OxyContin Tamper Resistant

A US Food and Drug Administration (FDA) advisory panel has recommended approval for a new formulation of controlled release oxycodone (OxyContin). As those of us in the addiction field well know Oxycontin is a significant drug of abuse with high addictive potential and dangerous and life threatening if taken in overdose. As I have mentioned before, oral opioids such as OxyContin except for alcohol and nicotine are the drugs of choice for youth today, surpassing that of marijuana. But people don't just take OxyContin orally. They crush it and then snort it, smoke it, or inject it and the physical dependence rises dramatically with this kind of use.

Purdue pharmaceuticals have made a new version of OxyContin, OxyContin TR (tamper resistant) which is designed to release less of the drug when chewed or crushed. It is supposed to turn into some kind of gel when it is dissolved in water. However, there is no current evidence to show that this formulation is safer or less abusable than the current formulation. Purdue plans to replace 90% of the OxyContin supply within 6-8 weeks of getting the final FDA approval.

Maybe it will be less abusable than the current formulation. I doubt it will be any safer. But I know someone very quickly will find a good way to use the gel it turns into and find a way to abuse it.

Thought for the day

The more things change the more they remain the same.

Quantitative EEG Biomarker Depression

One of the problems that we have had in the medication treatment of depression is that we don't have a way of predicting who will respond well to any given antidepressant. Because it takes up to several weeks for any antidepressant to be effective it often takes a long time to find the right medication that the patient will respond to and which has tolerable side effects. This is very frustrating both for the patient and the provider and results in long periods of suffering. What we have needed is some way, a biomarker which can predict accurately very early on whether the medication will effective or not. Aspect Medical Systems claim they have found one such biomarker.

There are two studies being published in the September issue of Psychiatric Research from what is being called the Biomarkers for Rapid Identification of Treatment Effectiveness study. The first report is of 375 patients aged 18-75 who suffered from major depression. Using the non invasive technique of quantitative electroencephalography the researchers report they determined after one week of treatment by measurements in the prefontal cortex who would respond to the antidepressant escitalopram (Lexapro). They reported that they could accurately predict what was going to happen at seven weeks with 74% accuracy.

The second study reported by the same researchers on the same group of patients showed that for those who did not show the biomarker on quantitative EEG that those switching to the antidepressant buproprion (Wellbutrin) were 1.9 times likely to respond to the new drug. It sounds very promising ..... but......

The research was highly funded by Aspect Medical Systems which makes the electrodes used in the study. Although the researchers are supposed to be independent the lead investigator disclosed that he has provided scientific consultation or served on the advisory board of Aspect Medical Systems and that he is also a minor stockholder as well.

The need for a biomarker is so great that this testing may be used on many patients before there has been any time to assess if anyone else can replicate their results. The quantitative EEG device is already in use for other conditions so already has FDA approval. The technique carries almost no risk greater than the hassle of getting the electrode goop out of your hair. So I am not concerned about any harm to patients but rather that many providers may be buying these devices, and using them prematurely before the evidence is in (and making a lot of money for the procedure charges).

Thought for the day

Sometimes only time will tell.

Drumming: Honoring Your Internal Rhythms

As part of the InnerPath experience at Cottonwood Tucson,we drum. Yes, drum! We bring in a full sized West African djembe for each participant, and they play it. Not only do they play it, by the end of the session they are 'jammin!' So what does the drum have to do with the InnerPath process?

We know intuitively, and now research has shown, that drumming elevates immune levels, releases stress, and literally alters our brain waves to reflect a more centered, joyful, alert state. Drumming not only lifts spirits, it directly connects us to our internal rhythms, and our ability to honor those rhythms as we relate with others. The practice of drumming with others serves as a great metaphor for working in synergy and relationship in all areas of life - and it delivers a full dose of joy and laughter while centering the mind and calming the nervous system.

When we focus on this simultaneously meditative and energizing practice, we receive immediate benefits, relevant to our personal process and our healing journey. And even more importantly, it requires no previous musical experience whatsoever! No wonder the drum's ancient medicine has been utilized cross culturally for centuries. The power of the beat, the energy of the rhythm, and the excitement of the community groove we create transforms lives, every time.

Kenya S. Masala is a national corporate development trainer and human development consultant, and co-director of Source Consulting Group.

Kenya is a dose of core invigoration for organizations and communities. With a charismatic style and effusive energy, he engages everyone in highly effective (and authentic) leadership and workplace development. He ushers groups through the hard work of growth and expanding excellence. Utilizing cutting edge kinesthetic modules, he inspires them to success.

Kenya facilitates trainings, leadership development programs, outdoor adventure excursions, and phenomenal percussion programs. He also designs and develops multimedia curricula and interactive presentations on a national level. He is a REMO endorsed recreational rhythm facilitator and one of the North American Drum Cafe facilitators. He has published his first book, "Rhythm Play!™" and released two first full-length albums, Soul Journey Groove and Spacious Time.

Kenya enthusiastically creates a highly effective learning context, authentically motivating individuals and groups towards excellence.

Medicare End of Life Care part 3

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

I want to finish up on the topic of end of life care as it is an issue that needs to be faced which hasn't happened in this year's political debates on health care reform.

I will briefly recap the problem. Medicare is going broke. At current spending levels all asserts will be depleted in eight years. To save Medicare it will require a significant increase in payroll taxes as well as spending reductions. The 2009 Annual Report of the Medicare Board of Trustees indicated that payroll taxes may have to be raised to 6.78% (currently it is 2.9) and spending may have to be reduced by as much as 50%. That's a large reduction! So where are these reductions going to come from? They will come from where the money is now and that is in end of life care which currently takes 27.4% of the entire Medicare budget. 40% of that amount is spent in the last thirty days of life. The reality is that we will have to come up with some solutions that are neither "death panels" and'"We are not going to pull the plug on Grandma". At some point the plug will be pulled on Grandma and someone will be making those decisions.

I am not hopeful that we will have this debate in the public arena as we need to. It would be political suicide for a congressman or senator to bring up the idea of reducing end of life care. So I believe that we will not have this debate but that changes will come gradually with no thought or foresight.

I fear that the first change will be limitations on dialysis for end stage renal disease. Medicare pays for all dialysis regardless of age and the costs are over 6 billion dollars per year. I am concerned that we are not going to go about rethinking use of dialysis but just slowly to provide subtle encouragement for patients to voluntarily cease dialysis at some point. I don't know. I can't really say what will happen. I certainly don't have any solutions to the problem, but I do hope at some point in the near future we can have a public debate on this issue which is not going to go away by hiding from it.

Thought for the day

There is no reason we can't have that debate here. I encourage any readers to make comments or raise questions about this issue.

Cottonwood Web New Look

The Cottonwood web site has a new look! We have been in the process of changing the site for several months and I am really happy with the results. It is very user friendly and it is easy to link to a number of pages that provide good information on the types of disorders that we treat here at Cottonwood.It is also easy now to learn about our treatment staff and who we are.

I encourage any readers of this blog to check out the new site at

www.cottonwooddetucson.com

Thought for the day

Give thanks to the Lord for He is good, his mercy endures forever.

Medicare End of Life Care Part 2

I want to continue to talk about the issue of end of life care and Medicare, and point out some of the problems we are going to have to come to terms with without the rhetoric of "death panels'" and "We are not going to pull the plug on Grandma".

I am using the definition of end of life care to include all the medical services and costs associated with treatments provided in the last year of a person's life. Since the majority of deaths are in patients 65 and older Medicare is the primary payor for these services and it is important to know what I pointed out yesterday in that Medicare is going broke and it is projected that within eight years all assets will be completely depleted. This is a dire circumstance and one that is being avoided by both political parties in all the discussions about health care reform.

So how does this relate to end of life care? 80% of people who die here in the United States are Medicare beneficiaries. 27% of Medicare's total budget is spent on last year of life care with 40% of that in the last 30 days of life. Any reductions in Medicare costs is going to have to take into account end of life care with the goal of having more people who die of chronic terminal illnesses die at home or in hospice care rather than in hospitals. Hospital care results in greater costs not just for the hospitalization itself but all the expensive tests including MRIs and laboratory work. Many of these costs are for treatments that may extend the life span of someone with a chronic terminal illness by one or two days. That will have to change. Unfortunately, most people don't have access to hospice care and ethnic minorities have even less access that whites.

I am not saying that limiting end of life care is a good thing. But it will have to be done and this is an area that is being avoided in all the various discussions about health care reform.

Thought for the day

One of the problems of deliberate rationed care is that someone has to do the rationing.

Medicare End of Life Care Part 1

Lost in the rhetoric about "death panels" and "We're not going to pull the plug on Grandma" in health care reform there is a real issue that we are going to need to come to terms with and that is we can no longer afford to pay for end of life care as we are now doing. End of life care can be defined as those treatments and costs associated with the last year of an individuals life. Because most end of life care is provided through Medicare for the elderly I want to talk first a little bit about our current Medicare dilemma.

We already have a form of socialized medicine in the United States and that is Medicare. Medicare is a public plan in which the Federal government is in effect the single payor. Medicare pays for treatment for all individuals over 65 as well as paying for the disabled and those on renal dialysis. There are approximately 45 million people now covered by Medicare. Our current dilemma is that Medicare is running out of money. This is one of the reasons I have been opposed to a "public plan" option in health care reform. We are in dire straits to pay for those already on the public Medicare plan. We simply can't afford to add the estimated additional 45 million people that would be covered under such a plan.

So what is our situation now? The Medicare Board of Trustees in it's 2009 annual report indicate "The projected long term costs are not sustainable under current program parameters". "Medicare's financial situation is much worse (than Social Security)". The report indicates that by 2012 the projected assets of the Hospital Insurance Fund will drop below annual expenditures and that by 2017 the resources will be "exhausted". In just eight more years Medicare will be out of money completely. The report indicates that it will take 75 more years to bring Medicare back in balance but that is only if there is "immediate" change by increasing payroll taxes by 134% from what is now 2.9% to 6.78% or by a 53% reduction in outlays or some combination of the two. I don't anticipate we will see either of these actions anytime soon as it would be political suicide for any member of Congress to propose this.

So how does this affect end of life care? I will discuss that over the next several days.

Thought for the day

Both political parties are avoiding the Medicare issue in all the discussions about health care reform.

INTUNIV Attention Defict Hyperactivity Disorder

Shire pharmaceuticals has announced the release of a new medication for Attention Deficit Hyperactivity Disorder (ADHD). They have received FDA approval to market and sell INTUIV which is a long acting form of the medication guanfacine. Guanfacine is a medication that is used to treat high blood pressure but has long been used as a third or fourth line treatment for ADHD when stimulants, Strattera, or imipramine were unsuccessful or could not be tolerated or safely used. It has a chemical cousin, clonidine, which also has been used. Now guanfacine has been approved as a first line treatment.

Guanfacine has been approved for the use in children and adolescents ages 6 - 17. It is thought to work by affecting norepinephrine receptors in the prefrontal cortex, an area thought to be implicated in ADHD. Gunfacine is not a controlled substance, is not a stimulant, and has no abuse potential. Like many medications it has it's potential drawbacks as well. Common side effects are sedation, headaches, fatigue, upper abdominal pain and small changes in heart rate and blood pressure. In some patients it can cause a potentially dangerous drop in blood pressure and heart rate leading to fainting episodes. It should not be mixed with any othrt medication that can lower the blood pressure or heart rate.

Having another option for ADHD, particularly one that is not abusable is welcome. It is good to have another first line treatment. It does bring up the point I have made before about the need for caution in using any of the ADHD medications as they all have some effects on the cardiovascular system. It is my belief that all patients who are going to take these medications should have a prescreening electrocardiogram to help rule out any underlying heart disease. Not everyone agree with me about this. The American Heart Association does but the pediatric and pediactric psychiatry organizations have not yet adopted this viewpoint. I hope they will.

Thought for the day

All medical treatments have risks as well as benefits.

President Obama Education Speech

I was surprised to learn that there has been some controversy over Presdent Obama's planned speech to schools nationwide. On Tuesday September 9th the president will be addressing school aged children directly encouraging them to work hard and stay in school. His address will be broadcast on CSPAN at noon EDT when students across the nation can tune in to hear the president speak directly to them.

There has been some controversy with a number of people concerned that President Obama will be using this format as an opportunity to further his administration's agenda. The same thing was said about George H.W. Bush when he made a similar address in 1991. Unfortunately a number of school districts do not plan on showing the speech. This is too bad. Education is vital and the president of the United States can have a great affect on many students, providing for many much needed encouragement not to drop out but to work hard to reach their goals.

The proposed speech will be posted on line on Monday and I hope this can alleviate what I feel are misplaced concerns.

Thought for the day

Education is essential to maintain a working democracy.