An Interview with Ken McKim: Educating the public about chronic illness

http://www.prohealth.com/library/showarticle.cfm?libid=21823

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A new study in The Journal of School Health has found that alcohol is more likely to act as a gateway drug to substance abuse than marijuana.

http://yournewswire.com/study-finds-alcohol-is-the-gateway-drug-not-marijuana/

The study proves that marijuana consumption is not an indicator as to whether a person is likely to move onto harder drugs or not.

Hot6today.com reports:

“By delaying the onset of alcohol initiation, rates of both licit substance abuse like tobacco and illicit substance use like marijuana and other drugs will be positively affected, and they’ll hopefully go down,” study co-author Adam E. Barry, an assistant professor at the University of Florida’s Department of Health Education & Behavior, told Raw Story in an exclusive interview.

While Barry’s study shows evidence that substance abuse behaviors can be predicted with a high degree of accuracy by examining a subject’s drug history, he believes thatthe persistent and misguided notion of marijuana as the primary gateway to more harmful substances went awry because its creators — who called it the “Stepping Stone Hypothesis” in the “Reefer Madness” era of the 1930s — fundamentally misread the data and failed to conduct an adequate follow-up.

“Some of these earlier iterations needed to be fleshed out,” Barry said. “That’s why we wanted to study this. The latest form of the gateway theory is that it begins with [marijuana] and moves on finally to what laypeople often call ‘harder drugs.’ As you can see from the findings of our study, it confirmed this gateway hypothesis, but it follows progression from licit substances, specifically alcohol, and moves on to illicit substances.”

“So, basically, if we know what someone says with regards to their alcohol use, then we should be able to predict what they respond to with other [drugs],” he explained. “Another way to say it is, if we know someone has done [the least prevalent drug] heroin, then we can assume they have tried all the others.”

And while that standardized progression certainly doesn’t fit every single drug user, the study took that into account too. “There were a low enough number of errors that you are able to accurately predict [future substance abuse behavior]… with about 92 percent accuracy,” Barry said.

By comparing substance abuse rates between drinkers and non-drinkers, they ultimately found that seniors in high school who had consumed alcohol at least once in their lives “were 13 times more likely to use cigarettes, 16 times more likely to use marijuana and other narcotics, and 13 times more likely to use cocaine.”

Barry also noted that the rates of tobacco and marijuana use among all 12th grade high school students were virtually the same, confirming a report the Centers for Disease Control published in June, and an analysis Raw Story published in May.

The study should give pause to anyone involved in youth drug awareness programs, as its findings suggest that making science-based alcohol education a top priority could actually turn the tide of the drug war — but only if lawmakers and leading educators decide to use that same science as a foundation for public policy and school curriculum.

“I think [these results] have to do with level of access children have to alcohol, and that alcohol is viewed as less harmful than some of these other substances,” Barry added.

That social misconception, largely driven by the sheer popularity of alcohol and the profits it generates for private industry, is diametrically opposed to the most current science available on drug harms. A study published in 2010 in the medical journal Lancet ranked alcohol as the most harmful drug of all, above heroin, crack, meth, cocaine and tobacco. Even more striking: The Lancet study found that harms to others near the user were more than double those of the second most harmful drug, heroin.

In its last Youth Risk Behavior Survey, the CDC found (PDF) that about 71 percent of American students have had at least one alcoholic beverage in their lifetime, and almost 39 percent reported having at least one drink within the last 30 days.

“This is a time of budget tightening,” Barry concluded. “Many social services are being cut. If you take [our findings] and apply them to a school health setting, we believe that you are going to get the best bang for your buck by focusing on alcohol.”

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DRUG ENFORCEMENT ADMINISTRATION
OFFICIAL NOTIFICATION
POSTED ON
NOVEMBER 15, 2015

Civil Forfeiture Aug – Sept 2015 DEA

http://www.forfeiture.gov/pdf/DEA/OfficialNotification.pdf

“The names of persons or businesses appearing in this notice are not necessarily criminal defendants or suspects, nor does the appearance of their names in this notice necessarily mean that they are the target of DEA investigations or other activities.”

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Petition To Fire DEA Head Chuck Rosenberg Surpasses 75,000 Signatures

http://www.theweedblog.com/petition-to-fire-dea-head-chuck-rosenberg-surpasses-75000-signatures/

DEA head Chuck Rosenberg recently made some insensitive, unscientific comments about medical marijuana that demonstrated just how little compassion he has for suffering patients in this country. Below are Chuck Rosenberg’s comments, via the Huffington Post:

“What really bothers me is the notion that marijuana is also medicinal — because it’s not,” Rosenberg told reporters last week. “We can have an intellectually honest debate about whether we should legalize something that is bad and dangerous, but don’t call it medicine — that is a joke.

“There are pieces of marijuana — extracts or constituents or component parts — that have great promise,” he continued. “But if you talk about smoking the leaf of marijuana, which is what people are talking about when they talk about medicinal marijuana, it has never been shown to be safe or effective as medicine.”

In reaction to those comments, the Marijuana Majority created a petition calling for the termination of Chuck Rosenberg. Below is the language of the petition (which can be signed at this link here):

Chuck Rosenberg, acting head of the Drug Enforcement Administration (DEA), just made highly offensive comments calling medical marijuana a “joke.”

While it’s nothing new for drug war bureaucrats to oppose sensible marijuana policies, Rosenberg’s comments go way too far.

Medical marijuana is not a “joke” to the millions of seriously ill patients in a growing number of states who use it legally in accordance with doctors’ recommendations.

It is not a “joke” to the growing number of prominent medical organizations — American Nurses Association, American College of Physicians, American Academy of Family Physicians, for example — who know that cannabis has real and proven medical benefits.

And it’s not a “joke” to the clear majority of U.S voters who support passing laws to protect medical marijuana patients from harassment by police and the DEA.

President Obama should fire Chuck Rosenberg and appoint a new DEA administrator who will respect science, medicine, patients and voters.

LETTER TO
Barack Obama

“Fire DEA Administrator Chuck Rosenberg for referring to medical marijuana, which many seriously ill people rely on, as a “joke.”

As of this blog post, 76,302 people have signed the petition. Singer/songwriter, and cancer survivor, Melissa Etheridge signed the petition, and you should too. You should also donate to the Marijuana Majority so that they can continue to do great work like this. Tom Angell is an activism manchild, and you better believe that if/when I ever get money, I’m backing him as much as I can because of his ability to do big things, like what he has been able to do with bringing awareness to this issue and petition.

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Battle to curb obesity is failing, CDC reports

http://www.modernhealthcare.com/article/20151112/NEWS/151119959?utm_source=modernhealthcare&utm_medium=email&utm_content=20151112-NEWS-151119959&utm_campaign=dose

Just when a <href=”http: jama.jamanetwork.com=”” article.aspx?articleid=”2434665″”>JAMA editorial this September saw a “glimmer of hope” that U.S. obesity (and diabetes) rates had leveled off, a new survey slashed those hopes.

The government Thursday released data that show obesity continuing to creep upward with women having higher rates than men and both having increasing rates as they get older.

For the past several years, experts thought the nation’s alarming, decades-long rise in obesity had leveled off. But the Centers for Disease Control and Prevention reports that the obesity rate climbed to nearly 38% of adults in 2013-14, up from 32% about a decade earlier.

“This is a striking finding” and suggests that a situation that was thought to be stable is getting worse, said Dr. William Dietz, an obesity expert at George Washington University.

But other experts urged people to be cautious about how the interpret the report.

The University of North Carolina’s Barry Popkin said the participants selected for the study may not have been representative of the nation as a whole.

And Dr. Scott Kahan of the George Washington University Milken Institute School of Public Health, chided the media for blowing a blip in the data out of proportion.

“I don’t get worried from this data,” said Kahan, medical director for the Strategies to Overcome and Prevent Obesity Alliance. “We’re very early in the public health approach to obesity.”

He compared it to the anti-smoking movement. Definitive data came out in the 1940s that smoking was harmful, the U.S. Surgeon General issued an anti-smoking report in 1964, and then policy decisions taking cigarette marketing off of television were made in 1970.

“It took a half century of effort to accrue the benefits we’re now seeing,” Kahan said. “These are complex efforts that take time.”

The report also found the scales tipping toward women. Obesity rates for men and women had been roughly the same for about a decade. But in the new report, the rate was significantly higher for women, 38.3% compared with 34.3% for men.

Jocelyn Johnson, community education dietitian and registered dietitian with Sanford Health in Sioux Falls, S.D., attributed the higher female obesity rates–particularly for middle-age women–to weight gain during pregnancy and hormonal shifts.

“I also think women are more likely to be ’emotional eaters’ than men, with more stress eating,” Johnson said.

Obesity—which means not merely overweight, but seriously overweight—is considered one of the nation’s leading public health problems. Until the early 1980s, only about 1 in 6 adults were obese, but the rate climbed dramatically until it hit about 1 in 3 around a decade ago.

The new figures come from an annual government survey of about 5,000 participants. In interviews, people tend to understate their weight and overstate their height. But participants are actually weighed in this survey and thus it is considered the gold standard for measuring the nation’s waistline.

The disheartening news comes after years of government anti-obesity campaigns to encourage people to eat better and exercise. Also, soda consumption has dropped in recent years, and fast-food chains have adopted healthier menus.

A study published in Health Affairs noted that a provision in the Affordable Care Act mandating calorie counts on menus for restaurants with more than 20 locations is set to take effect Dec. 1, 2016. But the researchers studied how a similar mandate in New York City that went in place in 2008 has had little effect on menu choices.

The widening gap between men and women seems to be driven by what’s happening among blacks and Hispanics, said the study’s lead author, the CDC’s Cynthia Ogden.

Obesity rates for white men and white women remain very close. But for blacks, the female obesity rate has soared to 57%, far above the male rate of 38%. The gender gap is widening among Hispanics, too—46% for women, 39% for men.

The report also looked at obesity in children but did not see much change. For young people ages 2 to 19, the rate has been holding at about 17% over the past decade or so.

Health officials have been especially focused on obesity in kids, who are the target of the Let’s Move campaign launched by first lady Michelle Obama in 2010.

The CDC measures obesity by calculating body mass index, a ratio of weight to height. For adults, a BMI of 25 to 29.9 is overweight, and 30 or higher is obese. According to CDC definitions, a 5-foot-10 man is overweight at 174 pounds and obese at 209.

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America’s poorest white town: abandoned by coal, swallowed by drugs

In the first of a series of dispatches from the US’s poorest communities, we visit Beattyville, Kentucky, blighted by a lack of jobs and addiction to painkillers

http://www.theguardian.com/us-news/2015/nov/12/beattyville-kentucky-and-americas-poorest-towns

Karen Jennings patted her heavily made up face, put on a sardonic smile and said she thought she looked good after all she’d been through.

“I was an alcoholic first. I got drunk and fell in the creek and broke my back. Then I got hooked on the painkillers,” the 59-year-old grandmother said.

Over the years, Jennings’ back healed but her addiction to powerful opioids remained. After the prescriptions dried up, she was drawn to the underground drug trade that defines eastern Kentucky today as coal, oil and timber once did.

Jennings spoke with startling frankness about her part in a plague gripping the isolated, fading towns dotting this part of Appalachia. Frontier communities steeped in the myth of self-reliance are now blighted by addiction to opioids – “hillbilly heroin” to those who use them. It’s a dependency bound up with economic despair and financed in part by the same welfare system that is staving off economic collapse across much of eastern Kentucky. It’s a crisis that crosses generations.

One of those communities is Beattyville, recorded by a US census survey as the poorest white town – 98% of its 1,700 residents are white – in the country. It was also by one measure – the Census Bureau’s American Community Survey 2008-2012 of communities of more than 1,000 people, the latest statistics available at the time of reporting – among the four lowest income towns in the country. It is the first stop for a series of dispatches by the Guardian about the lives of those trying to do more than survive in places that seem the most remote from the aspirations and possibilities of the American Dream.

Beattyville sits at the northern tip of a belt of the most enduring rural poverty in America. The belt runs from eastern Kentucky through the Mississippi delta to the Texas border with Mexico, taking in two of the other towns – one overwhelmingly African American and the other exclusively Latino – at the bottom of the low income scale. The town at the very bottom of that census list is an outlier far to the west on an Indian reservation in Arizona.

The communities share common struggles in grappling with blighted histories and uncertain futures. People in Beattyville are not alone in wondering if their kind of rural town even has a future. To the young, such places can sometimes feel like traps in an age when social mobility in the US is diminishing and they face greater obstacles to a good education than other Americans.

At the same time, each of the towns is distinguished by problems not common to the rest. In Beattyville it is the drug epidemic, which has not only destroyed lives but has come to redefine a town whose fleeting embrace of prosperity a generation ago is still visible in some of its grander official buildings and homes near the heart of the town. Now they seem to accentuate the decline of a main street littered with ghost shops that haven’t seen business in years.

Jennings shook off her addiction after 15 years. She struggled to find work but eventually got a job serving in a restaurant that pays the $300 a month rent on her trailer home. She collects a small disability allowance from the government and volunteers at a food bank as a kind of atonement. Helping other people is, she said, her way of “getting through”: “I just want to serve God and do what I can for people here.”

It was at the local food bank that Jennings spilled out her story.

“There are lots of ways of getting drugs. The elderly sell their prescriptions to make up money to buy food. There are doctors and pharmacies that just want to make money out of it,” she said. “I was the manager of a fast food place. I used to buy from the customers. People could come in for a hamburger and do a drug transaction with me and no one would ever notice.”

Even as Jennings related the toll of drug abuse – the part it played in destroying at least some of her five marriages, the overdose that nearly cost her life and the letter she wrote to her doctor begging for the help that finally wrenched her off the pills – she spoke as if one step removed from the experience.

“You get hooked and you’re not yourself. You go on functioning. You do your job. But I really don’t see how I’m alive today,” she said.

It was only when Jennings got to the part about her son, Todd, a bank vice-president, that she faltered. “I lost my son three years ago from suicide. My lifestyle contributed to his depression. I take responsibility for my part of it,” she said.

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Sudden, Unexpected Death in Chronic Pain Patients why?

http://dailyhealthrecords.com/2015/10/29/sudden-unexpected-death-in-chronic-pain-patients-why/?fdx_switcher=true

Sudden, unexpected death may occur in a severe, chronic pain patient, and the terminal event may be unrelated to medical therapeutics. Fortunately, sudden death is not as commonly observed in pain patients as in past years most likely due to better access to at least some treatment. Sudden death still occurs, however, and practitioners need to know how to spot an “at-risk” patient.

Unexpected, sudden death due to severe pain is poorly appreciated, since many observers still view severe pain as a harmless nuisance rather than a potential physiologic calamity. In many cases, just prior to death, the patient informs their family that they feel more ill than usual and seek relief in their bed or on their couch. Unfortunately, some of these patients don’t awaken. Other patients die, without warning, in their sleep or are found collapsed on the floor. Modern medicine’s aggressive toxicology and forensic procedures after death have contributed to the poor understanding of pain’s death threat. In some cases, a pain patient that was being treated appropriately with an opioid or other agent with overdose or abuse potential has suddenly and unexpectedly died. Drugs were found in body fluids after death, and in my opinion a coroner wrongly declared the death to be an “accidental overdose” or “toxic reaction” to drugs rather than implicate the real culprit, which may have been an “out-of-control” pain flare.

This article is partially intended to call attention to the fact that the mere finding of abusable drugs at autopsy doesn’t necessarily mean that the drugs caused the death. In fact, the drugs may have postponed death. Some physicians have been falsely accused of causing deaths due to drug overtreatment when, in fact, undertreatment of pain may have caused the death. Additionally, opioid blood levels assessed at autopsy of a patient who died suddenly are all too often wrongfully considered accidental overdoses because the pathologist is unaware that chronic pain patients on a stable dose of opioids can be fully functional with serum levels of their prescribed opioids that far exceed lethal levels in opioid-naïve patients.¹

Given here are the mechanisms of sudden, unexpected death in pain patients and some protective measures that practitioners must take to keep from being falsely accused of causing a sudden, unexpected death. More importantly, given here are some clinical tips to help identify the chronic pain patient who is at high risk of sudden, unexpected death so that more aggressive pain treatment can be rendered.

A Brief Anecdotal History
As a senior medical student at Kansas University in the early 1960s, I was required to take a rural preceptorship with a country doctor. In making our rounds one day to the county’s nursing home, I heard a farmer’s wife declare, “pain killed my mother last night.” Since then, I’ve repeatedly heard that pain killed a loved one. Folklore frequently mentions that people die “from,” as well as “in” pain. There is, however, little written detail of these events.

In the early years of my pain practice, which I began in 1975, I had several patients die suddenly and unexpectedly. This rarely happens to me today as I’ve learned to “expect the unexpected” and to identify which patients are at high risk of sudden death. In recent years, I’ve reviewed a number of litigation and malpractice cases of sudden, unexpected death in chronic pain patients. In some of these cases, physicians were accused of over- or misprescribing and causing a sudden, unexpected death, even though the patient had taken stabilized dosages of opioids and other drugs for extended periods. Also, the autopsy showed no evidence of pulmonary edema (a defining sign for overdose and respiratory depression). In cases where the physician was falsely accused, the post-death finding of abusable drugs in body fluids caused a family member, regulatory agency, or public attorney to falsely bring charges against a physician.

Setting and Cause
Unexpected deaths in chronic pain patients usually occur at home. Sometimes the death is in a hospital or detoxification center. The history of these patients is rather typical. Most are too ill to leave home and spend a lot of time in bed or on a couch. Death often occurs during sleep or when the patient gets up to go to the toilet. In some cases, the family reports the patient spent an extraordinary amount of time on the toilet just prior to collapse and death. Sudden and unexpected death, however, can occur anywhere at any time, as pain patients who have died unexpectedly and suddenly have been found at work or in a car.

Coronary spasm and/or cardiac arrhythmia leading to cardiac arrest or asystole is the apparent cause of death in the majority of these cases, since no consistent gross pathology has been found at autopsy.^2-5 Instant cardiac arrest appears to account for sudden collapse or death during sleep. Perhaps constipation and straining to pass stool may be cardiac strain factors as some pain patients die during defecation. Acute sepsis due to adrenal failure and immune suppression may account for some sudden deaths.

Two Mechanisms of Cardiac Death
Severe pain is a horrific stress.^6,7 Severe pain flares, acute or chronic, cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenalin and noradrenalin) in an effort to biologically contain the stress.^8,9 Catecholamines have a direct, potent stimulation effect on the cardiovascular system and severe tachycardia and hypertension result.¹⁰ Pulse rates may commonly rise to more than 100 beats per minute and even rise to more than 130 beats per minute. Blood pressure may reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to adrenal catecholamine release, pain flares cause overactivity of the autonomic, sympathetic nervous system, which add additional stimulation to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic, sympathetic overactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, vasoconstriction with cold extremities, hyperreflexia, hyperthermia, nausea, diarrhea, and vomiting.Source

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Dookhan Pleads Guilty, Gets 3-5 Years In Prison

http://badchemistry.wbur.org/2013/11/22/dookhan-plea-prison

Disgraced former state chemist Annie Dookhan is now behind bars, after she pleaded guilty Friday to all 27 counts against her related to the drug lab crisis.

Dookhan showed little emotion and spoke softly as she pleaded guilty.

After accepting Dookhan’s plea, Judge Carol Ball sentenced her to three to five years in state prison in Framingham.

Prosecutors had sought a five- to seven-year sentence. Dookhan had sought a one-year sentence.

Original story:

BOSTON — A former state chemist is expected to go to prison Friday for a drug lab crisis that’s created turmoil throughout the Massachusetts criminal justice system.

Ex-chemist Annie Dookhan, 36, is scheduled to plead guilty Friday to falsifying drug tests and potentially compromising tens of thousands of criminal cases.

Her actions allegedly caused what may be the nation’s largest forensic testing scandal.

Massachusetts officials identified more than 40,000 criminal cases affected by testing Dookhan did during the nine years she worked at the now-closed Hinton state lab.

Michael O’Keefe, president of the Massachusetts District Attorneys Association, says prosecutors have sifted through hundreds of cases and close to 350 people have been released from prison.

“Prosecutors have been very reasonable about this,” he said, “dealing with a problem that is not of our making and that has to be addressed by balancing individual liberty and public safety.”

But defense attorneys are quick to point to documents from the Dookhan investigation showing that some prosecutors would often contact her directly and Dookhan would try to get their tests done quickly. One prosecutor resigned after his emails with Dookhan became public.

Anne Goldbach, of the Massachusetts public defenders agency, says forensic scientists are supposed to be impartial.

“You can tell that Annie Dookhan felt a sense of allegiance to the prosecution,” she said. “That is absolutely unconscionable.”

The documents in the case also show that for years Dookhan tested thousands more drug samples than her colleagues. A WBUR analysis shows that between 2009 and 2010, the time it took Dookhan to conduct a test went down by more than half.

“She continued to decrease the turnaround time,” said Tom Workman, a defense attorney and forensic expert. “You scratch your head and say, ‘How could someone do that?’ The obvious answer that comes to mind is they weren’t doing the work, they were dry-labbing.”

Dry-labbing is when a chemist just looks at a sample, with no actual testing involved. State Police say Dookhan admitted to dry-labbing when they questioned her about a year ago.

After Dookhan’s arrest, five of her coworkers and the state public health commissioner, John Auerbach, resigned. Auerbach admitted that his department, which oversaw the Hinton Lab, was at fault.

“I want to be absolutely clear,” he said. “I accept no responsibility for the actions of a rogue chemist, but I do think the Department of Public Health’s managers erred in lacking proper oversight of the forensic drug laboratory.”

Still, the question remains: Why did she do it? There is little in Dookhan’s history to provide an answer.

She’s the only child of immigrant parents who were proud of their daughter’s accomplishments. Her lab supervisors described her as a valuable member of the team.

The American Civil Liberties Union of Massachusetts says a trial might have shed light on her motivation.

“By pleading guilty, Annie Dookhan has taken a step,” said Matt Segal, Massachusetts ACLU’s legal director, “which means that there won’t be a trial, there won’t be a public airing of the evidence against her and the evidence that might exist against anyone else.”

During a recent hearing, Dookhan’s attorney, Nicholas Gordon, said his client made mistakes trying to be the top chemist — and then tried to cover up those mistakes.

“Her motivation is to be the hardest working and most prolific and most productive chemist that she could possibly be, and that’s how this whole mess begins,” he said.

Gordon also said Dookhan is now divorced and the primary caretaker of her 7-year-old disabled son. So he asked the judge for a one-year prison sentence. Prosecutors asked for significantly more, citing the millions of dollars the state has spent to deal with the scandal. The judge said she would not exceed a three- to five-year sentence for actions she described as “shaking the criminal justice system to its core.”

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Costly, and often deadly, medical errors prompt calls for hospitals to accept fault

There’s no hard-and-fast rule for how hospitals handle cost of care when patients have bad outcomes and fault is disputed.

http://www.healthcarefinancenews.com/news/costly-and-often-deadly-medical-errors-prompt-calls-hospitals-accept-fault

When Charles Thompson checked into the hospital one July morning in 2011, he expected a standard colonoscopy.

He never anticipated how wrong things would go.

Partway through, the doctor emerged and said there were complications, remembered Ann, Charles’ wife. Charles’ colon may have been punctured. He needed emergency surgery to repair it.

Charles, now 61, from Greenville, S.C., almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker.

“He’s not the same as before,” said Ann, 62. “Our whole lifestyle changed – now all we do is sit at home and go to church. And that’s because he’s scared of dying.”

[Also: See which hospitals scored an ‘F’ in the Leapfrog Group’s Fall 2015 safety ratings]

When things like this happen in the hospital, questions arise: Who’s responsible? If treatment makes things worse – meaning patients need more care – who pays?

The answer, it seems, is that it depends.

Despite the Institute of Medicine‘s landmark 1999 report, “To Err Is Human,” and, more recently, provisions in the 2010 health law emphasizing quality of care, entering the hospital still brings risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better.

More than 400,000 people die annually, in part thanks to avoidable medical errors, according to a 2013 estimate from the Journal of Patient Safety. In 2008, the most recent year studied, medical errors cost an extra $19.5 billion in national spending, most of which was spent on extra care and medication, according to another report.

If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But this can take time and money. And lawyers who collect only when there’s a settlement or victory may not want to take on a case unless it’s exceptionally clear that the doctor or hospital is at fault.

That creates a Catch-22 situation, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.” That leaves the patient responsible for extra costs.

[Also: See which hospitals earned an ‘A’ in the Fall 2015 Leapfrog safety ratings]

Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, Ann said, and the physician’s notes indicated the Thompsons had been advised of the risks of the procedure, including injury to the colon. She and her husband tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor who performed the test declined to comment, with the hospital citing patient privacy laws.

Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson couldn’t keep working as a truck driver and lost the health insurance he had through his job, depriving him of help in paying for follow-up care. The Thompsons paid for almost $600,000 in follow-up care out of pocket – depleting their life savings. They struggled to pay other bills until Charles qualified for disability benefits, Ann said.

“You would expect if [health care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their ability to prevent errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”

There’s no hard-and-fast rule for how hospitals handle cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association. Since cases vary, she added, what’s best one time may not always be.

Some hospitals have rules requiring they tell patients if something went wrong and, to the best of their knowledge, why. Typically, those stipulate that if the hospital finds it erred, necessary follow-up care is free.

“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, a health system in Washington, D.C. and Maryland.

Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell.

Most hospitals don’t have this kind of disclosure policy, said Julia Hallisy, a patient safety advocate from California. That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.

But even when they tell patients something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, themselves or through insurance.

Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.

Other times, people follow correct procedures, but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said.

If hospitals don’t help pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.

On average, a privately insured patient cost about $39,000 more in hospital bills – $56,000 vs. $17,000 – when surgery yielded complications, according to a 2013 study published in the Journal of the American Medical Association.

Patients with employer-based insurance – 147 million non-elderly people in 2015 – who experienced complications or otherwise became worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said.

If that doesn’t pan out, insurance plans can step in.

When insurers include hospitals in networks, they sometimes put provisions in these contracts stipulating how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. Then, complications must clearly stem from the bad treatment.

In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.

Patients, Krusing said, shouldn’t pay for what’s out of their control.

And if the hospital doesn’t provide financial assistance, regular insurance should cover these unexpected expenses. But if a patient hasn’t met his or her deductible – what he or she owes out-of-pocket before insurance kicks in – the patient will have to pay his or her share.

Federal programs have taken the lead in clarifying who pays for what. Medicare won’t pay for treatments that are fixing certain errors, like surgery on the wrong part of a patient’s body or a blood transfusion of the wrong type. And hospitals can’t charge patients – they must cover the costs themselves.

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The 2010 health law requires Medicaid implement a similar policy, which may be easier in theory than in practice, said Rachel Morgan, health and human services committee director at the National Conference of State Legislatures. It takes time and requires expertise for state Medicaid agencies to review hospital charges and then determine if the services were in fact the result of error. That extra work makes enforcing these rules difficult – so while some states have had success doing so, others haven’t, Morgan said. Some commercial insurers are also experimenting with comparable policies, she added.

Even then, those cover a limited set of errors. Otherwise, who pays can remain unclear.

“Patients don’t normally think about these issues – and who would? They don’t think of any of these issues until they’re right in the middle of it,” Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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