The use of antipsychotic medication in nearly 100 Massachusetts nursing homes was significantly reduced when staff was trained to recognize challenging behaviors of cognitively impaired residents as communication of their unmet needs, according to a new study led by Jennifer Tjia, MD, MSCE, associate professor of quantitative health sciences. See article at News Medical.  Results of the study were published in JAMA Internal Medicine on April 17.

This study examined the rate of off-label antipsychotic use in 93 Massachusetts nursing homes enrolled in the OASIS intervention from 2011 to 2013, compared to 831 nursing homes in Massachusetts and New York who were not using that program, (although some were using a different reduction program.) Among OASIS facilities, the prevalence of antipsychotic prescriptions was cut from 34 to 27 percent after nine months, a 7 percent drop. At the comparative facilities, the prevalence of those drugs was cut from 23 to 19 percent; a 4 percent drop. No increases in other psychotropic medicine or behavioral disturbances were observed. Over the maintenance period of the intervention, however, the decreases did not continue.

This is the largest study to show that it is possible to reduce antipsychotic use in the nursing home population,” said Dr. Tjia. “This intervention focused on treating the residents as human beings with needs, not as patients with problems. We don’t medicate babies when they cry or act out, because we assume that they have a need that we need to address. However, when people with dementia are unable to communicate, the current approach medicates them when they have undesirable behaviors.”

The off-label prescription of antipsychotics for nursing home residents with dementia is common and dangerous, despite numerous studies that have shown it increases risk of stroke and death and is only minimally effective in controlling behavioral symptoms of dementia.

“The OASIS program asks nursing staff to create care plans that include what residents can do, shifting away from the model that focuses on what they can’t do,” Tjia said. “This is a fundamental shift in how to think about caring for persons with dementia and we showed that it is effective.”

“Since 1987, no fewer than 11 controlled studies have been published that report varying efficacy in reducing antipsychotics in nursing homes using a variety of approaches. The largest successful intervention enrolled 12 nursing homes; however, it was time and resource intensive. In contrast, the OASIS program reached almost 100 nursing homes, and was effective,” Tjia said.

Tjia said nursing homes using the OASIS program need to reinforce training periodically to maintain success at reducing the rate of antipsychotics.

The Conservative Review had an article by Logan Albright, a researcher for Conservative Review and Director of Research for Free the People, on the AARP’s multi-year investigation into the practices of America’s nursing homes. Below are excerpts:

In an alarming number of cases, elderly residents have been given powerful and dangerous drugs without their consent. In addition to the illegality and the moral transgressions against the residents’ autonomy, in some cases this practice has had deadly consequences.

Antipsychotic drugs are routinely used in nursing homes, often without good reason. According to research from the University of California, San Francisco, up to one in five patients in 15,500 nursing homes has been inappropriately prescribed a dangerous drug.

Patients are simply an inconvenience to staff, and keeping them drugged up makes them more manageable.  The pretense of “medical care” is used to give legitimacy to what would otherwise be a crime.

American society is now at a stage in which unproven allegations of mental incompetence can be used to rob our fellow human beings of their liberty and their dignity, with only the opinion of a so-called expert required to do so. And while the legal team of the AARP has won some commendable victories in exposing wrongful death and mistreatment of the elderly, these cases only scratch the surface of the deeper problem.

The elderly do not cease to be human. Their rights are not forfeited when they reach a certain age. That they should be so misused against their wills is a damning indictment of a system that ought not be possible in “the land of the free.”

 

Bobby Glenn Tweed was admitted to a nursing home in January 2013.  While diagnosed with dementia, Tweed, 78, was still a vigorous man. But without his family’s consent, Tweed was given dangerous psychotropic drugs that are known to be fatal among older patients with dementia. In 10 months, he was dead.

The AARP reported the that with the help of AARP Foundation lawyers, Tweed’s family settled a wrongful death lawsuit against the nursing home and others that were responsible for caring for their father. Terms of the settlement are confidential.

The dangerous overuse of psychotropic drugs in nursing facilities received widespread national attention from an AARP Bulletin investigative report in the July-August 2014 issue.

“After that story, we started hearing from people all over the country whose loved ones suffered because they had received these drugs often without consent,” said Kelly Bagby, senior attorney with AARP Foundation Litigation.

“These lawsuits are among the efforts of AARP Foundation to help address this nationwide health crisis,” Bagby said. “Unfortunately, what happened to Mr. Tweed has happened to countless others.”

The practice is done for the convenience of understaffed nursing homes where the care is inadequate, according to experts.

 

Vox had two great articles on the opiod crisis.  Drug overdoses now kill more Americans than HIV/AIDS did at its peak. In 2015, more than 52,000 people died of drug overdoses, nearly two-thirds of which were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. That’s more drug overdose deaths than any other period in US history — even more than past heroin epidemics, the crack epidemic, or the recent meth epidemic. And the preliminary data we have from 2016 suggests that the epidemic may have gotten worse since 2015.  Vox has maps and charts that tell the story:

  1.  Drug overdoses now kill more people than gun homicides and car crashes combined.
  2. Drug, painkiller, heroin, and other opioid overdose deaths are still on the rise.
  3. Opioid overdoses are one reason US life expectancy declined for the first time in decades.
  4. The epidemic is much worse in some states than others.
  5. By and large, the drug overdose epidemic has hit white Americans the hardest.
  6. Americans consume more opioids than any other country.
  7. In some states such as South Carolina, doctors have filled out more painkiller prescriptions than there are people.
  8. Drug companies have made a lot of money from opioids.
  9. At the same time, Americans report greater levels of pain.

A Senate investigation into the pharmaceutical companies’ role and responsibility for the nation’s worst drug overdose crisis in history:  Sen. Claire McCaskill (D-MO), the top Democrat on the Senate Homeland Security and Governmental Affairs Committee, announced that she is requesting marketing, sales, and addiction study material from the companies behind America’s top five opioid products. The investigation, she said, will draw out the role that opioid manufacturers played in causing the epidemic and letting it continue.

As USA Today noted, McCaskill will need Republican support on the committee to be able to subpoena opioid makers’ documents should the companies not comply with her requests.

Drug manufacturers played a major role in the epidemic. By marketing their opioid painkillers as safe and effective, they convinced doctors to prescribe painkillers in droves to patients. That allowed the drugs to proliferate, leading not just to widespread painkiller misuse but also to the misuse of more dangerous opioids like heroin and illegally manufactured fentanyl. With this, the risk of overdose increased — spawning the opioid crisis we have today. As opioid painkiller sales increased, more people got addicted — and died.Annual Review of Public Health

Much of this was the result of misleading marketing by major drug companies. In fact, Purdue Pharma, a producer of “hillbilly herion” OxyContin, in 2007 was forced to pay hundreds of millions of dollars in fines due to its false claims about opioids.

In wide-ranging investigations, the Los Angeles Times has uncovered more evidence of how Purdue’s misleading advertisement played out at the ground level. It found that Purdue exaggerated the effectiveness and safety of OxyContin, while covering up any criticisms and complaints about the drug. As a particularly egregious example of why Purdue and its marketers did this, one sales memo uncovered by the Times was literally titled “$$$$$$$$$$$$$ It’s Bonus Time in the Neighborhood!”

Other opioid makers have faced similar allegations. Insys, a drugmaker, allegedly pushed its fentanyl spray for uses far beyond late-stage cancer pain treatment, according to McCaskill’s office. A sales representative claimed that the company’s informal motto was, “Start them high and hope they don’t die.”

A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

KCUR had an interesting article on how one Kansas facility has reduced dangerous antipsychotic drugs provided to nursing home residents.

Antipsychotic medications are commonly used to treat mental illness, but they’re not approved for treating dementia. The U.S. Food and Drug Administration has issued a “black box” warning outlining the significant side effects the medications can have if used improperly.

The federal Centers for Medicare and Medicaid Services launched an initiative to reduce their use in nursing homes in 2011, when nearly 24 percent of long-stay nursing home residents nationwide were on the drugs.

Janell Wohler and Kate Rieth of the Linn Community Nursing Home believes that it doesn’t have to be that way. Wohler is the administrator and Rieth is the director of nursing at the facility, which has eliminated off-label use of antipsychotics for residents over the last five years. The two led a presentation on “Antipsychotic Reduction in Action” at a conference of Kansas nursing home administrators in Manhattan.

Rieth said it’s a matter of educating staff to look for the underlying reasons behind residents’ non-compliant behavior and addressing those, rather than reaching for a phone to call a doctor who can prescribe a “chemical restraint.”

“Doctors are fixers,” Rieth said. “And how do they fix things? With medicine.”

The “fix” can do more harm than good, with side effects that include increased risk of infections, blood clots, stroke and death.  In addition to meeting basic needs like hunger and thirst, they said their facility focuses on keeping residents with dementia busy with activities, including a “Music and Memory” program.

The solution in these situations is more staffing and better training, not medications.  Rieth and Wohler said it had not been an easy process to wean staff from the quick fix of calling a doctor, but it’s worth it.

 

New York Magazine had a great article on the epidemic of opioid deaths and who and what is to blame.

“During the worst year of the HIV/AIDS crisis, 43,000 Americans lost their lives to the virus. In 2015, 52,000 died of a drug overdose. Never in recorded history had narcotics killed so many Americans in a single year; the drug-induced death toll was so staggering, it helped reduce life expectancy in the United States for the first time since 1993.”

The article suggests that “a great deal of blame belongs to our system of pharmaceutical patents, and the sociopathic greed that it incentivizes.” The for profit pharmaceuticals companies spend upwards of $200 million a year lobbying Congress to ensure that no profit-reducing regulations are imposed on them.

Pharmaceutical research is an expensive and uncertain endeavor therefore the government provides pharmaceutical companies with a motivation for researching new drugs — and a means of recouping losses from failed experiments — by offering those companies a temporary monopoly on newly discovered medications. This formula for pharmaceutical innovation has many downsides including legal price-gouging that patent monopolies enable and concealment of the harmful effects of their products.

“American doctors have been free to prescribe morphine and other generic opioid painkillers since the early 20th century. But they started prescribing such narcotics at drastically higher rates in the mid-1990s, when Purdue Pharma patented OxyContin, and began aggressively marketing the drug to doctors and patients.”

The problem with this focus is that there’s little evidence that treating chronic pain with opioids is effective — and a lot of evidence that it’s dangerous. The Centers for Disease Control and Prevention have concluded that there is “insufficient evidence” that opioids provide effective pain relief when taken for a period of longer than three months.

A recent study by the Center for Economic and Policy Research found that the total cost of OxyContin abuse in the U.S. between 1998 and 2007 — as measured by spending on “abuse treatment, medical complications, productivity loss (minus mortality), and criminal justice proceedings” — totaled $38.6 billion.

The CDC has also concluded that roughly a quarter of those who use opioids on a long-term basis become addicted. But you can make a lot of money selling dope to addicts; and Mundipharma has shown little deference to the CDC’s findings.

In 2007, Purdue and three of its executives pleaded guilty to federal charges of misbranding drugs — and were forced to pay a $635 million fine (a sum far lower than their profit of $35 billion). But by then, 29,600 Americans had already died of OxyContin overdoses – and the notion that opioids were a low-risk treatment for chronic pain had become widespread.

 

The Chicago Tribune reported that half of pharmacies fail to warn consumers of drug interactions and contraindications.  In the largest and most comprehensive study of its kind, the Tribune tested 255 pharmacies to see how often stores would dispense dangerous drug pairs without warning patients. Fifty-two percent of the pharmacies sold the medications without ever mentioning the potential harmful interaction, striking evidence of an industry wide failure that places millions of consumers at risk.

Pharmacists failed to catch combinations that could trigger a stroke, result in kidney failure, deprive the body of oxygen or lead to unexpected pregnancy with a risk of birth defects.

Dangerous drug combinations are a major public health problem, hospitalizing tens of thousands of people each year. Pharmacists are the last line of defense, and their role is growing as Americans use more prescription drugs than ever. One in 10 people take five or more drugs — twice the percentage seen in 1994.

The Tribune study, two years in the making, exposes fundamental flaws in the pharmacy industry. Safety laws are not being followed, computer alert systems designed to flag drug interactions either don’t work or are ignored, and some pharmacies emphasize fast service over patient safety. Several chain pharmacists, in interviews, described assembly-line conditions in which staff hurried to fill hundreds of prescriptions a day.

In the fight to protect patients from dangerous drug interactions, doctors shoulder significant responsibility. They are the ones who write the prescriptions.  However, in filling prescriptions, pharmacists are uniquely positioned to detect potential drug interactions, warn patients and prevent harm. Pharmacists themselves say that is one of their primary duties.

Carmen Catizone, executive director of the National Association of Boards of Pharmacy, said the professional standard is clear. “Anytime there’s a serious interaction, there’s no excuse for the pharmacist not warning the patient about that interaction,” he said.

 In 2012, the nonprofit Institute for Safe Medication Practices conducted a national survey of 673 pharmacists and found that nearly two-thirds worked at stores that track the time it takes to fill prescriptions. About 25 percent worked at companies that guaranteed short wait times.

In 2013, the National Association of Boards of Pharmacy called on states to prohibit, restrict or regulate company policies that measure the speed of pharmacists’ work. If pharmacists fall behind, the backlog pops up in color on their computer screens, said Chande, also a former union steward. “It’s an unreal pressure,” he said. “Your mind is kind of frantically trying to obey it.”

In response to the Tribune tests, CVS, Walgreens and Wal-Mart each vowed to take significant steps to improve patient safety at its stores nationwide. Combined, the actions affect 22,000 drugstores and involve additional training for 123,000 pharmacists and technicians.

 

 

 

 

 

The Atlantic had a great article on the recent report on life expectancy in America.  There is some good news and some bad news.  Young Americans are dying at a faster rate.  Elderly Americans are extending their life expectancy.

A pair of new studies suggest Americans are sicker than people in other developed countries. The studies suggest so-called “despair deaths”—alcoholism, drugs, and suicide—are a big part of the problem, but so is obesity, poverty, and social isolation.  Deaths from unintentional injuries, including drug overdoses, are up, rising by 10,000 since 2014 which can partly be explained by the epidemic of heroin and prescription-painkiller abuse.

American life expectancy fell by one-tenth of a year since 2014, from 78.9 to 78.8, according to a report released last week by the National Center for Health Statistics. Meanwhile, the number of years people are expected to live at 65 remained unchanged, suggesting people are falling ill and dying young.Heart disease and cancer were the most common causes, accounting for nearly half of all deaths. Still, cancer deaths are declining, while deaths from all other causes, including heart and lung diseases, strokes, Alzheimer’s, diabetes, and suicides have ticked up.

Much of the increase in mortality can be explained by obesity. However, poverty and its associated struggles, such as depression, stress, and poor nutrition, are also clearly playing a role. Americans are hit harder than other rich countries are by these forces, because of lack of preventive health care and because “the U.S. has higher income inequality and less comprehensive social safety net, so the ill-effects of poverty may take an undo toll.”

One paper published this month suggested that Americans would live nearly four years longer if the U.S. had a safety net as generous as those of European countries. Nationally, better health-care access could improve mortality rates. But if Obamacare is repealed, 30 million Americans might lose their health insurance coverage as early as January—unless, of course, Trump can create a better plan.

The Observer-Reporter had a disturbing article about Amy C. Durbin, a registered nurse from Greensboro, who worked at the assisted-living facility previously known as Golden Living Center (now known as Waynesburg Healthcare and Rehabilitation Center).

Durbin is accused of not logging prescription drug reports for medication she was supposed to be giving to patients.  Twelve charges of prohibited acts for fraudulent or omitted drug reports were filed against Durbin.

“Agent Andrew Sakmar wrote in court documents his investigation began in March after the office was notified of the nursing home’s internal investigation into medication that was unaccounted for. Durbin allegedly was not documenting medication administration properly for controlled substances, according to the criminal complaint.”

Records indicate Durbin was “withdrawing medications which were unaccounted for by documentation on pain evaluation forms and were not recorded as administered to patients on medical administration records,” the complaint said.  The medications include 40 oxycodone pills and six hydrocodone-acetaminophen pills, investigators said.

Durbin allegedly became “verbally hostile,” refusing to come into work to be questioned or tested.

The Indiana Gazette reported the guilty pleas of Lance D. Shirey and Tonya R. Shirey, the owners and operators of Shirey Personal Care Home, charged in the death of Gary Armstrong.  Armstrong died of a fentanyl overdose from his prescribed patches. In a plea agreement, each pleaded guilty to a charge of recklessly endangering another person.

In an affidavit of probable cause, the Office of the Attorney General and Department of Human Services said the keeping of medication logs and failure to recognize overdose symptoms led to the death of Armstrong on May 8, 2014.

Investigators said Lance Shirey told them he saw Armstrong chewing on something between 4:30 and 5 p.m. May 7, but assumed it was food. Tonya Shirey told DHS interviewers that Lance told her he thought it could have been a patch.

Lance Shirey told investigators he found a chewed gel patch in Armstrong’s hand between 8 and 8:30 p.m. and that the patient was slumped over. Armstrong was then put to bed unresponsive.

An aide said she and Lance and Tonya Shirey went into Armstrong’s room at 10 p.m. to change him due to a leaking catheter bag and noticed his breathing was hard and raspy and that bubbles were coming out of his mouth. The aide and Tonya Shirey discussed calling 911. The aide couldn’t find a fentanyl patch on Armstrong’s body and found a patch in his mouth, but it was erroneously believed it to be a nicotine patch.

At 1 a.m., the aide said he did not seem to be breathing and had a weak pulse. She woke Lance and Tonya Shirey, placed Armstrong on the floor and gave CPR. Medical responders stopped their rescue attempts at 1:44 a.m.

DHS said Tonya Shirey told them they had problems keeping track of Armstrong’s fentanyl patches. Investigators said they also detailed other problems with medication logs.

A doctor from Pennsylvania Toxicologists P.C. told investigators it was “gross negligence” that the personal care home failed to initiate an emergency response when he was first found unresponsive at 8 p.m. and again at 10 p.m.