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Trump support high in counties with chronic opioid use
Chronic use of prescription opioid drugs correlated with support for the Republican candidate in the 2016 U.S. presidential election, according to a cross-sectional analysis published in JAMA Network Open.
The mean Republican presidential vote was 60% in U.S. counties with significantly higher-than-average rates of prescriptions for prolonged opioid use, versus 39% for counties with significantly lower rates, according to the study, which was based on prescription data for Medicare Part D enrollees (JAMA Network Open. 2018;1(2):e180450).
Those findings suggest the importance of economic, cultural, and environmental factors in the opioid epidemic, according to study author James S. Goodwin, MD, of the University of Texas Medical Branch, Galveston, and co-authors.
“Public health policy directed at stemming the opioid epidemic must go beyond the medical model and incorporate socioenvironmental disadvantage factors and health behaviors into policy planning and implementation,” Dr. Goodwin and co-authors wrote.
The cross-sectional analysis included data for 3.76 million Medicare Part D enrollees. They looked specifically at the proportion of enrollees with chronic opioid use, which they defined as receipt of at least a 90-day supply in 1 year.
After adjusting for age, disability, and other factors, they found 693 out of 3,100 counties (22.4%) had rates of chronic opioid use higher than the mean, and 638 (20.6%) had rates lower than the mean. The correlation between opioid use rates and the presidential vote was 0.42 (P < .001), according to investigators.
They also published two county maps that they said shared some similar patterns. The first shows the proportion of older chronic opioid users by quintile, and the second shows Republican vote percentages, also by quintile. The correlation coefficient between those two rates was 0.32 (P < .001).
This study adds to the emerging literature on the relationships between health status and support of Donald Trump in the 2016 election, according to authors.
However, there were limitations to the study, they added. Of note, the presidential vote data was from 2016, but the information on prolonged opioid prescriptions was from 2015. Moreover, the voting data included all voters, while the opioid data came only from Medicare Part D enrollees, which represent about 72% of the full Medicare population.
One study author reported grants from the National Institute on Drug Abuse and Agency for Healthcare Research and Quality. Another reported membership in Physicians for Responsible Opioid Prescribing
SOURCE: Goodwin JS, et al. JAMA Network Open. 2018;1(2):e180450.
This article was updated 6/26/18.
, James Niels Rosenquist, MD, PhD, wrote in an editorial.
Public mental health is continually influencing economic and other societal forces, and in turn, being influenced by them, Dr. Rosenquist explained.
In the present study, opiate prescription rates were correlated with voting margins for Donald Trump in the 2016 presidential election using a “unique” data set based on Medicare Part D data, he said.
Studies such as these are good examples of how available data sources can be used creatively to test whether mental health trends such as opiate addiction might be correlated with “key outcomes such as elections,” Dr. Rosenquist wrote. “As elections are how political leaders are chosen in a democracy, arguments for focusing on mental health in this context may be particularly convincing to elected policy makers.”
James Niels Rosenquist, MD, PhD, is with the Center for Quantitative Health, Massachusetts General Hospital, Harvard Medical School, Boston. These comments are based on his editorial in JAMA Network Open (2018;1(2):e180451) . Dr. Rosenquist disclosed no relevant conflicts of interest.
, James Niels Rosenquist, MD, PhD, wrote in an editorial.
Public mental health is continually influencing economic and other societal forces, and in turn, being influenced by them, Dr. Rosenquist explained.
In the present study, opiate prescription rates were correlated with voting margins for Donald Trump in the 2016 presidential election using a “unique” data set based on Medicare Part D data, he said.
Studies such as these are good examples of how available data sources can be used creatively to test whether mental health trends such as opiate addiction might be correlated with “key outcomes such as elections,” Dr. Rosenquist wrote. “As elections are how political leaders are chosen in a democracy, arguments for focusing on mental health in this context may be particularly convincing to elected policy makers.”
James Niels Rosenquist, MD, PhD, is with the Center for Quantitative Health, Massachusetts General Hospital, Harvard Medical School, Boston. These comments are based on his editorial in JAMA Network Open (2018;1(2):e180451) . Dr. Rosenquist disclosed no relevant conflicts of interest.
, James Niels Rosenquist, MD, PhD, wrote in an editorial.
Public mental health is continually influencing economic and other societal forces, and in turn, being influenced by them, Dr. Rosenquist explained.
In the present study, opiate prescription rates were correlated with voting margins for Donald Trump in the 2016 presidential election using a “unique” data set based on Medicare Part D data, he said.
Studies such as these are good examples of how available data sources can be used creatively to test whether mental health trends such as opiate addiction might be correlated with “key outcomes such as elections,” Dr. Rosenquist wrote. “As elections are how political leaders are chosen in a democracy, arguments for focusing on mental health in this context may be particularly convincing to elected policy makers.”
James Niels Rosenquist, MD, PhD, is with the Center for Quantitative Health, Massachusetts General Hospital, Harvard Medical School, Boston. These comments are based on his editorial in JAMA Network Open (2018;1(2):e180451) . Dr. Rosenquist disclosed no relevant conflicts of interest.
Chronic use of prescription opioid drugs correlated with support for the Republican candidate in the 2016 U.S. presidential election, according to a cross-sectional analysis published in JAMA Network Open.
The mean Republican presidential vote was 60% in U.S. counties with significantly higher-than-average rates of prescriptions for prolonged opioid use, versus 39% for counties with significantly lower rates, according to the study, which was based on prescription data for Medicare Part D enrollees (JAMA Network Open. 2018;1(2):e180450).
Those findings suggest the importance of economic, cultural, and environmental factors in the opioid epidemic, according to study author James S. Goodwin, MD, of the University of Texas Medical Branch, Galveston, and co-authors.
“Public health policy directed at stemming the opioid epidemic must go beyond the medical model and incorporate socioenvironmental disadvantage factors and health behaviors into policy planning and implementation,” Dr. Goodwin and co-authors wrote.
The cross-sectional analysis included data for 3.76 million Medicare Part D enrollees. They looked specifically at the proportion of enrollees with chronic opioid use, which they defined as receipt of at least a 90-day supply in 1 year.
After adjusting for age, disability, and other factors, they found 693 out of 3,100 counties (22.4%) had rates of chronic opioid use higher than the mean, and 638 (20.6%) had rates lower than the mean. The correlation between opioid use rates and the presidential vote was 0.42 (P < .001), according to investigators.
They also published two county maps that they said shared some similar patterns. The first shows the proportion of older chronic opioid users by quintile, and the second shows Republican vote percentages, also by quintile. The correlation coefficient between those two rates was 0.32 (P < .001).
This study adds to the emerging literature on the relationships between health status and support of Donald Trump in the 2016 election, according to authors.
However, there were limitations to the study, they added. Of note, the presidential vote data was from 2016, but the information on prolonged opioid prescriptions was from 2015. Moreover, the voting data included all voters, while the opioid data came only from Medicare Part D enrollees, which represent about 72% of the full Medicare population.
One study author reported grants from the National Institute on Drug Abuse and Agency for Healthcare Research and Quality. Another reported membership in Physicians for Responsible Opioid Prescribing
SOURCE: Goodwin JS, et al. JAMA Network Open. 2018;1(2):e180450.
This article was updated 6/26/18.
Chronic use of prescription opioid drugs correlated with support for the Republican candidate in the 2016 U.S. presidential election, according to a cross-sectional analysis published in JAMA Network Open.
The mean Republican presidential vote was 60% in U.S. counties with significantly higher-than-average rates of prescriptions for prolonged opioid use, versus 39% for counties with significantly lower rates, according to the study, which was based on prescription data for Medicare Part D enrollees (JAMA Network Open. 2018;1(2):e180450).
Those findings suggest the importance of economic, cultural, and environmental factors in the opioid epidemic, according to study author James S. Goodwin, MD, of the University of Texas Medical Branch, Galveston, and co-authors.
“Public health policy directed at stemming the opioid epidemic must go beyond the medical model and incorporate socioenvironmental disadvantage factors and health behaviors into policy planning and implementation,” Dr. Goodwin and co-authors wrote.
The cross-sectional analysis included data for 3.76 million Medicare Part D enrollees. They looked specifically at the proportion of enrollees with chronic opioid use, which they defined as receipt of at least a 90-day supply in 1 year.
After adjusting for age, disability, and other factors, they found 693 out of 3,100 counties (22.4%) had rates of chronic opioid use higher than the mean, and 638 (20.6%) had rates lower than the mean. The correlation between opioid use rates and the presidential vote was 0.42 (P < .001), according to investigators.
They also published two county maps that they said shared some similar patterns. The first shows the proportion of older chronic opioid users by quintile, and the second shows Republican vote percentages, also by quintile. The correlation coefficient between those two rates was 0.32 (P < .001).
This study adds to the emerging literature on the relationships between health status and support of Donald Trump in the 2016 election, according to authors.
However, there were limitations to the study, they added. Of note, the presidential vote data was from 2016, but the information on prolonged opioid prescriptions was from 2015. Moreover, the voting data included all voters, while the opioid data came only from Medicare Part D enrollees, which represent about 72% of the full Medicare population.
One study author reported grants from the National Institute on Drug Abuse and Agency for Healthcare Research and Quality. Another reported membership in Physicians for Responsible Opioid Prescribing
SOURCE: Goodwin JS, et al. JAMA Network Open. 2018;1(2):e180450.
This article was updated 6/26/18.
FROM JAMA NETWORK OPEN
Key clinical point: Chronic use of prescription opioid drugs correlated with support for the Republican candidate in the 2016 U.S. presidential election.
Major finding: The mean Republican presidential vote was 60% in U.S. counties with significantly higher-than-average rates of prescriptions for prolonged opioid use, versus 39% for counties with significantly lower rates.
Study details: A retrospective, cross-sectional analysis including 3.76 million Medicare Part D enrollees.
Disclosures: One study author reported grants from the National Institute on Drug Abuse and Agency for Healthcare Research and Quality. Another reported membership in Physicians for Responsible Opioid Prescribing.
Source: Goodwin JS, et al. JAMA Network Open. 2018;1(2):e180450.
HHS’s Azar teases changes to APMs
“I am not sure that simply being in an alternative payment model, which was the metric the Obama administration used, is the one that I would find to be substantive and real in terms of transformation of our health care system,” Mr. Azar said June 20 at a forum hosted by the Washington Post.
The previous administration set a goal of having at least 50% of physician Medicare payments tied to quality by the end of this year. It’s first milestone of 30% by the end of 2016 was reached in March of that year.
The current administration may have had a tough time meeting the 50% goal because of changes it made to the Quality Payment Program exempted two-thirds of eligible clinicians from the Merit-Based Incentive Payment System track in 2018.
Mr. Azar said that he is working with the team at the Centers for Medicare & Medicaid Services to come up with a better way to determine whether paying for quality is effective.
“What I don’t want to do is have an approach where it’s a tag the base, hit a scorecard number,” he said. “We genuinely want to revolutionize how health care is paid for in this country in an outcome-based, health-based, non-procedure-, non-sickness-based way. We are working on that. We want to get to real concrete metrics.”
Mr. Azar also noted that the agency is working on “the concrete strategy for the Center for Medicare & Medicaid Innovation. That will also have dimensions for what we are doing within the fee-for-service program and Medicare Advantage around moving toward value-based payment arrangements.”
He praised the efforts of the Bush Administration and the Obama Administration as providing a good foundation for the transition to paying for quality and “we will build on that.”
“I am not sure that simply being in an alternative payment model, which was the metric the Obama administration used, is the one that I would find to be substantive and real in terms of transformation of our health care system,” Mr. Azar said June 20 at a forum hosted by the Washington Post.
The previous administration set a goal of having at least 50% of physician Medicare payments tied to quality by the end of this year. It’s first milestone of 30% by the end of 2016 was reached in March of that year.
The current administration may have had a tough time meeting the 50% goal because of changes it made to the Quality Payment Program exempted two-thirds of eligible clinicians from the Merit-Based Incentive Payment System track in 2018.
Mr. Azar said that he is working with the team at the Centers for Medicare & Medicaid Services to come up with a better way to determine whether paying for quality is effective.
“What I don’t want to do is have an approach where it’s a tag the base, hit a scorecard number,” he said. “We genuinely want to revolutionize how health care is paid for in this country in an outcome-based, health-based, non-procedure-, non-sickness-based way. We are working on that. We want to get to real concrete metrics.”
Mr. Azar also noted that the agency is working on “the concrete strategy for the Center for Medicare & Medicaid Innovation. That will also have dimensions for what we are doing within the fee-for-service program and Medicare Advantage around moving toward value-based payment arrangements.”
He praised the efforts of the Bush Administration and the Obama Administration as providing a good foundation for the transition to paying for quality and “we will build on that.”
“I am not sure that simply being in an alternative payment model, which was the metric the Obama administration used, is the one that I would find to be substantive and real in terms of transformation of our health care system,” Mr. Azar said June 20 at a forum hosted by the Washington Post.
The previous administration set a goal of having at least 50% of physician Medicare payments tied to quality by the end of this year. It’s first milestone of 30% by the end of 2016 was reached in March of that year.
The current administration may have had a tough time meeting the 50% goal because of changes it made to the Quality Payment Program exempted two-thirds of eligible clinicians from the Merit-Based Incentive Payment System track in 2018.
Mr. Azar said that he is working with the team at the Centers for Medicare & Medicaid Services to come up with a better way to determine whether paying for quality is effective.
“What I don’t want to do is have an approach where it’s a tag the base, hit a scorecard number,” he said. “We genuinely want to revolutionize how health care is paid for in this country in an outcome-based, health-based, non-procedure-, non-sickness-based way. We are working on that. We want to get to real concrete metrics.”
Mr. Azar also noted that the agency is working on “the concrete strategy for the Center for Medicare & Medicaid Innovation. That will also have dimensions for what we are doing within the fee-for-service program and Medicare Advantage around moving toward value-based payment arrangements.”
He praised the efforts of the Bush Administration and the Obama Administration as providing a good foundation for the transition to paying for quality and “we will build on that.”
Administration eases way for small businesses to buy insurance in bulk
Small employers will more easily be able to band together to buy health insurance under rules issued June 19 by the Trump administration, but the change could raise premiums for plans sold through the Affordable Care Act’s (ACA’s) online marketplaces, analysts say.
The move loosens restrictions on so-called association health plans, allowing more businesses, including sole proprietors, to join forces to buy health coverage in bulk for their workers.
By effectively shifting small-business coverage into the large-group market, it exempts such plans from ACA requirements for 10 “essential” health benefits, such as mental health care and prescription drug coverage, prompting warnings of “junk insurance” from consumer advocates.
Supporters say the new Labor Department rules, which the government estimated could create health plans covering as many as 11 million people, will lead to more affordable choices for some employers.
When it comes to health insurance, “the regulatory burden on small businesses should certainly not be more than that on large companies,” Labor Secretary Alexander Acosta told reporters June 19.
Existing rules limit association plans to groups of employers in the same industry in the same region.
The new regulations eliminate the geographical restriction for similar employers, allowing, for example, family-owned auto-repair shops in multiple states to offer one big health plan, said Christopher Condeluci, a health benefits lawyer and former Senate Finance Committee aide.
The rules, to be implemented in stages into next year, also allow companies in different industries in the same region to form a group to offer coverage – even if the only reason is to provide health insurance.
Like other coverage under the ACA, association insurance plans will still be required to cover preexisting illnesses.
Analysts warn that, because these changes will likely siphon away employers with relatively healthy consumers from ACA coverage into less-expensive trade-association plans, the result could be higher costs in the online marketplaces.
“If you have a group that is healthier than average, you might get a better rate from one of these plans, and your broker is going to come and say, ‘Hey, I can get you a better deal,’ ” said Dan Mendelson, president of Avalere Health, a consulting firm.
That would mean that, on balance, consumers insured through ACA small-group and individual plans could be older, sicker, and more expensive, adding to years of erosion of the ACA marketplaces engineered by Republicans hostile to the law.
Loosening rules for association plans would lead to 3.2 million people leaving the ACA plans by 2022 and raising premiums for those remaining in individual markets by 3.5%, Avalere calculated this year.
America’s Health Insurance Plans, the largest medical insurance trade group, issued a statement saying the regulation “may lead to higher premiums” in ACA insurance and “could result in fewer insured Americans.”
Unlike ACA plans, association coverage does not have to include benefits across the broad “essential” categories, including hospitalization and emergency care.
The National Association of Insurance Commissioners previously warned that such plans “threaten the stability of the small group market” and “provide inadequate benefits and insufficient protection to consumers.”
The American Academy of Actuaries has expressed similar concerns.
Business groups praised the change, proposed in draft form earlier this year.
“We’ve been advocating for association health plans for almost 20 years, and we’re pleased to see the department moving aggressively forward,” said David French, senior vice president of government relations for the National Retail Federation.
Association plans have been around for decades, although enrollment has been more limited since the ACA’s passage. While some of the plans have worked well for their members, others have a checkered history.
In April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.8 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.
The coverage “was sold across state lines and was issued through a third-party association,” according to a release from the Massachusetts attorney general’s office.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Small employers will more easily be able to band together to buy health insurance under rules issued June 19 by the Trump administration, but the change could raise premiums for plans sold through the Affordable Care Act’s (ACA’s) online marketplaces, analysts say.
The move loosens restrictions on so-called association health plans, allowing more businesses, including sole proprietors, to join forces to buy health coverage in bulk for their workers.
By effectively shifting small-business coverage into the large-group market, it exempts such plans from ACA requirements for 10 “essential” health benefits, such as mental health care and prescription drug coverage, prompting warnings of “junk insurance” from consumer advocates.
Supporters say the new Labor Department rules, which the government estimated could create health plans covering as many as 11 million people, will lead to more affordable choices for some employers.
When it comes to health insurance, “the regulatory burden on small businesses should certainly not be more than that on large companies,” Labor Secretary Alexander Acosta told reporters June 19.
Existing rules limit association plans to groups of employers in the same industry in the same region.
The new regulations eliminate the geographical restriction for similar employers, allowing, for example, family-owned auto-repair shops in multiple states to offer one big health plan, said Christopher Condeluci, a health benefits lawyer and former Senate Finance Committee aide.
The rules, to be implemented in stages into next year, also allow companies in different industries in the same region to form a group to offer coverage – even if the only reason is to provide health insurance.
Like other coverage under the ACA, association insurance plans will still be required to cover preexisting illnesses.
Analysts warn that, because these changes will likely siphon away employers with relatively healthy consumers from ACA coverage into less-expensive trade-association plans, the result could be higher costs in the online marketplaces.
“If you have a group that is healthier than average, you might get a better rate from one of these plans, and your broker is going to come and say, ‘Hey, I can get you a better deal,’ ” said Dan Mendelson, president of Avalere Health, a consulting firm.
That would mean that, on balance, consumers insured through ACA small-group and individual plans could be older, sicker, and more expensive, adding to years of erosion of the ACA marketplaces engineered by Republicans hostile to the law.
Loosening rules for association plans would lead to 3.2 million people leaving the ACA plans by 2022 and raising premiums for those remaining in individual markets by 3.5%, Avalere calculated this year.
America’s Health Insurance Plans, the largest medical insurance trade group, issued a statement saying the regulation “may lead to higher premiums” in ACA insurance and “could result in fewer insured Americans.”
Unlike ACA plans, association coverage does not have to include benefits across the broad “essential” categories, including hospitalization and emergency care.
The National Association of Insurance Commissioners previously warned that such plans “threaten the stability of the small group market” and “provide inadequate benefits and insufficient protection to consumers.”
The American Academy of Actuaries has expressed similar concerns.
Business groups praised the change, proposed in draft form earlier this year.
“We’ve been advocating for association health plans for almost 20 years, and we’re pleased to see the department moving aggressively forward,” said David French, senior vice president of government relations for the National Retail Federation.
Association plans have been around for decades, although enrollment has been more limited since the ACA’s passage. While some of the plans have worked well for their members, others have a checkered history.
In April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.8 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.
The coverage “was sold across state lines and was issued through a third-party association,” according to a release from the Massachusetts attorney general’s office.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Small employers will more easily be able to band together to buy health insurance under rules issued June 19 by the Trump administration, but the change could raise premiums for plans sold through the Affordable Care Act’s (ACA’s) online marketplaces, analysts say.
The move loosens restrictions on so-called association health plans, allowing more businesses, including sole proprietors, to join forces to buy health coverage in bulk for their workers.
By effectively shifting small-business coverage into the large-group market, it exempts such plans from ACA requirements for 10 “essential” health benefits, such as mental health care and prescription drug coverage, prompting warnings of “junk insurance” from consumer advocates.
Supporters say the new Labor Department rules, which the government estimated could create health plans covering as many as 11 million people, will lead to more affordable choices for some employers.
When it comes to health insurance, “the regulatory burden on small businesses should certainly not be more than that on large companies,” Labor Secretary Alexander Acosta told reporters June 19.
Existing rules limit association plans to groups of employers in the same industry in the same region.
The new regulations eliminate the geographical restriction for similar employers, allowing, for example, family-owned auto-repair shops in multiple states to offer one big health plan, said Christopher Condeluci, a health benefits lawyer and former Senate Finance Committee aide.
The rules, to be implemented in stages into next year, also allow companies in different industries in the same region to form a group to offer coverage – even if the only reason is to provide health insurance.
Like other coverage under the ACA, association insurance plans will still be required to cover preexisting illnesses.
Analysts warn that, because these changes will likely siphon away employers with relatively healthy consumers from ACA coverage into less-expensive trade-association plans, the result could be higher costs in the online marketplaces.
“If you have a group that is healthier than average, you might get a better rate from one of these plans, and your broker is going to come and say, ‘Hey, I can get you a better deal,’ ” said Dan Mendelson, president of Avalere Health, a consulting firm.
That would mean that, on balance, consumers insured through ACA small-group and individual plans could be older, sicker, and more expensive, adding to years of erosion of the ACA marketplaces engineered by Republicans hostile to the law.
Loosening rules for association plans would lead to 3.2 million people leaving the ACA plans by 2022 and raising premiums for those remaining in individual markets by 3.5%, Avalere calculated this year.
America’s Health Insurance Plans, the largest medical insurance trade group, issued a statement saying the regulation “may lead to higher premiums” in ACA insurance and “could result in fewer insured Americans.”
Unlike ACA plans, association coverage does not have to include benefits across the broad “essential” categories, including hospitalization and emergency care.
The National Association of Insurance Commissioners previously warned that such plans “threaten the stability of the small group market” and “provide inadequate benefits and insufficient protection to consumers.”
The American Academy of Actuaries has expressed similar concerns.
Business groups praised the change, proposed in draft form earlier this year.
“We’ve been advocating for association health plans for almost 20 years, and we’re pleased to see the department moving aggressively forward,” said David French, senior vice president of government relations for the National Retail Federation.
Association plans have been around for decades, although enrollment has been more limited since the ACA’s passage. While some of the plans have worked well for their members, others have a checkered history.
In April, for example, Massachusetts regulators settled with Kansas-based Unified Life Insurance Company, which agreed to pay $2.8 million to resolve allegations that it engaged in deceptive practices, such as claiming it covered services that it did not.
The coverage “was sold across state lines and was issued through a third-party association,” according to a release from the Massachusetts attorney general’s office.
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
MI risk prediction after noncardiac surgery simplified
ORLANDO – The risk of perioperative MI or death associated with noncardiac surgery is vanishingly low in patients free of diabetes, hypertension, and smoking, Tanya Wilcox, MD, reported at the annual meeting of the American College of Cardiology.
How small is the risk? A mere 1 in 1,000, according to her analysis of more than 3.8 million major noncardiac surgeries in the American College of Surgeons National Surgical Quality Improvement Program database for 2009-2015, according to Dr. Wilcox of New York University.
Physicians are frequently asked by surgeons to clear patients for noncardiac surgery in terms of cardiovascular risk. Because current risk scores are complex, aren’t amenable to rapid bedside calculations, and may entail cardiac stress testing, Dr. Wilcox decided it was worth assessing the impact of three straightforward cardiovascular risk factors – current smoking and treatment for hypertension or diabetes – on 30-day postoperative MI-free survival. For this purpose she turned to the National Surgical Quality Improvement Program database, a validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care utilizing data from 250 U.S. surgical centers.
Of the 3,817,113 patients who underwent major noncardiac surgery, 1,586,020 (42%) of them had none of the three cardiovascular risk factors of interest, 1,541,846 (40%) had one, 643,424 (17%) had two, and 45,823, or 1.2%, had all three. The patients’ mean age was 57, 75% were white, and 57% were women. About half of all patients underwent various operations within the realm of general surgery; next most frequent were orthopedic procedures, accounting for 18% of total noncardiac surgery. Of note, only 23% of patients with zero risk factors were American Society of Anesthesiologists Class 3-5, compared with 51% of those with one cardiovascular risk factor, 76% with two, and 71% with all three.
The incidence of acute MI or death within 30 days of noncardiac surgery climbed in stepwise fashion according to a patient’s risk factor burden. In a multivariate analysis adjusted for age, race, and gender, patients with any one of the cardiovascular risk factors had a 30-day risk of acute MI or death that was 1.52 times greater than those with no risk factors, patients with two risk factors were at 2.4-fold increased risk, and those with all three were at 3.63-fold greater risk than those with none. The degree of increased risk associated with any single risk factor ranged from 1.47-fold for hypertension to 1.94-fold for smoking.
“Further study is needed to determine whether aggressive risk factor modifications in the form of blood pressure control, glycemic control, and smoking cessation could reduce the incidence of postoperative MI,” Dr. Wilcox observed.
She reported having no financial conflicts regarding her study.
ORLANDO – The risk of perioperative MI or death associated with noncardiac surgery is vanishingly low in patients free of diabetes, hypertension, and smoking, Tanya Wilcox, MD, reported at the annual meeting of the American College of Cardiology.
How small is the risk? A mere 1 in 1,000, according to her analysis of more than 3.8 million major noncardiac surgeries in the American College of Surgeons National Surgical Quality Improvement Program database for 2009-2015, according to Dr. Wilcox of New York University.
Physicians are frequently asked by surgeons to clear patients for noncardiac surgery in terms of cardiovascular risk. Because current risk scores are complex, aren’t amenable to rapid bedside calculations, and may entail cardiac stress testing, Dr. Wilcox decided it was worth assessing the impact of three straightforward cardiovascular risk factors – current smoking and treatment for hypertension or diabetes – on 30-day postoperative MI-free survival. For this purpose she turned to the National Surgical Quality Improvement Program database, a validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care utilizing data from 250 U.S. surgical centers.
Of the 3,817,113 patients who underwent major noncardiac surgery, 1,586,020 (42%) of them had none of the three cardiovascular risk factors of interest, 1,541,846 (40%) had one, 643,424 (17%) had two, and 45,823, or 1.2%, had all three. The patients’ mean age was 57, 75% were white, and 57% were women. About half of all patients underwent various operations within the realm of general surgery; next most frequent were orthopedic procedures, accounting for 18% of total noncardiac surgery. Of note, only 23% of patients with zero risk factors were American Society of Anesthesiologists Class 3-5, compared with 51% of those with one cardiovascular risk factor, 76% with two, and 71% with all three.
The incidence of acute MI or death within 30 days of noncardiac surgery climbed in stepwise fashion according to a patient’s risk factor burden. In a multivariate analysis adjusted for age, race, and gender, patients with any one of the cardiovascular risk factors had a 30-day risk of acute MI or death that was 1.52 times greater than those with no risk factors, patients with two risk factors were at 2.4-fold increased risk, and those with all three were at 3.63-fold greater risk than those with none. The degree of increased risk associated with any single risk factor ranged from 1.47-fold for hypertension to 1.94-fold for smoking.
“Further study is needed to determine whether aggressive risk factor modifications in the form of blood pressure control, glycemic control, and smoking cessation could reduce the incidence of postoperative MI,” Dr. Wilcox observed.
She reported having no financial conflicts regarding her study.
ORLANDO – The risk of perioperative MI or death associated with noncardiac surgery is vanishingly low in patients free of diabetes, hypertension, and smoking, Tanya Wilcox, MD, reported at the annual meeting of the American College of Cardiology.
How small is the risk? A mere 1 in 1,000, according to her analysis of more than 3.8 million major noncardiac surgeries in the American College of Surgeons National Surgical Quality Improvement Program database for 2009-2015, according to Dr. Wilcox of New York University.
Physicians are frequently asked by surgeons to clear patients for noncardiac surgery in terms of cardiovascular risk. Because current risk scores are complex, aren’t amenable to rapid bedside calculations, and may entail cardiac stress testing, Dr. Wilcox decided it was worth assessing the impact of three straightforward cardiovascular risk factors – current smoking and treatment for hypertension or diabetes – on 30-day postoperative MI-free survival. For this purpose she turned to the National Surgical Quality Improvement Program database, a validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care utilizing data from 250 U.S. surgical centers.
Of the 3,817,113 patients who underwent major noncardiac surgery, 1,586,020 (42%) of them had none of the three cardiovascular risk factors of interest, 1,541,846 (40%) had one, 643,424 (17%) had two, and 45,823, or 1.2%, had all three. The patients’ mean age was 57, 75% were white, and 57% were women. About half of all patients underwent various operations within the realm of general surgery; next most frequent were orthopedic procedures, accounting for 18% of total noncardiac surgery. Of note, only 23% of patients with zero risk factors were American Society of Anesthesiologists Class 3-5, compared with 51% of those with one cardiovascular risk factor, 76% with two, and 71% with all three.
The incidence of acute MI or death within 30 days of noncardiac surgery climbed in stepwise fashion according to a patient’s risk factor burden. In a multivariate analysis adjusted for age, race, and gender, patients with any one of the cardiovascular risk factors had a 30-day risk of acute MI or death that was 1.52 times greater than those with no risk factors, patients with two risk factors were at 2.4-fold increased risk, and those with all three were at 3.63-fold greater risk than those with none. The degree of increased risk associated with any single risk factor ranged from 1.47-fold for hypertension to 1.94-fold for smoking.
“Further study is needed to determine whether aggressive risk factor modifications in the form of blood pressure control, glycemic control, and smoking cessation could reduce the incidence of postoperative MI,” Dr. Wilcox observed.
She reported having no financial conflicts regarding her study.
REPORTING FROM ACC 2018
Key clinical point: Noncardiac surgery patients can breathe easier regarding perioperative cardiovascular risk provided they don’t smoke and aren’t hypertensive or diabetic.
Major finding: .
Study details: This was a retrospective analysis of more than 3.8 million noncardiac surgeries contained in the American College of Surgeons National Surgical Quality Improvement Program database for 2009-2015.
Disclosures: The study presenter reported having no financial conflicts.
Magnetic LES augmentation for Barrett’s regression debated
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
The enthusiasm and reservation surrounding the presented results supporting relatively high rates of regression of Barrett’s esophagus in patients undergoing LES magnetic sphincter augmentation are both well founded. Barrett’s regression, which has been observed to occur spontaneously as well as following antireflux interventions, is always a rich topic for debate. The reported rate of regression in this study being higher than that of complete fundoplication (Nissen fundoplication) is perplexing. The premise for the development of magnetic sphincter augmentation at a focal site was based on the theory that complete fundoplication is supraphysiologic, resulting in desired resolution of regurgitation with unwanted sequelae of dysphagia and bloat in a substantial number of patients. The development of magnetic sphincter augmentation was inspired by the concept that it would provide very reproducible control of regurgitation nearing that of complete fundoplication in a permanent fashion and do so at a focal point (< 1 cm) at the level of the lower esophageal sphincter, minimizing dysphagia and bloat. Since the design is one to replicate appropriate physiology without over treating the targeted reflux disease, theoretically any regression of Barrett’s esophagus should likewise approach but not exceed that of complete fundoplication.
I anticipate further studies will add to this rich debate. Any reservations about the results of this study should not overshadow the inherent advantages of magnetic sphincter augmentation. Its implantation is fairly straightforward to teach to surgeons who have a practice focused on antireflux surgery and due to the limited dissection/tissue mobilization required, most patients can return home a few hours after surgery and immediately resume a diet of solid foods.
Dr. Alicuban and colleagues discuss the small but real concern of erosion, however, another point of inherent concern is the binary function of the device. It is either implanted or not, there is no ability beyond endoscopic dilation to treat relative outflow obstruction and no means to convert the device to a “partial wrap.”
As we forge ahead with increasingly creative ways to address reflux disease the lessons we learn will contribute to the development of better medical, endoscopic and minimally invasive surgical technologies and the robust, civil debate seen here is something we can all enthusiastically anticipate.
Kevin M. Reavis, MD, FACS, is with the Division of Gastrointestinal and Minimally Invasive Surgery The Oregon Clinic; associate professor, Oregon Health & Science University, Portland, and President, Oregon Medical Society.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
SEATTLE –
The study caught the attention of audience members – and raised a few eyebrows – at the 2018 World Congress of Endoscopic Surgery, where its results were presented, because the regression rate with the current standard operation for medically refractory gastroesophageal reflux – Nissen fundoplication – is only about 40%.
Lead investigator Evan Alicuben, MD, a general surgery resident at the university, cautioned that “longer-term follow-up is required to make a meaningful comparison with results following fundoplication.”
Fundoplication has been studied for decades, whereas the new study is likely the very first to look at the rates of Barrett’s regression after magnetic augmentation, and the 70% regression rate was based on postop endoscopies a median of 1.2 years after the procedure, not after the 5, 10, or even more years typically seen in fundoplication studies.
Magnetic sphincter augmentation (LINX Reflux Management System) was approved by the Food and Drug Administration in 2012 for reflux that persists despite maximum drug therapy. Patients have a band of magnetic titanium beads surgically placed around their LES; the band opens to let food pass, but tightens again to bolster the LES and prevent reflux.
The approach is gaining popularity. “We now know that it’s effective at controlling reflux symptoms, taking patients off proton pump inhibitors, and curing esophagitis,” at least in the short term. “One of the issues with [fundoplication] is that it may not last forever; the wrap comes undone or it slips. This device may give longer lasting” protection, Dr. Alicuben said.
“The main criticism is that it’s relatively new; people are still questioning it. The optimist in me wants to say that this is the answer we’ve been looking for; the pessimist [says] we need to wait to see what longer-term data show,” he said.
Barrett’s esophagus was confirmed by endoscopy in all 67 subjects before the magnets were placed, and each had at least one postop endoscopy.
At baseline, 29 had ultrashort-segment disease, which means there was no visible Barrett’s, but did have columnar epithelium with goblet cells on pathology. Thirty patients had short-segment disease, with up to 3 cm of visible involvement confirmed by pathology, while eight had long-segment disease, with involvement extending 3 cm or more.
Of the 67 patients, 48 had no evidence of Barrett’s after the procedure, for an overall regression rate of 71.6%. The regression rate was 82.8% in the ultrashort group (24/29); 73.3% in the short segment group (22/30); and 25% in the long segment group (2/8). Long-segment disease is notorious for persisting despite treatment; both patients had 3-cm lesions.
Among the 34 patients with two or more postop endoscopies, the regression rate was 73.5% (25).
There’s a lot of debate about whether ultrashort-segment disease is truly Barrett’s and whether it carries the same risk of malignant transformation, as one surgeon in the audience noted pointedly, worrying that including ultrashort patients oversold the results.
Dr. Alicuben countered that the regression rate remained strong even when ultrashort patients were excluded: 63% (24/38). “This is every bit as good if not better than the results of fundoplication,” another surgeon in the audience said.
The subjects were aged about 60 years, on average, with more men than women. Most had hiatal hernias, often measuring 3 cm or more. The mean body mass index was 27.3 kg/m2, but BMI ranged as high as 44.3.
Mean operative time was 66 minutes, and there were no major complications. None of the patients progressed to dysplasia or carcinoma. Median DeMeester scores fell from 35.3 to 9.2 after the operation in the 47 patients who had postop pH testing.
Surgeons have worried about esophageal erosion with the LINX system. A recent paper by Dr. Alicuben and his colleagues found 29 cases among almost 10,000 patients, which makes for an erosion rate of 0.3% at a median of about 2 years (J Gastrointest Surg. 2018 Apr 17. doi: 10.1007/s11605-018-3775-0).
About 500 LINX systems have been placed at the University of Southern California. Procedures in the study were performed between 2012 and late 2017.
Dr. Alicuben had no disclosures. Two investigators, including senior author John Lipham, MD, are paid consultants for Torax Medical, the maker of the LINX system, and Johnson & Johnson, which owns Torax through a subsidiary. There was no company funding for the review.
The World Congress of Endoscopic Surgery is hosted by the Society of American Gastrointestinal and Endoscopic Surgeons and the Canadian Association of General Surgeons
SOURCE: Alicuben E et al. WCE 2018, Abstract S095.
REPORTING FROM WCE 2018
Key clinical point: Magnetic lower esophageal sphincter augmentation might offer an easier and more effective fix for gastroesophageal reflux than the current standard, Nissen fundoplication.
Major finding: The overall regression rate of Barrett’s esophagus topped 70%.
Study details: Review of 67 patients
Disclosures: There was no industry funding, and the presenter had no disclosures. Two authors are consultants for Torax Medical, the company that makes the device.
Source: Alicuben E et al. WCE 2018, Abstract S095
Register for ACS Comprehensive General Surgery Review Course
The 2018 American College of Surgeons (ACS) Comprehensive General Surgery Review Course, July 26–29 in Chicago, IL, is an intensive three-and-a-half-day review course that will cover essential content areas in general surgery, including alimentary tract, endocrine and soft tissue, oncology, skin and breast, surgical critical care, trauma, and vascular operations, as well as perioperative care.
Course Chair John A. Weigelt, MD, DVM, MMA, FACS, and a distinguished faculty will use didactic and case-based formats to present a comprehensive and practical review. Dr. Weigelt recently retired from the Medical College of Wisconsin, where he was the Milt & Lidy Lunda/Charles Aprahamian Professor of Trauma Surgery, as well as professor and chief, division of trauma and critical care. He is joining the University of South Dakota and the Sanford Health System, Sioux Falls, this summer as professor of surgery. Dr. Weigelt is Medical Director of the ACS Surgical Education and Self-Assessment Program (SESAP®).
The course is a pragmatic review designed to focus on practice issues and will offer several special features, including self-assessment materials, such as pre- and posttests. It may be helpful in preparing for examinations. Self-assessment credit will be available.
The ACS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education for physicians.
The ACS designates this liv
Register today at bit.ly/2s19VtX, and read more about the course at www.facs.org/gsreviewcourse. Space is limited and registration will be accepted on a first-come, first-served basis. For more information and registration, visit the ACS website or e-mail [email protected] or [email protected].
The 2018 American College of Surgeons (ACS) Comprehensive General Surgery Review Course, July 26–29 in Chicago, IL, is an intensive three-and-a-half-day review course that will cover essential content areas in general surgery, including alimentary tract, endocrine and soft tissue, oncology, skin and breast, surgical critical care, trauma, and vascular operations, as well as perioperative care.
Course Chair John A. Weigelt, MD, DVM, MMA, FACS, and a distinguished faculty will use didactic and case-based formats to present a comprehensive and practical review. Dr. Weigelt recently retired from the Medical College of Wisconsin, where he was the Milt & Lidy Lunda/Charles Aprahamian Professor of Trauma Surgery, as well as professor and chief, division of trauma and critical care. He is joining the University of South Dakota and the Sanford Health System, Sioux Falls, this summer as professor of surgery. Dr. Weigelt is Medical Director of the ACS Surgical Education and Self-Assessment Program (SESAP®).
The course is a pragmatic review designed to focus on practice issues and will offer several special features, including self-assessment materials, such as pre- and posttests. It may be helpful in preparing for examinations. Self-assessment credit will be available.
The ACS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education for physicians.
The ACS designates this liv
Register today at bit.ly/2s19VtX, and read more about the course at www.facs.org/gsreviewcourse. Space is limited and registration will be accepted on a first-come, first-served basis. For more information and registration, visit the ACS website or e-mail [email protected] or [email protected].
The 2018 American College of Surgeons (ACS) Comprehensive General Surgery Review Course, July 26–29 in Chicago, IL, is an intensive three-and-a-half-day review course that will cover essential content areas in general surgery, including alimentary tract, endocrine and soft tissue, oncology, skin and breast, surgical critical care, trauma, and vascular operations, as well as perioperative care.
Course Chair John A. Weigelt, MD, DVM, MMA, FACS, and a distinguished faculty will use didactic and case-based formats to present a comprehensive and practical review. Dr. Weigelt recently retired from the Medical College of Wisconsin, where he was the Milt & Lidy Lunda/Charles Aprahamian Professor of Trauma Surgery, as well as professor and chief, division of trauma and critical care. He is joining the University of South Dakota and the Sanford Health System, Sioux Falls, this summer as professor of surgery. Dr. Weigelt is Medical Director of the ACS Surgical Education and Self-Assessment Program (SESAP®).
The course is a pragmatic review designed to focus on practice issues and will offer several special features, including self-assessment materials, such as pre- and posttests. It may be helpful in preparing for examinations. Self-assessment credit will be available.
The ACS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education for physicians.
The ACS designates this liv
Register today at bit.ly/2s19VtX, and read more about the course at www.facs.org/gsreviewcourse. Space is limited and registration will be accepted on a first-come, first-served basis. For more information and registration, visit the ACS website or e-mail [email protected] or [email protected].
ACS, other organizations concerned with patient safety offer recommendations on OR attire
The American College of Surgeons (ACS), the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, the Association for Professionals in Infection Control and Epidemiology, the Association of Surgical Technologists, the Council on Surgical and Perioperative Safety, and The Joint Commission recently developed consensus recommendations on operating room (OR) attire. The recommendations focus specifically on ear and hair covering.
The group has reached the following conclusions:
Evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multidisciplinary team representing surgery, anesthesia, nursing, and infection prevention.
The requirement for ear coverage is not supported by sufficient evidence.
At present, available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and surgical site infection rates. In fact, a recent report in the
Other issues regarding areas of surgical attire need further evaluation.
For details, read the consensus statement on the ACS website at facs.org/about-acs/consensus-statements/or-attire.
In addition, the ACS recently received notification from The Joint Commission indicating that the accrediting body will incorporate the specifications outlined in the consensus statement into its survey procedures for hospitals and other relevant health care facilities.
The American College of Surgeons (ACS), the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, the Association for Professionals in Infection Control and Epidemiology, the Association of Surgical Technologists, the Council on Surgical and Perioperative Safety, and The Joint Commission recently developed consensus recommendations on operating room (OR) attire. The recommendations focus specifically on ear and hair covering.
The group has reached the following conclusions:
Evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multidisciplinary team representing surgery, anesthesia, nursing, and infection prevention.
The requirement for ear coverage is not supported by sufficient evidence.
At present, available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and surgical site infection rates. In fact, a recent report in the
Other issues regarding areas of surgical attire need further evaluation.
For details, read the consensus statement on the ACS website at facs.org/about-acs/consensus-statements/or-attire.
In addition, the ACS recently received notification from The Joint Commission indicating that the accrediting body will incorporate the specifications outlined in the consensus statement into its survey procedures for hospitals and other relevant health care facilities.
The American College of Surgeons (ACS), the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, the Association for Professionals in Infection Control and Epidemiology, the Association of Surgical Technologists, the Council on Surgical and Perioperative Safety, and The Joint Commission recently developed consensus recommendations on operating room (OR) attire. The recommendations focus specifically on ear and hair covering.
The group has reached the following conclusions:
Evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multidisciplinary team representing surgery, anesthesia, nursing, and infection prevention.
The requirement for ear coverage is not supported by sufficient evidence.
At present, available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and surgical site infection rates. In fact, a recent report in the
Other issues regarding areas of surgical attire need further evaluation.
For details, read the consensus statement on the ACS website at facs.org/about-acs/consensus-statements/or-attire.
In addition, the ACS recently received notification from The Joint Commission indicating that the accrediting body will incorporate the specifications outlined in the consensus statement into its survey procedures for hospitals and other relevant health care facilities.
ACS Clinical Scholars in Residence Program Application Deadline Extended
The American College of Surgeons (ACS) is offering a two-year, onsite fellowship in surgical outcomes research, health services research, and health care policy through the Clinical Scholars in Residence program. The application deadline for positions starting in 2019 has been extended to June 29, 2018.
Applicants must have completed two years of clinical training, be U.S. citizens, and obtained two years of program funding from their home institution or other granting agency. The applicant also must be a member of the ACS and in good standing with the College.
The Clinical Scholar will have the opportunity to work in multiple areas within the ACS Division of Research and Optimal Patient Care at the ACS headquarters in Chicago, IL, to advance the quality improvement initiatives of the ACS and to perform research relevant to ongoing projects within the ACS. Participants also will earn a masters degree after the two years program. The Clinical Scholar will receive strong mentorship in clinical, statistical, and health services research. Previous ACS Clinical Scholars in Residence since 2005 have had excellent, productive experiences that have launched careers in the field.
Important dates for Clinical Scholars in Residence program follow:
Application deadline extended: June 29, 2018
Interview notification: July 13, 2018
Interview Process: July 16–31, 2018
Notification of appointment: August 1, 2018
Starting date: July 1, 2019
For more information, go to facs.org/quality-programs/about/clinical-scholars-program. Contact the ACS Clinical Scholars in Residence Program at [email protected] with additional questions.
The American College of Surgeons (ACS) is offering a two-year, onsite fellowship in surgical outcomes research, health services research, and health care policy through the Clinical Scholars in Residence program. The application deadline for positions starting in 2019 has been extended to June 29, 2018.
Applicants must have completed two years of clinical training, be U.S. citizens, and obtained two years of program funding from their home institution or other granting agency. The applicant also must be a member of the ACS and in good standing with the College.
The Clinical Scholar will have the opportunity to work in multiple areas within the ACS Division of Research and Optimal Patient Care at the ACS headquarters in Chicago, IL, to advance the quality improvement initiatives of the ACS and to perform research relevant to ongoing projects within the ACS. Participants also will earn a masters degree after the two years program. The Clinical Scholar will receive strong mentorship in clinical, statistical, and health services research. Previous ACS Clinical Scholars in Residence since 2005 have had excellent, productive experiences that have launched careers in the field.
Important dates for Clinical Scholars in Residence program follow:
Application deadline extended: June 29, 2018
Interview notification: July 13, 2018
Interview Process: July 16–31, 2018
Notification of appointment: August 1, 2018
Starting date: July 1, 2019
For more information, go to facs.org/quality-programs/about/clinical-scholars-program. Contact the ACS Clinical Scholars in Residence Program at [email protected] with additional questions.
The American College of Surgeons (ACS) is offering a two-year, onsite fellowship in surgical outcomes research, health services research, and health care policy through the Clinical Scholars in Residence program. The application deadline for positions starting in 2019 has been extended to June 29, 2018.
Applicants must have completed two years of clinical training, be U.S. citizens, and obtained two years of program funding from their home institution or other granting agency. The applicant also must be a member of the ACS and in good standing with the College.
The Clinical Scholar will have the opportunity to work in multiple areas within the ACS Division of Research and Optimal Patient Care at the ACS headquarters in Chicago, IL, to advance the quality improvement initiatives of the ACS and to perform research relevant to ongoing projects within the ACS. Participants also will earn a masters degree after the two years program. The Clinical Scholar will receive strong mentorship in clinical, statistical, and health services research. Previous ACS Clinical Scholars in Residence since 2005 have had excellent, productive experiences that have launched careers in the field.
Important dates for Clinical Scholars in Residence program follow:
Application deadline extended: June 29, 2018
Interview notification: July 13, 2018
Interview Process: July 16–31, 2018
Notification of appointment: August 1, 2018
Starting date: July 1, 2019
For more information, go to facs.org/quality-programs/about/clinical-scholars-program. Contact the ACS Clinical Scholars in Residence Program at [email protected] with additional questions.
Sharpen your ax
Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:
Airway, Breathing, CT scan.
Airway, Breathing, C-spine collar.
Airway, Breathing, Consult with ortho.
Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?
After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.
There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.
Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.
It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.
In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.
Dr. Crosslin is a general surgeon practicing in Rockport, Maine.
Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:
Airway, Breathing, CT scan.
Airway, Breathing, C-spine collar.
Airway, Breathing, Consult with ortho.
Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?
After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.
There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.
Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.
It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.
In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.
Dr. Crosslin is a general surgeon practicing in Rockport, Maine.
Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:
Airway, Breathing, CT scan.
Airway, Breathing, C-spine collar.
Airway, Breathing, Consult with ortho.
Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?
After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.
There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.
Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.
It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.
In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.
Dr. Crosslin is a general surgeon practicing in Rockport, Maine.
DEA ruling may have stoked illicit opioid sales
Illicit online sales of opioids increased significantly following a 2014 regulatory decision that restricted the legal supply of opioids in the United States, results of a recent analysis show.
Opioid sales in the so-called cryptomarkets also shifted toward more potent drugs, including fentanyl, after the U.S. Drug Enforcement Administration rescheduled hydrocodone combination products, making them harder to access, authors of the analysis reported.
Those results suggest “the possibility of a causal relation” between the schedule change and sales trends on cryptomarket sites, according to James Martin, PhD, of Swinburne University, Melbourne, Australia, and co-authors.
“Our analysis cannot rule out other possible causal explanatory factors, but our results are consistent with the possibility that the schedule change might have directly contributed to the changes we observed in the supply of illicit opioids,” Dr. Martin and colleagues wrote in the BMJ.
Cryptomarkets outside the United States had no such uptick in opioid traffic over time, reinforcing the possibility that the 2014 DEA decision caused an increase in the illicit opioid supply. The analysis included 31 online illicit markets operating between October 2013 and July 2016.
Investigators collected data using web crawling software that downloaded HTML pages on the cryptomarket sites and extracted relevant information such as listing titles and drug types for later analysis. Generally, each market was fully crawled every 2 weeks. After data was scraped and extracted, they conducted an interrupted time series analysis of drug sales for each day of the data collection period.
Opioids represented 13.7% of all drug sales through U.S. cryptomarkets in July 2016, they found, compared with a modeled estimate of 6.7% of sales that would have occurred in the absence of the new schedule introduction.
“This represents an approximate doubling of the percentage of the total drug sales through cryptomarkets within the United States,” the authors wrote.
Fentanyl was the least purchased product at the beginning of the analysis, but by July 2016 it was the second most frequently purchased. No other drug category had any meaningful changes in the proportion of sales over time.
There was no way for researchers to confirm that U.S.-based cryptomarket sites were selling to customers in the United States or elsewhere. However, they said, cryptomarket buyers often use sites in the same country to avoid shipment losses and increased delivery time.
Part of the study were funded by the Social Sciences and Humanities Research Council of Canada, Macquarie University internal grants, and the Ministry of Justice and Security of the Netherlands. Study authors had no current financial relationships relevant to the study.
SOURCE: Martin J, et al. BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2270.
The overdose crisis in the United States will likely worsen if “supply-side” measures, such as the tighter prescribing regulations evaluated in this study, are not coupled with interventions to reduce harm and decrease demand, according to Scott E. Hadland, MD, and Leo Beletsky.
On a more basic level, the analysis by James Martin and colleagues raises questions about the use of drug scheduling to regulate public health, the authors concluded in an accompanying editorial.
“The U.S. scheduling scheme inexplicably holds such disparate substances as cannabis, heroin, and psilocybin to be equally dangerous,” they wrote. “It is high time to rethink how, why, and when this regulatory framework is deployed to curb drug-related harms.”
The shift from schedule III to schedule II creates barriers to medication access that disproportionately affect individuals in rural areas and those with limited mobility, since refills for schedule II drugs can only be obtained through an in-person visit to a provider and pharmacist, the authors wrote.
Scott E Hadland, MD, is with Grayken Center for Addiction/Department of Pediatrics, Boston Medical Center, and Leo Beletsky is with the School of Law and Bouvé College of Health Sciences, Northeastern University, Boston. Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis. These comments are from their accompanying editorial (BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2480 ). Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis.
The overdose crisis in the United States will likely worsen if “supply-side” measures, such as the tighter prescribing regulations evaluated in this study, are not coupled with interventions to reduce harm and decrease demand, according to Scott E. Hadland, MD, and Leo Beletsky.
On a more basic level, the analysis by James Martin and colleagues raises questions about the use of drug scheduling to regulate public health, the authors concluded in an accompanying editorial.
“The U.S. scheduling scheme inexplicably holds such disparate substances as cannabis, heroin, and psilocybin to be equally dangerous,” they wrote. “It is high time to rethink how, why, and when this regulatory framework is deployed to curb drug-related harms.”
The shift from schedule III to schedule II creates barriers to medication access that disproportionately affect individuals in rural areas and those with limited mobility, since refills for schedule II drugs can only be obtained through an in-person visit to a provider and pharmacist, the authors wrote.
Scott E Hadland, MD, is with Grayken Center for Addiction/Department of Pediatrics, Boston Medical Center, and Leo Beletsky is with the School of Law and Bouvé College of Health Sciences, Northeastern University, Boston. Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis. These comments are from their accompanying editorial (BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2480 ). Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis.
The overdose crisis in the United States will likely worsen if “supply-side” measures, such as the tighter prescribing regulations evaluated in this study, are not coupled with interventions to reduce harm and decrease demand, according to Scott E. Hadland, MD, and Leo Beletsky.
On a more basic level, the analysis by James Martin and colleagues raises questions about the use of drug scheduling to regulate public health, the authors concluded in an accompanying editorial.
“The U.S. scheduling scheme inexplicably holds such disparate substances as cannabis, heroin, and psilocybin to be equally dangerous,” they wrote. “It is high time to rethink how, why, and when this regulatory framework is deployed to curb drug-related harms.”
The shift from schedule III to schedule II creates barriers to medication access that disproportionately affect individuals in rural areas and those with limited mobility, since refills for schedule II drugs can only be obtained through an in-person visit to a provider and pharmacist, the authors wrote.
Scott E Hadland, MD, is with Grayken Center for Addiction/Department of Pediatrics, Boston Medical Center, and Leo Beletsky is with the School of Law and Bouvé College of Health Sciences, Northeastern University, Boston. Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis. These comments are from their accompanying editorial (BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2480 ). Mr. Beletsky reported sitting on the advisory board of a data analytics company that has an interest in the U.S. opioid crisis.
Illicit online sales of opioids increased significantly following a 2014 regulatory decision that restricted the legal supply of opioids in the United States, results of a recent analysis show.
Opioid sales in the so-called cryptomarkets also shifted toward more potent drugs, including fentanyl, after the U.S. Drug Enforcement Administration rescheduled hydrocodone combination products, making them harder to access, authors of the analysis reported.
Those results suggest “the possibility of a causal relation” between the schedule change and sales trends on cryptomarket sites, according to James Martin, PhD, of Swinburne University, Melbourne, Australia, and co-authors.
“Our analysis cannot rule out other possible causal explanatory factors, but our results are consistent with the possibility that the schedule change might have directly contributed to the changes we observed in the supply of illicit opioids,” Dr. Martin and colleagues wrote in the BMJ.
Cryptomarkets outside the United States had no such uptick in opioid traffic over time, reinforcing the possibility that the 2014 DEA decision caused an increase in the illicit opioid supply. The analysis included 31 online illicit markets operating between October 2013 and July 2016.
Investigators collected data using web crawling software that downloaded HTML pages on the cryptomarket sites and extracted relevant information such as listing titles and drug types for later analysis. Generally, each market was fully crawled every 2 weeks. After data was scraped and extracted, they conducted an interrupted time series analysis of drug sales for each day of the data collection period.
Opioids represented 13.7% of all drug sales through U.S. cryptomarkets in July 2016, they found, compared with a modeled estimate of 6.7% of sales that would have occurred in the absence of the new schedule introduction.
“This represents an approximate doubling of the percentage of the total drug sales through cryptomarkets within the United States,” the authors wrote.
Fentanyl was the least purchased product at the beginning of the analysis, but by July 2016 it was the second most frequently purchased. No other drug category had any meaningful changes in the proportion of sales over time.
There was no way for researchers to confirm that U.S.-based cryptomarket sites were selling to customers in the United States or elsewhere. However, they said, cryptomarket buyers often use sites in the same country to avoid shipment losses and increased delivery time.
Part of the study were funded by the Social Sciences and Humanities Research Council of Canada, Macquarie University internal grants, and the Ministry of Justice and Security of the Netherlands. Study authors had no current financial relationships relevant to the study.
SOURCE: Martin J, et al. BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2270.
Illicit online sales of opioids increased significantly following a 2014 regulatory decision that restricted the legal supply of opioids in the United States, results of a recent analysis show.
Opioid sales in the so-called cryptomarkets also shifted toward more potent drugs, including fentanyl, after the U.S. Drug Enforcement Administration rescheduled hydrocodone combination products, making them harder to access, authors of the analysis reported.
Those results suggest “the possibility of a causal relation” between the schedule change and sales trends on cryptomarket sites, according to James Martin, PhD, of Swinburne University, Melbourne, Australia, and co-authors.
“Our analysis cannot rule out other possible causal explanatory factors, but our results are consistent with the possibility that the schedule change might have directly contributed to the changes we observed in the supply of illicit opioids,” Dr. Martin and colleagues wrote in the BMJ.
Cryptomarkets outside the United States had no such uptick in opioid traffic over time, reinforcing the possibility that the 2014 DEA decision caused an increase in the illicit opioid supply. The analysis included 31 online illicit markets operating between October 2013 and July 2016.
Investigators collected data using web crawling software that downloaded HTML pages on the cryptomarket sites and extracted relevant information such as listing titles and drug types for later analysis. Generally, each market was fully crawled every 2 weeks. After data was scraped and extracted, they conducted an interrupted time series analysis of drug sales for each day of the data collection period.
Opioids represented 13.7% of all drug sales through U.S. cryptomarkets in July 2016, they found, compared with a modeled estimate of 6.7% of sales that would have occurred in the absence of the new schedule introduction.
“This represents an approximate doubling of the percentage of the total drug sales through cryptomarkets within the United States,” the authors wrote.
Fentanyl was the least purchased product at the beginning of the analysis, but by July 2016 it was the second most frequently purchased. No other drug category had any meaningful changes in the proportion of sales over time.
There was no way for researchers to confirm that U.S.-based cryptomarket sites were selling to customers in the United States or elsewhere. However, they said, cryptomarket buyers often use sites in the same country to avoid shipment losses and increased delivery time.
Part of the study were funded by the Social Sciences and Humanities Research Council of Canada, Macquarie University internal grants, and the Ministry of Justice and Security of the Netherlands. Study authors had no current financial relationships relevant to the study.
SOURCE: Martin J, et al. BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2270.
FROM BMJ
Key clinical point: Major finding: Opioids represented 13.7% of all drug sales through U.S. cryptomarkets in July 2016, compared with a modeled estimate of 6.7%.
Study details: An analysis of 31 online cryptomarkets operating between October 2013 and July 2016.
Disclosures: Part of the study were funded by the Social Sciences and Humanities Research Council of Canada, Macquarie University internal grants, and the Ministry of Justice and Security of the Netherlands. Study authors reported having no current financial relationships relevant to the study.
Source: Martin J, et al. BMJ. 2018 Jun 13. doi: 10.1136/bmj.k2270.