WASHINGTON – Encouraging data on an external vagal nerve stimulator and a minimally invasive system that targets the sphenopalatine ganglion are propelling the two neuromodulation devices toward approval for headache, Stewart J. Tepper, MD, said at the Summit in Neurology & Psychiatry.

“This would bring to four the number of devices we now have available to us to treat headache,” said Dr. Tepper, director of research at the Dartmouth Headache Clinic, Lebanon, N.H. Two types are already available in the United States: a trigeminal nerve stimulator approved for migraine prevention and two brands of transcranial magnetic stimulators approved for acute treatment of migraine with aura.

Noninvasive vagal nerve stimulator

The gammaCore device (electroCore Medical) could be approved for cluster headache this year, Dr. Tepper said. A company spokesman said the company submitted its pivotal trial data to the Food and Drug Administration in 2015, but couldn’t offer any insight into how far the process has progressed.

©Christopher Robbins/Thinkstockphotos.com

“That application is currently under review, and we look forward to the FDA’s decision when it comes,” Eric Liebler, electroCore vice president for scientific, medical, and governmental affairs, said in an interview.

The gammaCore device is an external vagal nerve stimulator already approved in Canada and Europe for the treatment of primary headache disorders. In April 2016, it was approved in the United Kingdom as well, Dr. Tepper said at the meeting, sponsored by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

The device is a small, handheld unit that the patient uses twice each day, and which transmits mild current to the vagal nerve. It’s activated over the carotid pulse point on the neck for about 90 seconds. It’s thought to work by suppressing excessive extracellular glutamate and suppressing cortical spreading depression, Dr. Tepper said.

The most recent data for the gammaCore device, presented at the annual meeting of the American Headache Society (AHS) in June, suggest that it could also be beneficial in chronic headache and in menstrual migraine.

A 12-week, open-label study of 51 women with menstrual migraine looked at pain intensity, analgesic use, and migraine disability. Women used the device prophylactically, six stimulations each day for 3 days before and after the onset of menstruation. The mean number of menstrual migraine days each month declined significantly from 7.2 to 4.7. About 40% of the group had at least a 50% reduction in migraine days. Pain intensity also decreased significantly, as well as did the number of doses of analgesics. There were significant improvements on both the Headache Impact Test and Migraine Disability Assessment. One subject discontinued treatment due to dizziness during stimulation.

An 8-week study on cluster headache was published in May and updated at the AHS meeting. Investigators randomized 87 patients with cluster headache to standard therapy alone or plus the gammaCore device. The PREVA (Prevention and Acute treatment of chronic cluster headache) study determined that dual therapy reduced the number of weekly attacks by four, compared with standard therapy. A total of 40% of patients experienced at least a 50% response rate, compared with 8% of controls. A subanalysis presented at the AHS meeting showed that 18% of the dual-therapy group experienced at least a 75% response rate.

Implantable sphenopalatine ganglion stimulator

Dr. Tepper is particularly excited about the Pulsante device, an implantable, wireless sphenopalatine ganglion (SPG) stimulator manufactured by Autonomic Technologies, which he called “a dramatic change in paradigm,” for the treatment of cluster headaches.

The system consists of a neurostimulator about the size of an almond and a lead with six electrodes. It’s inserted under local anesthetic via a small incision in the upper gum on the side in which the patient experiences symptoms. The electrodes are positioned along the SPG nerve and the neurostimulator is affixed to the zygomatic process.

A handheld wireless controller placed against the cheek activates the device and controls the intensity of stimulation, which is thought to work by blocking signals to the postganglionic parasympathetic fibers. Those fibers innervate facial structures and the cerebral and meningeal blood vessels and are implicated in the pain and accompanying autonomic symptoms of a cluster headache attack.

“You can literally see this device working right before your eyes,” he said. “Patients having a cluster attack will exhibit ptosis, red watering eyes, nose running, and as soon as the device is turned on, you see the lid come up, the eye turn white, and the tearing and runny nose stop. This is an objective correlate to a subjective pain response. It’s dramatic and exciting.”

The pivotal Pathway CH-1study that led to European Union approval was small – just 43 patients – but found that half the cluster attacks could be terminated within 15 minutes of onset. About half of the patients, who had a decades-long history of cluster headaches, experienced close to a 90% reduction in attack frequency.

The latest Pulsante data were also presented in June at the AHS meeting. Two papers – one with 24-month data from the pivotal trial, and one with 12-month data from an ongoing registry study – were overwhelmingly positive, Dr. Tepper said.

The 24-month follow-up data to the pivotal study found that 61% of patients experienced a therapeutic response to SPG stimulation. Most attacks (79%) responded to stimulation alone without the need for abortive therapy. Most patients (64%) also experienced clinical improvements in preventive medication use. Twenty-one were able to reduce or even eliminate the use of preventive medications.

The registry study provided data on 85 patients. Of these, 68% experienced at least a 50% reduction in attack frequency; some reported close to a 90% reduction. A third of patients actually experienced some period of remission, and some patients who were not initially responders became responders after a year of treatment. Acute medication use declined by 52% overall and by 82% in those considered therapeutic responders.

“These data are extremely encouraging,” Dr. Tepper said.

Adverse events are minimal and most are related to implantation. A safety study of 99 patients found that adverse events included sensory disbranch, pain, and swelling, which resolved in 90 days.

The U.S. Pathway CH-2 Cluster Headache Study is now underway and aims to enroll 120 patients. “If the data are positive on this, the company will go ahead and pursue U.S. approval,” Dr. Tepper said.

Dr. Tepper has received personal remuneration and research funding from a number of pharmaceutical companies. He holds stock in Autonomic Technologies.

[email protected]

On Twitter @alz_gal

WASHINGTON – Encouraging data on an external vagal nerve stimulator and a minimally invasive system that targets the sphenopalatine ganglion are propelling the two neuromodulation devices toward approval for headache, Stewart J. Tepper, MD, said at the Summit in Neurology & Psychiatry.

“This would bring to four the number of devices we now have available to us to treat headache,” said Dr. Tepper, director of research at the Dartmouth Headache Clinic, Lebanon, N.H. Two types are already available in the United States: a trigeminal nerve stimulator approved for migraine prevention and two brands of transcranial magnetic stimulators approved for acute treatment of migraine with aura.

Noninvasive vagal nerve stimulator

The gammaCore device (electroCore Medical) could be approved for cluster headache this year, Dr. Tepper said. A company spokesman said the company submitted its pivotal trial data to the Food and Drug Administration in 2015, but couldn’t offer any insight into how far the process has progressed.

©Christopher Robbins/Thinkstockphotos.com

“That application is currently under review, and we look forward to the FDA’s decision when it comes,” Eric Liebler, electroCore vice president for scientific, medical, and governmental affairs, said in an interview.

The gammaCore device is an external vagal nerve stimulator already approved in Canada and Europe for the treatment of primary headache disorders. In April 2016, it was approved in the United Kingdom as well, Dr. Tepper said at the meeting, sponsored by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

The device is a small, handheld unit that the patient uses twice each day, and which transmits mild current to the vagal nerve. It’s activated over the carotid pulse point on the neck for about 90 seconds. It’s thought to work by suppressing excessive extracellular glutamate and suppressing cortical spreading depression, Dr. Tepper said.

The most recent data for the gammaCore device, presented at the annual meeting of the American Headache Society (AHS) in June, suggest that it could also be beneficial in chronic headache and in menstrual migraine.

A 12-week, open-label study of 51 women with menstrual migraine looked at pain intensity, analgesic use, and migraine disability. Women used the device prophylactically, six stimulations each day for 3 days before and after the onset of menstruation. The mean number of menstrual migraine days each month declined significantly from 7.2 to 4.7. About 40% of the group had at least a 50% reduction in migraine days. Pain intensity also decreased significantly, as well as did the number of doses of analgesics. There were significant improvements on both the Headache Impact Test and Migraine Disability Assessment. One subject discontinued treatment due to dizziness during stimulation.

An 8-week study on cluster headache was published in May and updated at the AHS meeting. Investigators randomized 87 patients with cluster headache to standard therapy alone or plus the gammaCore device. The PREVA (Prevention and Acute treatment of chronic cluster headache) study determined that dual therapy reduced the number of weekly attacks by four, compared with standard therapy. A total of 40% of patients experienced at least a 50% response rate, compared with 8% of controls. A subanalysis presented at the AHS meeting showed that 18% of the dual-therapy group experienced at least a 75% response rate.

Implantable sphenopalatine ganglion stimulator

Dr. Tepper is particularly excited about the Pulsante device, an implantable, wireless sphenopalatine ganglion (SPG) stimulator manufactured by Autonomic Technologies, which he called “a dramatic change in paradigm,” for the treatment of cluster headaches.

The system consists of a neurostimulator about the size of an almond and a lead with six electrodes. It’s inserted under local anesthetic via a small incision in the upper gum on the side in which the patient experiences symptoms. The electrodes are positioned along the SPG nerve and the neurostimulator is affixed to the zygomatic process.

A handheld wireless controller placed against the cheek activates the device and controls the intensity of stimulation, which is thought to work by blocking signals to the postganglionic parasympathetic fibers. Those fibers innervate facial structures and the cerebral and meningeal blood vessels and are implicated in the pain and accompanying autonomic symptoms of a cluster headache attack.

“You can literally see this device working right before your eyes,” he said. “Patients having a cluster attack will exhibit ptosis, red watering eyes, nose running, and as soon as the device is turned on, you see the lid come up, the eye turn white, and the tearing and runny nose stop. This is an objective correlate to a subjective pain response. It’s dramatic and exciting.”

The pivotal Pathway CH-1study that led to European Union approval was small – just 43 patients – but found that half the cluster attacks could be terminated within 15 minutes of onset. About half of the patients, who had a decades-long history of cluster headaches, experienced close to a 90% reduction in attack frequency.

The latest Pulsante data were also presented in June at the AHS meeting. Two papers – one with 24-month data from the pivotal trial, and one with 12-month data from an ongoing registry study – were overwhelmingly positive, Dr. Tepper said.

The 24-month follow-up data to the pivotal study found that 61% of patients experienced a therapeutic response to SPG stimulation. Most attacks (79%) responded to stimulation alone without the need for abortive therapy. Most patients (64%) also experienced clinical improvements in preventive medication use. Twenty-one were able to reduce or even eliminate the use of preventive medications.

The registry study provided data on 85 patients. Of these, 68% experienced at least a 50% reduction in attack frequency; some reported close to a 90% reduction. A third of patients actually experienced some period of remission, and some patients who were not initially responders became responders after a year of treatment. Acute medication use declined by 52% overall and by 82% in those considered therapeutic responders.

“These data are extremely encouraging,” Dr. Tepper said.

Adverse events are minimal and most are related to implantation. A safety study of 99 patients found that adverse events included sensory disbranch, pain, and swelling, which resolved in 90 days.

The U.S. Pathway CH-2 Cluster Headache Study is now underway and aims to enroll 120 patients. “If the data are positive on this, the company will go ahead and pursue U.S. approval,” Dr. Tepper said.

Dr. Tepper has received personal remuneration and research funding from a number of pharmaceutical companies. He holds stock in Autonomic Technologies.

[email protected]

On Twitter @alz_gal

WASHINGTON – Encouraging data on an external vagal nerve stimulator and a minimally invasive system that targets the sphenopalatine ganglion are propelling the two neuromodulation devices toward approval for headache, Stewart J. Tepper, MD, said at the Summit in Neurology & Psychiatry.

“This would bring to four the number of devices we now have available to us to treat headache,” said Dr. Tepper, director of research at the Dartmouth Headache Clinic, Lebanon, N.H. Two types are already available in the United States: a trigeminal nerve stimulator approved for migraine prevention and two brands of transcranial magnetic stimulators approved for acute treatment of migraine with aura.

Noninvasive vagal nerve stimulator

The gammaCore device (electroCore Medical) could be approved for cluster headache this year, Dr. Tepper said. A company spokesman said the company submitted its pivotal trial data to the Food and Drug Administration in 2015, but couldn’t offer any insight into how far the process has progressed.

©Christopher Robbins/Thinkstockphotos.com

“That application is currently under review, and we look forward to the FDA’s decision when it comes,” Eric Liebler, electroCore vice president for scientific, medical, and governmental affairs, said in an interview.

The gammaCore device is an external vagal nerve stimulator already approved in Canada and Europe for the treatment of primary headache disorders. In April 2016, it was approved in the United Kingdom as well, Dr. Tepper said at the meeting, sponsored by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

The device is a small, handheld unit that the patient uses twice each day, and which transmits mild current to the vagal nerve. It’s activated over the carotid pulse point on the neck for about 90 seconds. It’s thought to work by suppressing excessive extracellular glutamate and suppressing cortical spreading depression, Dr. Tepper said.

The most recent data for the gammaCore device, presented at the annual meeting of the American Headache Society (AHS) in June, suggest that it could also be beneficial in chronic headache and in menstrual migraine.

A 12-week, open-label study of 51 women with menstrual migraine looked at pain intensity, analgesic use, and migraine disability. Women used the device prophylactically, six stimulations each day for 3 days before and after the onset of menstruation. The mean number of menstrual migraine days each month declined significantly from 7.2 to 4.7. About 40% of the group had at least a 50% reduction in migraine days. Pain intensity also decreased significantly, as well as did the number of doses of analgesics. There were significant improvements on both the Headache Impact Test and Migraine Disability Assessment. One subject discontinued treatment due to dizziness during stimulation.

An 8-week study on cluster headache was published in May and updated at the AHS meeting. Investigators randomized 87 patients with cluster headache to standard therapy alone or plus the gammaCore device. The PREVA (Prevention and Acute treatment of chronic cluster headache) study determined that dual therapy reduced the number of weekly attacks by four, compared with standard therapy. A total of 40% of patients experienced at least a 50% response rate, compared with 8% of controls. A subanalysis presented at the AHS meeting showed that 18% of the dual-therapy group experienced at least a 75% response rate.

Implantable sphenopalatine ganglion stimulator

Dr. Tepper is particularly excited about the Pulsante device, an implantable, wireless sphenopalatine ganglion (SPG) stimulator manufactured by Autonomic Technologies, which he called “a dramatic change in paradigm,” for the treatment of cluster headaches.

The system consists of a neurostimulator about the size of an almond and a lead with six electrodes. It’s inserted under local anesthetic via a small incision in the upper gum on the side in which the patient experiences symptoms. The electrodes are positioned along the SPG nerve and the neurostimulator is affixed to the zygomatic process.

A handheld wireless controller placed against the cheek activates the device and controls the intensity of stimulation, which is thought to work by blocking signals to the postganglionic parasympathetic fibers. Those fibers innervate facial structures and the cerebral and meningeal blood vessels and are implicated in the pain and accompanying autonomic symptoms of a cluster headache attack.

“You can literally see this device working right before your eyes,” he said. “Patients having a cluster attack will exhibit ptosis, red watering eyes, nose running, and as soon as the device is turned on, you see the lid come up, the eye turn white, and the tearing and runny nose stop. This is an objective correlate to a subjective pain response. It’s dramatic and exciting.”

The pivotal Pathway CH-1study that led to European Union approval was small – just 43 patients – but found that half the cluster attacks could be terminated within 15 minutes of onset. About half of the patients, who had a decades-long history of cluster headaches, experienced close to a 90% reduction in attack frequency.

The latest Pulsante data were also presented in June at the AHS meeting. Two papers – one with 24-month data from the pivotal trial, and one with 12-month data from an ongoing registry study – were overwhelmingly positive, Dr. Tepper said.

The 24-month follow-up data to the pivotal study found that 61% of patients experienced a therapeutic response to SPG stimulation. Most attacks (79%) responded to stimulation alone without the need for abortive therapy. Most patients (64%) also experienced clinical improvements in preventive medication use. Twenty-one were able to reduce or even eliminate the use of preventive medications.

The registry study provided data on 85 patients. Of these, 68% experienced at least a 50% reduction in attack frequency; some reported close to a 90% reduction. A third of patients actually experienced some period of remission, and some patients who were not initially responders became responders after a year of treatment. Acute medication use declined by 52% overall and by 82% in those considered therapeutic responders.

“These data are extremely encouraging,” Dr. Tepper said.

Adverse events are minimal and most are related to implantation. A safety study of 99 patients found that adverse events included sensory disbranch, pain, and swelling, which resolved in 90 days.

The U.S. Pathway CH-2 Cluster Headache Study is now underway and aims to enroll 120 patients. “If the data are positive on this, the company will go ahead and pursue U.S. approval,” Dr. Tepper said.

Dr. Tepper has received personal remuneration and research funding from a number of pharmaceutical companies. He holds stock in Autonomic Technologies.

[email protected]

On Twitter @alz_gal

[WpProQuiz 10] [WpProQuiz_toplist 10]

[WpProQuiz 10] [WpProQuiz_toplist 10]

[WpProQuiz 10] [WpProQuiz_toplist 10]

The Diagnosis: Temporal Triangular Alopecia

Temporal triangular alopecia (TTA), also known as congenital triangular alopecia, was first described in the early 1900s.¹ It presents clinically as a triangular-shaped area of nonscarring alopecia either unilaterally or bilaterally. Limited clinical data suggest that most unilateral cases are on the left frontotemporal region of the scalp. In bilateral cases, there may be asymmetry in size of the area involved.² Dermatoscopically, TTA is characterized by decreased terminal hair follicle density as well as the presence of vellus hairs with an absence of inflammation.³ The majority of TTA is noted between birth and 6 years of life with the areas staying stable thereafter. Large areas of TTA may suggest cerebello-trigeminal-dermal dysplasia (Gomez-Lopez-Hernandez syndrome), a rare neurocutaneous syndrome characterized by rhombencephalosynapsis, trigeminal anesthesia, and parietooccipital alopecia (Online Mendelian Inheritance in Man 601853).⁴ Although TTA is largely idiopathic, it has been suggested that the trait may be paradominant, whereby a postzygotic loss of the wild-type allele in a heterozygotic state causes triangular alopecia and reflects hamartomatous mosaicism.⁵ It also is an important mimicker of alopecia areata. Correct identification prevents unnecessary treatment to the areas of the scalp. Hair restoration surgery has been reported as a tool to treat this disorder.⁶

The Diagnosis: Temporal Triangular Alopecia

Temporal triangular alopecia (TTA), also known as congenital triangular alopecia, was first described in the early 1900s.¹ It presents clinically as a triangular-shaped area of nonscarring alopecia either unilaterally or bilaterally. Limited clinical data suggest that most unilateral cases are on the left frontotemporal region of the scalp. In bilateral cases, there may be asymmetry in size of the area involved.² Dermatoscopically, TTA is characterized by decreased terminal hair follicle density as well as the presence of vellus hairs with an absence of inflammation.³ The majority of TTA is noted between birth and 6 years of life with the areas staying stable thereafter. Large areas of TTA may suggest cerebello-trigeminal-dermal dysplasia (Gomez-Lopez-Hernandez syndrome), a rare neurocutaneous syndrome characterized by rhombencephalosynapsis, trigeminal anesthesia, and parietooccipital alopecia (Online Mendelian Inheritance in Man 601853).⁴ Although TTA is largely idiopathic, it has been suggested that the trait may be paradominant, whereby a postzygotic loss of the wild-type allele in a heterozygotic state causes triangular alopecia and reflects hamartomatous mosaicism.⁵ It also is an important mimicker of alopecia areata. Correct identification prevents unnecessary treatment to the areas of the scalp. Hair restoration surgery has been reported as a tool to treat this disorder.⁶

The Diagnosis: Temporal Triangular Alopecia

Temporal triangular alopecia (TTA), also known as congenital triangular alopecia, was first described in the early 1900s.¹ It presents clinically as a triangular-shaped area of nonscarring alopecia either unilaterally or bilaterally. Limited clinical data suggest that most unilateral cases are on the left frontotemporal region of the scalp. In bilateral cases, there may be asymmetry in size of the area involved.² Dermatoscopically, TTA is characterized by decreased terminal hair follicle density as well as the presence of vellus hairs with an absence of inflammation.³ The majority of TTA is noted between birth and 6 years of life with the areas staying stable thereafter. Large areas of TTA may suggest cerebello-trigeminal-dermal dysplasia (Gomez-Lopez-Hernandez syndrome), a rare neurocutaneous syndrome characterized by rhombencephalosynapsis, trigeminal anesthesia, and parietooccipital alopecia (Online Mendelian Inheritance in Man 601853).⁴ Although TTA is largely idiopathic, it has been suggested that the trait may be paradominant, whereby a postzygotic loss of the wild-type allele in a heterozygotic state causes triangular alopecia and reflects hamartomatous mosaicism.⁵ It also is an important mimicker of alopecia areata. Correct identification prevents unnecessary treatment to the areas of the scalp. Hair restoration surgery has been reported as a tool to treat this disorder.⁶

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The average cost of U.S. hospital stays for injury or illness in patients discharged to postacute care is more than double that of visits with routine discharges, according to the Agency for Healthcare Research and Quality.

For patients who were discharged from hospitals to PAC, the average cost of an inpatient visit in 2013 was $16,900, compared with $8,300 for patients with routine discharges. The inpatient visits with PAC were almost twice as long as those with routine discharge – 7.0 days vs. 3.6 days – and patients with PAC-discharge visits were much older – 69.5% were aged 65 years or older, compared with 22.4% of visits with routine discharges, the AHRQ reported.

The AHRQ used data from the 2013 National Inpatient Sample (NIS) to estimates discharges to PAC for all types of payers and describe these discharges from the perspective of payers, patients, hospitals, conditions/procedures, and geographic regions.

The cost of stays varied considerably among the various PAC settings in 2013. Inpatient stays with discharge to home health agencies had the lowest average cost at $15,100, with skilled nursing facilities next at $16,600, followed by inpatient rehabilitation facilities at $24,200 and long-term-care hospitals at $36,800. Length of stays by PAC setting showed the same trend: those with discharge to home health agencies were shortest (6.2 days) and those with discharge to long-term-care hospitals were longest (13.5 days), the AHRQ said in the report.

Inpatient stays with discharge to PAC made up 22.3% of all hospital discharges in 2013, with the bulk being discharges to home health agencies (50.1%) and skilled nursing facilities (40.5%). Discharges to inpatient rehabilitation facilities made up 7.2% of all PAC visits, while those to long-term-care hospitals were just 2.2%, the data from the NIS show.

[email protected]

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed this patient with condyloma acuminata, also known as genital warts. The warts were well-keratinized since the patient was circumcised and the warts were not under foreskin. Genital warts found in the moist area under the foreskin of uncircumcised men tend to look more cauliflower-like.

Genital warts are caused by human papillomavirus infection, which encompasses a family of primarily sexually transmitted double-stranded DNA viruses. The incubation period after exposure ranges from 3 weeks to 8 months.

Anogenital warts are the most common viral sexually transmitted disease (STD) in the United States. There are approximately one million new cases of genital warts per year in the United States. Most infections are transient and clear up within 2 years, but some infections persist and recur, causing a great deal of distress for patients.

The diagnosis is usually clinical. Genital warts are typically asymptomatic and present as flesh-colored, exophytic lesions on the genitalia, including the penis, vulva, vagina, scrotum, perineum, and perianal skin. External warts can appear as small bumps, or they may be flat, verrucous, or pedunculated.

The FP discussed the patient’s history of unsafe sex and recommended that he receive screening for other STDs. The patient did not believe he had human immunodeficiency virus (HIV), but was willing to be tested for it and for syphilis. He denied any urethral discharge or burning on urination, but wanted to be screened for gonorrhea and chlamydia, as well. The FP ordered blood tests for syphilis and HIV and a urine screen for gonorrhea and chlamydia which were all negative.

After discussing treatment options, the patient opted to pursue cryotherapy. The FP sprayed the condyloma with liquid nitrogen using a freeze/thaw/freeze cycle and offered the patient a prescription for imiquimod cream. However, the patient preferred to return for additional cryotherapy. A follow-up appointment was set for 3 weeks.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:759-765.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

Tuberculosis caused by Mycobacterium africanum West Africa 2 is significantly less likely to be detected by a MPT64 rapid antigen test than is M. tuberculosis, according to a research team based in the Gambia.

A total of 173 MGIT culture-positive sputum samples were included in the study, and the initial MPT64 test was negative in 23 samples. Just over 90% of M. tuberculosis (MTB) samples converted to positive on day 0, while only 78.4% of M. africanum West Africa 2 (MAF2) samples converted. After 10 days, 97.5% of MTB samples were positive, while conversion of MAF2 samples remained low at 84.3%.

CDC/Janice Carr

In a comparison of the mRNA transcript from samples of six MTB and five MAF2 patients who had not been treated for TB, the MTP64 gene was about 2.5 times more abundant in the MTB samples than the MAF2 samples. No association was found between conversion to positivity and sex, age, therapy, or mycobacterial growth units.

“Given the relatively low cost, limited technical expertise, and shorter turnaround time associated with using rapid speciation tests, compared to alternative speciation methods, MPT64 rapid tests will likely remain one of the preferred options for timely diagnosis of suspected TB despite the possibility of false negative results. Therefore, a negative MPT64 result would require confirmation by an alternative method, such as molecular tests or culture on p-nitrobenzoic acid, depending on laboratory infrastructure and resources,” the investigators noted.

Read the full study in PLoS Neglected Tropical Diseases (doi:10.1371/journal.pntd.0004801).

[email protected]

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

You start your day refreshed, enthusiastic, and ready to take on every challenge that comes your way.

You print your list of patients for the day – not too bad, a mere 15; quite doable for a seasoned hospitalist. You scan your list: a hypertensive crisis – piece of cake; 3 patients with acute systolic heart failure – just follow the guidelines; 2 with a COPD exacerbation – no worries. You know how to treat these conditions, almost with your eyes closed. But, of course, all conditions do not have such straightforward treatments.

The next patient on your list is a 35-year-old on a methadone maintenance program admitted with an accidental heroin overdose. So sad. Then there is a 59-year-old with chronic back pain and known drug-seeking behavior, well known to you and your entire team. So frustrating. Next, you read about a healthy 24-year-old mother of two who slipped on a baby bottle and tumbled down two flights of stairs, breaking both femurs, a clavicle, and nine ribs.

As you mull over your approach to the first two, you cannot help but be concerned about the likelihood that this young mother will require strong narcotics to manage her pain for a considerable time, long after discharge. She has a legitimate reason to receive opioid analgesics, but how can you minimize her chances of becoming another statistic?

In 2012, an estimated 2.1 million Americans suffered from substance use disorders due to prescription opioid pain relievers while close to 467,000 were addicted to heroin.

To complicate matters, many who were legitimately prescribed painkillers go on to abuse heroin when they can no longer get prescription opiates from their health care providers. Naturally, we want to take away our patients’ pain, but in 2016 we must be keenly aware that every time we prescribe opiates for our patients there is a risk, whether great or small, that individual may some day suffer from a substance abuse disorder.

Evidence shows that the way the human brain deals with opiates, and subsequent opiate dependence, necessitates that we rethink how we view addiction. Addicts simply cannot be stereotyped as derelicts, always looking for their next high. They have a real disease.

According to the American Society of Addiction Medicine, addiction is a primary, chronic, and relapsing disease of the brain. When one thinks of addiction as a true disease, and not simply as a weakness of pleasure seekers with morals we deem beneath our own, it paints the addict in a completely different light.

We would never order a procedure or prescribe a medication that had more than a negligible risk of causing diabetes or hypertension. Remember, “First, do no harm?” Perhaps we should approach opiate prescribing by considering not only the immediate benefit our patients will receive, and thus how quickly they can be discharged, but the potential long term pain they may experience in the future should they become addicted.

The heroin epidemic has hit America with a vengeance. It is an equal opportunity destroyer with an unprecedented predilection to decimate lives in all communities – affluent, impoverished, and everyplace in between. It has no regard for race or ethnicity and knows no boundaries whatsoever.

No doubt, some of our most challenging patients are the ones who are least sick, medically speaking, but suffer from addictions that are beyond our expertise. They often require us to reach down much deeper than a textbook to find more understanding, more insight, more wisdom, and a huge helping of compassion, even in the midst of own frustration.

Sure, we want to relieve pain and suffering. There are few things as rewarding as doing so. Yet, because we have not understood the long-term consequences of writing an opioid prescription, health care professionals have played a tremendous role in the epidemic of addiction that is decimating lives. In the past, we simply didn’t know, but now we do and this knowledge empowers us to take the lead in turning around this monstrous epidemic.

I believe 3 simple steps can help us all become more responsible opiate prescribers and thus begin the long process of conquering the beast of addiction.

1. Think before you order. Is it possible that pain can be controlled with a non-narcotic medication, such as tramadol or NSAIDs?

2. Hone your prescribing skills by taking CMEs or simply reading reputable journal articles and other noteworthy resources.

3. Do not hesitate to consult your pain management service. Doing so does not denote weakness; it signifies wisdom and humility when you put your patient’s best interest above your pride. It’s honorable to “know what you don’t know” and seek help when needed.

Finally, I would like to dedicate this article to Mark, my 25-year-old, athletic father-to-be who accidentally overdosed on heroin long before his baby was born. May your child grow up in an America that rids itself of this drug nightmare long before he is old enough to know what drug addiction means. Rest in peace, Mark.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].