Absence

Some people have asked me about my absence on this blog lately. I have been preoccupied by a number of family matters which are much better now. I will be on vacation and resume regular blogging in August.

I have continued to follow the health care reform debates and am looking forward to see what versions the House and Senate will eventually agree upon. I doubt anything will be passed before the August recess. I think that would be good as the proposed deadline for legislation I have felt was too early given the complexity of the isues. I am sure that there will be reform and do not believe as some have said that this issue will die if action isn't taken immediately.

Thought for the day

" We need to be kind to one another".

A recent patient

Health Care Reform Medicare Payments

The views expressed in this blog are my own personal opinions and do not represent the view's  of Cottonwood nor it's administration.

The American Academy of Neurologists has sent a letter to Congress about some concerns regarding any health care reform. What they indicated in their letter is similar to what I have been saying on this blog, that current Medicare reimbursement is inadequate and undervalues many specialties. The letter was also signed off on by the American Society of Hematology, the American College of Allergy, Asthma, and Immunology, the American College of Rheumatology and the American Gastroentrological Association.

You might initially think that this is just some whining by doctors who make enough anyway, why should they be asking for more when we are at a time of cutbacks? But it is not whining. It is stating the reality that in today's medicine procedures are highly reimbursed while time spent with patients is not. I want to emphasize that. Time spent with patients is not adequately reimbursed, not under Medicare and certainly will not be under any Medicare like public health plan. We all want our doctors to take time for us, and these are specialties where time spent with patients is essential not only for diagnosis but for ongoing management of often difficult serious chronic diseases. A neurologist, hematologist, immunologist, or a rheumatologist cannot continue to support a practice at current Medicare reimbursement rates. It is as simple as that. We pay highly for any surgery or specialized procedures but not for taking time with patients.

This reality is not lost upon young physicians who simply are not entering these fields of medicine. Why would they? I think that the letter sent to Congress was a good idea and clearly states the problem but I don't anticipate any reimbursement rates under Medicare going up any time soon.

Thought for the day

If you won't pay for it you won't have it.

Chantix FDA Warning

The Food and Drug Administration has recommended a safety labeling change for varenicline( Chantix) which is manufactured by Pfizer and is used as an aid to nicotine cessation. This seems to me to be a good idea as it has been known to have psychiatric side effects in some people.

My experience with Chantix has been mixed. It clearly is effective and has worked for a number of my patients who were motivated to quit smoking. But I had a few experiences that have taught me a few lessons and made me more cautious about prescribing this medication. One case is that of Mrs.G, a 45 year old woman who was at Cottonwood for treatment of alcoholism. She had a history of depression and was on antidepressant medication although she was not depressed at the time of admission. She was doing quite well in treatment and understanding the link between tobacco use and alcoholism decided to quit smoking while she was here. She had tried quitting before with the help of the nicotine patch but was unsuccessful so I prescribed Chantix. About one week later she went into a profound depression which was worse than she had ever had before. There had been no apparent psychological trigger so we discontinued the Chantix and about 5-6 days later the depression had resolved completely. Fortunately she was able to quit smoking, used the nicotine patch again and was successful this time.

Not that long afterwards I had a similar experience with Mr. S., a 38 year old man who was at Cottonwood for treatment of polysucbstance dependence. He had a concurrent anxiety disorder which we treated along with his substance abuse problem. He did not want to attempt to quit smoking here but was doing well at the time of discharge so he decided it might be a good time to quit. I prescribed Chantix for him at the time of his going home and did warn him about the possibility of return of anxiety or depressive symptoms while taking Chantix. He called me in a frantic state about 10 days later saying he had a severe exacerbation of his anxiety disorder. I recommended he stop taking the Chantix and several days later his anxiety resolved. Interestingly enough to me he had not recalled our previous conversation about Chantix side effects. This taught me two lessons, first to not prescribe any new medication as the patient is leaving, and secondly a reminder that many patients have too much to remember and may not remember verbal instructions.

It has been known since February of 2008 that some people on Chantix develop behavior changes, depression, or suicidal thoughts. The manufacturer Pfizer did not attempt to hide this data but immediately made changes in the product labeling to include these side effects. What is new in the FDA recommendation is that Chantix carry a "black box " warning in the prescribing instructions. The black box warning means that this information is highlighted in bold letters in a black box which is the first thing a prescriber will see when looking up the medication.

Does this mean Chantix should not be used? This information about Chantix needs to be taken to account in the context that tobacco related illnesses are by far the greatest cause of death in the United States. The people that I see at Cottonwood though may represent a high risk group for psychiatric side effects so will continue to use Chantix only when other smoking cessation efforts fail.

Thought for the day

I will say it once more. All medical treatments carry some risk as well as their benefits.

Suicide Alcohol Abuse Link

A recent report in the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report (MMWR) confirmed what many of us in the substance abuse field have long seen, the connection and link between suicide and alcohol abuse. Here at Cottonwood we see many patients who have made suicide attempts, sometimes multiple attempts, in states of intoxication but who never struggle with suicidality when sober. The report does not touch on non successful suicide attempters but indicates that 24% of those who die from suicide showed evidence of alcohol intoxication.

It is not surprising to me that the CDC was able to clearly establish a link. The rates are lower than I expected , though they were higher than the CDC researchers expected. One important finding was that alcohol involvement was a factor across all populations and age groups. It highlights the need for all suicide prevention programs and all mental health centers to address substance abuse problems as a major part of treatment. Unfortunately this is not usually done to to funding issues and historical precedent. I am very happy that I work at a facility that takes both mental health problems and substance abuse problems as truly co occurring.

Thought for the day

We cannot address mental health problems without addressing the substance abuse problems that are highly prevalent and co occurring.