicare hundreds of millions of dollars, a law firm representing the whistleblower said on Thursday.

“We reject these more than five-year-old claims and will contest them vigorously,” UnitedHealth spokesman Matthew Burns said in a statement.

The lawsuit, filed in 2011 and unsealed on Thursday, alleges UnitedHealth Group overcharged Medicare by claiming the federal health insurance program’s members nationwide were sicker than they were, according to the law firm Constantine Cannon LLP.

The Justice Department has also joined in allegations against WellMed Medical Management Inc, a Texas-based healthcare company UnitedHealth bought in 2011.

The lawsuit by whistleblower Benjamin Phoeling, a former UnitedHealth executive, has been kept under seal in federal court in Los Angeles while the Justice Department investigated the claims for the past five years. Constantine Cannon posted the lawsuit online when it was unsealed on Thursday. (http://bit.ly/2lQTOh8)

No total damages were specified in the lawsuit.

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China May Have Solved A Serious Drug Problem For The US

http://dailycaller.com/2017/02/16/china-may-have-solved-a-serious-drug-problem-for-the-us/

China has decided to ban an extremely lethal substance contributing to the deaths of numerous American drug users.

The National Narcotics Control Commission announced Thursday China will add carfentanil and three other synthetic opioids to its list of controlled substances March 1. In addition to carfentanil, the country plans to ban the sale of the less potent furanyl fentanyl, acryl fentanyl, and valeryl fentanyl.

The U.S. has been pushing China to blacklist carfentanil for years.

Carfentanil is a synthetic opiate that has been the subject of chemical weapons research and is used to tranquilize large animals. The substance is reportedly 5,000 times more powerful than heroin and 10,000 times stronger than morphine, making it one of the most potent drugs on the market. As a dose the size of a poppy seed can kill a person, when the drug entered the U.S. last year, hundreds of American drug users overdosed.

The Drug Enforcement Administration said China’s latest move could be a “game changer.” “It’s a substantial step in the fight against opioids here in the United States,” Russell Baer, a DEA special agent in Washington, told The Associated Press.

“It shows China’s attitude as a responsible big country,” Yu Haibin, director of the Office of the National Narcotics Control Committee, told reporters. “It will be a strong deterrent.”

China has been working with the DEA on this particular problem since last year. “Our agents work hand in hand with the Chinese,” DEA spokesman Melvin Patterson told The Daily Caller News Foundation in November 2016. China has reportedly shut down labs, arrested drug exporters, and seized tons of the synthetic opioids.

Blacklisting a substance normally takes about nine months in China; however, the latest decision on the ban of carfentanil was made in just four months.

While China’s decision is a positive move, the fight against synthetic drugs is likely far from over. The demand for synthetic opiates may lead developers and exporters to invest in alternative drugs after the ban goes into effect. When China banned fentanyl last fall, some Chinese drug exporters stepped up their exports of carfentanil.

There are also concerns that China, due to the size of relevant industries and then number of players involved, may be unable to effectively regulate the sale of illegal substances.

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Male smokers impact future kids in unique way

http://www.foxnews.com/health/2017/02/16/male-smokers-impact-future-kids-in-unique-way.html

When research began to trickle out 10 years ago suggesting that what we do today can affect the health of our unborn children, it was largely “considered heretical,” medical biochemistry professor Dr.

Oliver Rando tells the Boston Herald. Not anymore. Habits like cigarette smoking have since been shown to negatively affect future generations, and now a new study, albeit on mice, suggests yet another side effect: When fathers smoke, their future children may be born with a higher tolerance of not just tobacco but drugs of all kinds—the danger being that life-saving ones such as antibiotics, chemo, and antidepressants could be less effective for them.

Researchers at the University of Massachusetts Medical School describe it as inheriting “enhanced chemical tolerance and drug clearance abilities.” The findings need to be replicated in humans and the ramifications are still unknown, but the implications could be broad.

Drugs of both the illicit and life-saving variety are metabolized similarly in the liver, so while the study involved only nicotine and cocaine, “it would also be reasonable to think other drugs would be less effective,” one of the researchers says.

Reporting in the journal eLife, the team concludes that the changes appear to be genetic and influence the way the livers of the offspring with “multitoxin resistance” break down drugs.

Next up they plan to study whether drugs like painkillers are also affected. “It’s important to understand what information is specifically being passed down from father to offspring and how that impacts us.”

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Constipation Isn’t a Fitting Punishment for People With Pain

http://thepainfultruthbook.com/2017/02/constipation-isnt-a-fitting-punishment-for-people-with-pain-opioid-induced-constipation-interferes-with-quality-of-life-and-can-be-fatal

Deb was in a near-fatal car accident. Her arms, legs, and pelvis were severely injured and would require multiple surgeries. She relied on opioids to ease the pain. Along with her other day-to-day medical challenges and constant setbacks, she suffered from constipation which her doctor attributed to her use of painkillers. But he offered no treatment or advice, nor did any other members of the hospital’s medical team. With all of Deb’s serious health problems, constipation wasn’t on the list of issues the team felt obligated to address. The medical team, therefore, allowed Deb to suffer, perhaps needlessly, from a common and potentially treatable side-effect of opioid use: constipation.

According to Deb’s husband, “The docs did recognize the possibility of OIC. They had Deb on over-the-counter medication that they thought would help. However, this actually became their excuse for dismissing our concerns about constipation.  ‘She’s on [the medication]….’ was their response, as if that resolved the reality that nothing was happening. When Deb complained about her constipation, it was not treated in a prompt and appropriate fashion.  In the end, I had to help her expel a large stool the consistency of modeling clay. Imagine, by way of comparison, that an infection gets worse after the healthcare team dismissed it for days with, ‘Well, she’s on an antibiotic.’ No one would stand for that.”

Deb was lucky in a sense because, by the time she experienced OIC, she was able to talk. However, as her husband reminded me, patients with OIC can’t always communicate their constipation.  IV sedation removes the patient’s input.  In those cases, constipation detection is at the mercy of staff who, without more awareness, tend to “let it go for another day to see what happens.” As Deb’s husband said, “Something more needs to be done….and promptly. The medical community needs to know the seriousness of the problem to  remove their safe haven of dismissal about OIC.”

Opioid-Induced Constipation Commercial Airs During Super Bowl 50

There is medication that can help some pain patients, like Deb, with Opioid-Induced Constipation (OIC). Yet when a 60-second commercial for one of those OIC drugs aired during the Super Bowl of 2016, there was an instant backlash. The ad was the object of derision and even anger. White House Chief of Staff Denis McDonough tweeted, “Next year, how about fewer ads that fuel opioid addiction and more on access to treatment.” Dr. Andrew Kolondy, Executive Director of Physicians for Responsible Opioid Prescribing, was quoted as saying, “It’s very disturbing to see an ad like that.”

Similarly, articles from such media outlets as the Los Angeles Times and USA Today scorned the advertisement and accused the pharmaceutical industry of inappropriate and tasteless advertising. In the minds of many, OIC was either a joke or an appropriate punishment for people who probably shouldn’t be taking opioids, anyway. In their opinion, it was morally wrong to advertise a solution to a side effect created by opioids when we were in the middle of an opioid epidemic.

And the negative response to the “Super Bowl 50” ad still hasn’t ended. As recently as February 4, a story appeared in Inverse titled, “The Shitty Legacy of 2016’s Super Bowl Constipation Ad.” The article criticizes the commercial as a “sheepish attempt to capitalize on a national epidemic” and calls it the most “horrifying ad in the history of American television.”

Super Bowl Commercial Is No Joking Matter, and Neither Is Opioid-Induced Constipation

I strongly disagreed with the complaints about the Super Bowl commercial when it aired, as I said in my blog, This Is the Reason OIC Is No Joking Matter. Deb’s story, and the experiences of so many other people with disabling OIC, convince me that the public has a right to know that treatment exists for opioid-induced constipation (OIC). As I explained in my blog, treating constipation doesn’t exacerbate the opioid crisis. Moreover, it is necessary to treat a serious health problem that can destroy, or even end, a patient’s life.

OIC can cause dyspepsia, GI reflux, aspiration, abdominal distention, urinary tract infections, sepsis, and even death from bowel perforation. Additionally, OIC can interfere with pain management. The Patient Reports of Opioid-related Bothersome Effects (PROBE) survey found that 33% of pain patients “missed doses, decreased the dose, or stopped using their opioid medication to relieve bowel-related side effects.” Subsequently, 92% of those patients experienced increased pain, and 86% of them reported that it reduced their quality of life and ability to engage in activities.  It appears that those who dismiss OIC as an illegitimate medical problem are willing to accept the consequences of increased pain as reported in the PROBE survey.

Treatments for Opioid-Induced Constipation Are Available

Fortunately, there are new and effective treatments for OIC available for people who must use opioids to control pain. I have worked with many pharmaceutical companies to develop these drugs. They can provide an enormous improvement in quality of life. It strikes me as twisted reasoning to refuse to treat OIC just because one opposes the use of opioids.

Of course, it would be better to avoid opioids and not develop OIC, but that is not always possible. For people like Deb, OIC is yet another punishment for the perceived offense of being a person in pain who uses opioids.

Taking opioids can be risky. However, it is also risky not to treat OIC. Regardless of whether one believes pharmaceutical companies should advertise, healthcare professionals are obligated to provide the best care possible, including treatment of constipation whether it is with an over-the-counter therapy or one of the new OIC medications. It is time to set aside our biases towards opioids and focus on what is best for patients.

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Hemp Industries Association Sues DEA for Regulating Hemp as a Schedule I Drug

https://lawstreetmedia.com/blogs/cannabis-in-america/hemp-industry-sues-dea-lawsuit/

This is an example of a entity suing the actions/interpretations of the CSA by the DEA as UNCONSTITUTIONAL and because this industry is not a licensee of the DEA.. there is less possible of retaliation from the DEA.

The Hemp Industries Association (HIA) has filed a motion against the DEA, challenging the agency’s handling of hemp foods as Schedule I drugs.

On February 6, the HIA filed a motion to find the DEA in contempt of court for failing to comply with a 13-year-old court injunction, prohibiting the agency from regulating hemp food products as Schedule I controlled substances. A 2004 ruling, made by the Ninth Circuit Court of Appeals, determined that the DEA had violated the Controlled Substances Act by designating hemp stalk, fiber, sterilized seed, and oil as “marijuana.”

Hemp contains trace amounts of naturally occurring THC, the main psychoactive ingredient in marijuana. The versatile crop be used in a variety of ways, from making rope and fabrics, to food and fuel. In December 2016, the DEA and North Dakota Department of Agriculture halted the export of Healthy Oilseeds’ hemp products grown under the state’s hemp pilot program and Congress’ Agricultural Act of 2014 (Farm Bill), claiming it was prohibited “because industrial hemp is a Schedule I controlled substance under the Federal Controlled Substances Act.”

“We will not stand idly by while the DEA flouts the will of Congress, violates the Ninth Circuit order, and harasses honest hemp producers trying to make a living with this in-demand crop,” said Colleen Keahey, Executive Director of the HIA, in a press release.

The motion comes nearly two months after the DEA added a new code to its Federal Register that reclassifies CBD oil and other marijuana extracts, like hemp oil, as Schedule 1 drugs. DEA officials argued that the code would allow the agency to track quantities of CBD and other marijuana extracts imported and exported to and from the U.S. separately from quantities of marijuana, but marijuana advocates have labeled the move as federal overreach.

Classifying marijuana–and its derivatives, such as hemp–in the same category as “hard drugs” like heroin and bath salts continues to baffle weed advocates; the drug is praised for its medicinal properties, and no deaths from a marijuana overdose have ever been recorded.

“Hemp is a healthy superfood with vital nutrients such as Omegas 3 and 6, protein, fiber and all 10 essential amino acids that are ideal for today’s family,” said Keahey. “The DEA must stop treating hemp, hempseed and hempseed oil, which is a nutritious ingredient, as something illicit.”

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