The use of opiates in the treatment of headache has a controversial history, and it remains a matter of debate today. Some believe that the medications, though risky, can be a useful tool in the neurologist’s treatment arsenal, while others argue that opioids are just too risky when there are other, safer alternatives available.

Those were the cruxes of arguments put forward by Paul Rizzoli, MD, and Christopher H. Gottschalk, MD, who conducted individual talks at the 2021 Scottsdale Headache Symposium. Dr. Rizzoli, associate professor of neurology at Harvard Medical School, Boston, argued in favor of the use of opioids and butalbital-containing medications. Dr. Gottschalk, assistant professor of neurology at Yale University, New Haven, Conn., argued against their use.

In certain situations opioids are worth the risk

Whether or not to use opioids in the treatment of headache is “a reasonable question, because these medications can clearly be seen as having risk. So perhaps another way to frame this question is as a risk-benefit issue. Are these medications worth the risk? How useful is the benefit of opioids, if the consequence is dependence or addiction?” Dr. Rizzoli began.

Although reviews show effectiveness of opioids in treating migraine, a three-part review in 2012 found greater efficacy of dihydroergotamine (DHE), ketorolac, and chlorpromazine. That’s not surprising, said Dr. Rizzoli, since those competing drugs are migraine-specific.

Dr. Rizzoli quoted a 2014 review indicating that there were incomplete data on the relative efficacy of opioids versus other analgesics, and for some patients opioids would likely be the optimal treatment, such as those who have contraindications to ergot-type medications or neuroleptic medications, pregnant women, or patients who don’t respond to other medications.

Dr. Rizzoli noted that The International Association for the Study of Pain has concluded that no other oral medications provide immediate and effective pain relief, and that short-term use rarely leads to addiction.

“So, to me, the answer is not to avoid opioids or outlaw them but instead to use them judiciously and infrequently, and in a short term or rescue fashion,” said Dr. Rizzoli.

He pointed out that physicians accept risks of other medications, and act to mitigate those risks. He said that risk mitigation with opioids can take the form of avoiding prescriptions in some situations, like when patients have a personal or family history of substance abuse, or in cases of some behavioral or emotional disorders.

Dr. Rizzoli went on to discuss the use of butalbital, which acts as a CNS depressant and has a variety of effects, including sedation, anxiolytic, hypnotic, and antiepileptic effects, but it is only a weak analgesic, but it nevertheless works in headache, said Dr. Rizzoli, citing patient reports and personal experience.

“It’s difficult to appreciate this theme of efficacy behind all the hype in the literature and in the press against butalbital, and the fact that it has not been adequately studied. But I would submit that the fact that we are even having this discussion is support enough for the use of butalbital. If butalbital either didn’t work or was simply a drug of abuse, it would likely have faded away by now,” said Dr. Rizzoli. He conceded that butalbital can be overused and may lead episodic headache to become chronic daily headache, but he noted that Seymour Solomon, MD, professor emeritus at Albert Einstein College of Medicine, New York, has estimated that removal of butalbital from the market would reduce chronic headache in the general population by only a small fraction of one percent.

Butalbital also has another interesting effect, which is that patients may quickly return to normal functioning after the headache resolves. “Maybe this is all due to management of anxiety, the presumed mechanism of action of barbiturates. So, instead of lobbying for its removal, I would propose that we should take a closer look at what’s going on here, and what the mechanism of action of this fairly interesting compound might be,” said Dr. Rizzoli.

Dr. Rizzoli also said there is some evidence that migraine-specific drugs also affect the tolerance to opioid drugs. “Somehow, they seem to interact with the opioid pain system. If that’s true, the implication is that you probably cannot escape the opioid receptors in the management of migraine,” said Dr. Rizzoli.

Ultimately, he supports the judicious use of opioids and butalbital containing-medications for headache relief. “My argument is that it is just too simplistic to cease use of these meds. Yes, they should be used in a restricted and careful way, but not abandoned,” said Dr. Rizzoli.
 

Opiates should be avoided

Following Dr. Rizzoli’s presentation, Dr. Gottschalk presented an argument against the use of opioids in the treatment of headache.

He began by quoting the ABIM Choosing Wisely Campaign of 2012, which concluded that fioricet and narcotics should be avoided in headache unless the patient is desperate. “As a headache specialist, I can tell you that I have not faced situations sufficiently desperate to use any of these. The American Headache Society in a series of evidence assessments has concluded similarly, that they are of no use,” said Dr. Gottschalk.

Opiates and barbiturates may also increase risk of migraine chronification. One study found that triptans are associated with low rates of chronification, at just a few percent when used fewer than 4 days a month, and about 20% per year when used 10-14 days per month. Opiate use showed a broadly similar pattern, while barbiturates showed a particularly alarming pattern: “Every level of use was associated with astronomically high rates and measurably higher at the highest level of use. For opiates, the odds ratio was about 2 – statistically significant. For barbiturates it was clearly greater than 2, whereas with triptans, the odds ratio showed a nonsignificant, slight increase in risk. And for NSAIDs, the odds ratio was, if anything, less than 1,” said Dr. Gottschalk.

He also discussed aspects of behavioral pharmacology, in which positive reinforcement associated with decreased headache may encourage repeated use of the drug. “Given these, it should be no surprise to anyone that emergency room treatment with opiates for acute migraine is clearly associated with increased recidivism for patients given those drugs,” said Dr. Gottschalk.

Opiate use is associated with increased pain sensitivity, and in the case of migraine, it may interfere with the activity of other treatments.

As for butalbital-containing compounds, they are positive-reinforcing drugs, and they are not indicated for migraine, only tension headache. There is no evidence of benefit in migraine, but butalbital is anxiolytic, which could lead an individual to increase its use.

A recent meta-analysis of therapies for episodic migraine found that hydromorphone and meperidine are less effective than standard therapies such as prochlorperazine or metoclopramide. Another study suggested that opioid use may interfere with the efficacy of NSAIDs in the emergency room environment, while a post hoc analysis of rizatriptan clinical trials found that recent opiate use was associated with a lower response rate, and the effect was more pronounced in women.

Among patients with chronic migraine, a 2004 study found that opiates were the most commonly used medication, and other studies found that chronic migraine does not arise in nonmigraine patients treated with opiates, “suggesting that migraine is specifically prone to opiate-induced hyperalgesia of migraine itself,” said Dr. Gottschalk.

Even under careful monitoring, misuse occurs in more than 50% of patients, “suggesting that even under the best circumstances, it is difficult to use this class of drugs safely in long term,” said Dr. Gottschalk.

He pointed out that the risk of drug addiction rises with various clinical and socioeconomic factors, including living in impoverished environments, adverse childhood experiences, low socioeconomic status, exposure to pollutants, and stressors. “In other words, all features associated with systemic racism are clearly associated with an increased risk of addiction,” said Dr. Gottschalk. Other factors include availability of the drug, such as whether or not a physician prescribes it, and repeated use.

These concerns, combined with positive-reinforcing properties of opiates and association with migraine progression and refractoriness, and the lack of progression risk found with use of NSAIDs and triptans, and the fact that effective acute therapy is associated with a lower risk of progression, argue against the use of opiates, said Dr. Gottschalk.

There is even a potential risk that the experience of migraine and its relief due to self-administration may become a rewarding experience that propagates the problem. It’s possible that anticipatory anxiety related to fear stressors could lead to migraine, or to physical sensations interpreted as migraine prodrome. “[It] raises the question of whether or not positive reinforcement by drugs makes migraine itself a rewarding experience and therefore more likely to occur as a cue for drug self-administration. The question I pose is: Is there any reason to test this theory in drugs of no proven benefit in the treatment of migraine? I would say very clearly, No,” said Dr. Gottschalk.
 

Clarifying the finer points of the debate

In the Q&A session after the talk, Dr. Rizzoli said that he doesn’t advocate for long-term use of opiates, except in rare cases where the diagnosis gets changed to a chronic pain syndrome. “We’re talking about intermittent use for treatment of an acute event. Do we put limits on them? I think the answer is clearly Yes, and the limits are more strict than those for triptans. My own sense as a clinician is I want all of the available tools. From a clinical perspective, there are a large number of people who do just fine with intermittent use of these medicines, and so I wouldn’t restrict them,” said Dr. Rizzoli.

Dr. Gottschalk agreed that opiates may make sense for some patients, but expressed concerns about any and all physicians prescribing them. “The part about the tools is partly a question of: Who gets to use them? In the hands of a headache specialist in those isolated cases with careful restrictions, sure. But what I’m making is a slippery slope argument: What we know is that in emergency rooms, these are used routinely, and that [those] patients are precisely the ones who are at higher risk of addiction. So in some sense, I’m just saying I think we need to have much clearer boundaries,” he said.

Dr. Rizzoli has no relevant financial disclosures. Dr. Gottschalk has been on the advisory boards of Alder, AbbVie, Amgen/Novartis, Biohaven, Theranica, Upsher-Smith, Axsome, Vorso, Currax, and Impel. He has been a consultant for Alder, Alexion, and Spherix Global Insights. He has received research support from Relivion.

The use of opiates in the treatment of headache has a controversial history, and it remains a matter of debate today. Some believe that the medications, though risky, can be a useful tool in the neurologist’s treatment arsenal, while others argue that opioids are just too risky when there are other, safer alternatives available.

Those were the cruxes of arguments put forward by Paul Rizzoli, MD, and Christopher H. Gottschalk, MD, who conducted individual talks at the 2021 Scottsdale Headache Symposium. Dr. Rizzoli, associate professor of neurology at Harvard Medical School, Boston, argued in favor of the use of opioids and butalbital-containing medications. Dr. Gottschalk, assistant professor of neurology at Yale University, New Haven, Conn., argued against their use.

In certain situations opioids are worth the risk

Whether or not to use opioids in the treatment of headache is “a reasonable question, because these medications can clearly be seen as having risk. So perhaps another way to frame this question is as a risk-benefit issue. Are these medications worth the risk? How useful is the benefit of opioids, if the consequence is dependence or addiction?” Dr. Rizzoli began.

Although reviews show effectiveness of opioids in treating migraine, a three-part review in 2012 found greater efficacy of dihydroergotamine (DHE), ketorolac, and chlorpromazine. That’s not surprising, said Dr. Rizzoli, since those competing drugs are migraine-specific.

Dr. Rizzoli quoted a 2014 review indicating that there were incomplete data on the relative efficacy of opioids versus other analgesics, and for some patients opioids would likely be the optimal treatment, such as those who have contraindications to ergot-type medications or neuroleptic medications, pregnant women, or patients who don’t respond to other medications.

Dr. Rizzoli noted that The International Association for the Study of Pain has concluded that no other oral medications provide immediate and effective pain relief, and that short-term use rarely leads to addiction.

“So, to me, the answer is not to avoid opioids or outlaw them but instead to use them judiciously and infrequently, and in a short term or rescue fashion,” said Dr. Rizzoli.

He pointed out that physicians accept risks of other medications, and act to mitigate those risks. He said that risk mitigation with opioids can take the form of avoiding prescriptions in some situations, like when patients have a personal or family history of substance abuse, or in cases of some behavioral or emotional disorders.

Dr. Rizzoli went on to discuss the use of butalbital, which acts as a CNS depressant and has a variety of effects, including sedation, anxiolytic, hypnotic, and antiepileptic effects, but it is only a weak analgesic, but it nevertheless works in headache, said Dr. Rizzoli, citing patient reports and personal experience.

“It’s difficult to appreciate this theme of efficacy behind all the hype in the literature and in the press against butalbital, and the fact that it has not been adequately studied. But I would submit that the fact that we are even having this discussion is support enough for the use of butalbital. If butalbital either didn’t work or was simply a drug of abuse, it would likely have faded away by now,” said Dr. Rizzoli. He conceded that butalbital can be overused and may lead episodic headache to become chronic daily headache, but he noted that Seymour Solomon, MD, professor emeritus at Albert Einstein College of Medicine, New York, has estimated that removal of butalbital from the market would reduce chronic headache in the general population by only a small fraction of one percent.

Butalbital also has another interesting effect, which is that patients may quickly return to normal functioning after the headache resolves. “Maybe this is all due to management of anxiety, the presumed mechanism of action of barbiturates. So, instead of lobbying for its removal, I would propose that we should take a closer look at what’s going on here, and what the mechanism of action of this fairly interesting compound might be,” said Dr. Rizzoli.

Dr. Rizzoli also said there is some evidence that migraine-specific drugs also affect the tolerance to opioid drugs. “Somehow, they seem to interact with the opioid pain system. If that’s true, the implication is that you probably cannot escape the opioid receptors in the management of migraine,” said Dr. Rizzoli.

Ultimately, he supports the judicious use of opioids and butalbital containing-medications for headache relief. “My argument is that it is just too simplistic to cease use of these meds. Yes, they should be used in a restricted and careful way, but not abandoned,” said Dr. Rizzoli.
 

Opiates should be avoided

Following Dr. Rizzoli’s presentation, Dr. Gottschalk presented an argument against the use of opioids in the treatment of headache.

He began by quoting the ABIM Choosing Wisely Campaign of 2012, which concluded that fioricet and narcotics should be avoided in headache unless the patient is desperate. “As a headache specialist, I can tell you that I have not faced situations sufficiently desperate to use any of these. The American Headache Society in a series of evidence assessments has concluded similarly, that they are of no use,” said Dr. Gottschalk.

Opiates and barbiturates may also increase risk of migraine chronification. One study found that triptans are associated with low rates of chronification, at just a few percent when used fewer than 4 days a month, and about 20% per year when used 10-14 days per month. Opiate use showed a broadly similar pattern, while barbiturates showed a particularly alarming pattern: “Every level of use was associated with astronomically high rates and measurably higher at the highest level of use. For opiates, the odds ratio was about 2 – statistically significant. For barbiturates it was clearly greater than 2, whereas with triptans, the odds ratio showed a nonsignificant, slight increase in risk. And for NSAIDs, the odds ratio was, if anything, less than 1,” said Dr. Gottschalk.

He also discussed aspects of behavioral pharmacology, in which positive reinforcement associated with decreased headache may encourage repeated use of the drug. “Given these, it should be no surprise to anyone that emergency room treatment with opiates for acute migraine is clearly associated with increased recidivism for patients given those drugs,” said Dr. Gottschalk.

Opiate use is associated with increased pain sensitivity, and in the case of migraine, it may interfere with the activity of other treatments.

As for butalbital-containing compounds, they are positive-reinforcing drugs, and they are not indicated for migraine, only tension headache. There is no evidence of benefit in migraine, but butalbital is anxiolytic, which could lead an individual to increase its use.

A recent meta-analysis of therapies for episodic migraine found that hydromorphone and meperidine are less effective than standard therapies such as prochlorperazine or metoclopramide. Another study suggested that opioid use may interfere with the efficacy of NSAIDs in the emergency room environment, while a post hoc analysis of rizatriptan clinical trials found that recent opiate use was associated with a lower response rate, and the effect was more pronounced in women.

Among patients with chronic migraine, a 2004 study found that opiates were the most commonly used medication, and other studies found that chronic migraine does not arise in nonmigraine patients treated with opiates, “suggesting that migraine is specifically prone to opiate-induced hyperalgesia of migraine itself,” said Dr. Gottschalk.

Even under careful monitoring, misuse occurs in more than 50% of patients, “suggesting that even under the best circumstances, it is difficult to use this class of drugs safely in long term,” said Dr. Gottschalk.

He pointed out that the risk of drug addiction rises with various clinical and socioeconomic factors, including living in impoverished environments, adverse childhood experiences, low socioeconomic status, exposure to pollutants, and stressors. “In other words, all features associated with systemic racism are clearly associated with an increased risk of addiction,” said Dr. Gottschalk. Other factors include availability of the drug, such as whether or not a physician prescribes it, and repeated use.

These concerns, combined with positive-reinforcing properties of opiates and association with migraine progression and refractoriness, and the lack of progression risk found with use of NSAIDs and triptans, and the fact that effective acute therapy is associated with a lower risk of progression, argue against the use of opiates, said Dr. Gottschalk.

There is even a potential risk that the experience of migraine and its relief due to self-administration may become a rewarding experience that propagates the problem. It’s possible that anticipatory anxiety related to fear stressors could lead to migraine, or to physical sensations interpreted as migraine prodrome. “[It] raises the question of whether or not positive reinforcement by drugs makes migraine itself a rewarding experience and therefore more likely to occur as a cue for drug self-administration. The question I pose is: Is there any reason to test this theory in drugs of no proven benefit in the treatment of migraine? I would say very clearly, No,” said Dr. Gottschalk.
 

Clarifying the finer points of the debate

In the Q&A session after the talk, Dr. Rizzoli said that he doesn’t advocate for long-term use of opiates, except in rare cases where the diagnosis gets changed to a chronic pain syndrome. “We’re talking about intermittent use for treatment of an acute event. Do we put limits on them? I think the answer is clearly Yes, and the limits are more strict than those for triptans. My own sense as a clinician is I want all of the available tools. From a clinical perspective, there are a large number of people who do just fine with intermittent use of these medicines, and so I wouldn’t restrict them,” said Dr. Rizzoli.

Dr. Gottschalk agreed that opiates may make sense for some patients, but expressed concerns about any and all physicians prescribing them. “The part about the tools is partly a question of: Who gets to use them? In the hands of a headache specialist in those isolated cases with careful restrictions, sure. But what I’m making is a slippery slope argument: What we know is that in emergency rooms, these are used routinely, and that [those] patients are precisely the ones who are at higher risk of addiction. So in some sense, I’m just saying I think we need to have much clearer boundaries,” he said.

Dr. Rizzoli has no relevant financial disclosures. Dr. Gottschalk has been on the advisory boards of Alder, AbbVie, Amgen/Novartis, Biohaven, Theranica, Upsher-Smith, Axsome, Vorso, Currax, and Impel. He has been a consultant for Alder, Alexion, and Spherix Global Insights. He has received research support from Relivion.

The use of opiates in the treatment of headache has a controversial history, and it remains a matter of debate today. Some believe that the medications, though risky, can be a useful tool in the neurologist’s treatment arsenal, while others argue that opioids are just too risky when there are other, safer alternatives available.

Those were the cruxes of arguments put forward by Paul Rizzoli, MD, and Christopher H. Gottschalk, MD, who conducted individual talks at the 2021 Scottsdale Headache Symposium. Dr. Rizzoli, associate professor of neurology at Harvard Medical School, Boston, argued in favor of the use of opioids and butalbital-containing medications. Dr. Gottschalk, assistant professor of neurology at Yale University, New Haven, Conn., argued against their use.

In certain situations opioids are worth the risk

Whether or not to use opioids in the treatment of headache is “a reasonable question, because these medications can clearly be seen as having risk. So perhaps another way to frame this question is as a risk-benefit issue. Are these medications worth the risk? How useful is the benefit of opioids, if the consequence is dependence or addiction?” Dr. Rizzoli began.

Although reviews show effectiveness of opioids in treating migraine, a three-part review in 2012 found greater efficacy of dihydroergotamine (DHE), ketorolac, and chlorpromazine. That’s not surprising, said Dr. Rizzoli, since those competing drugs are migraine-specific.

Dr. Rizzoli quoted a 2014 review indicating that there were incomplete data on the relative efficacy of opioids versus other analgesics, and for some patients opioids would likely be the optimal treatment, such as those who have contraindications to ergot-type medications or neuroleptic medications, pregnant women, or patients who don’t respond to other medications.

Dr. Rizzoli noted that The International Association for the Study of Pain has concluded that no other oral medications provide immediate and effective pain relief, and that short-term use rarely leads to addiction.

“So, to me, the answer is not to avoid opioids or outlaw them but instead to use them judiciously and infrequently, and in a short term or rescue fashion,” said Dr. Rizzoli.

He pointed out that physicians accept risks of other medications, and act to mitigate those risks. He said that risk mitigation with opioids can take the form of avoiding prescriptions in some situations, like when patients have a personal or family history of substance abuse, or in cases of some behavioral or emotional disorders.

Dr. Rizzoli went on to discuss the use of butalbital, which acts as a CNS depressant and has a variety of effects, including sedation, anxiolytic, hypnotic, and antiepileptic effects, but it is only a weak analgesic, but it nevertheless works in headache, said Dr. Rizzoli, citing patient reports and personal experience.

“It’s difficult to appreciate this theme of efficacy behind all the hype in the literature and in the press against butalbital, and the fact that it has not been adequately studied. But I would submit that the fact that we are even having this discussion is support enough for the use of butalbital. If butalbital either didn’t work or was simply a drug of abuse, it would likely have faded away by now,” said Dr. Rizzoli. He conceded that butalbital can be overused and may lead episodic headache to become chronic daily headache, but he noted that Seymour Solomon, MD, professor emeritus at Albert Einstein College of Medicine, New York, has estimated that removal of butalbital from the market would reduce chronic headache in the general population by only a small fraction of one percent.

Butalbital also has another interesting effect, which is that patients may quickly return to normal functioning after the headache resolves. “Maybe this is all due to management of anxiety, the presumed mechanism of action of barbiturates. So, instead of lobbying for its removal, I would propose that we should take a closer look at what’s going on here, and what the mechanism of action of this fairly interesting compound might be,” said Dr. Rizzoli.

Dr. Rizzoli also said there is some evidence that migraine-specific drugs also affect the tolerance to opioid drugs. “Somehow, they seem to interact with the opioid pain system. If that’s true, the implication is that you probably cannot escape the opioid receptors in the management of migraine,” said Dr. Rizzoli.

Ultimately, he supports the judicious use of opioids and butalbital containing-medications for headache relief. “My argument is that it is just too simplistic to cease use of these meds. Yes, they should be used in a restricted and careful way, but not abandoned,” said Dr. Rizzoli.
 

Opiates should be avoided

Following Dr. Rizzoli’s presentation, Dr. Gottschalk presented an argument against the use of opioids in the treatment of headache.

He began by quoting the ABIM Choosing Wisely Campaign of 2012, which concluded that fioricet and narcotics should be avoided in headache unless the patient is desperate. “As a headache specialist, I can tell you that I have not faced situations sufficiently desperate to use any of these. The American Headache Society in a series of evidence assessments has concluded similarly, that they are of no use,” said Dr. Gottschalk.

Opiates and barbiturates may also increase risk of migraine chronification. One study found that triptans are associated with low rates of chronification, at just a few percent when used fewer than 4 days a month, and about 20% per year when used 10-14 days per month. Opiate use showed a broadly similar pattern, while barbiturates showed a particularly alarming pattern: “Every level of use was associated with astronomically high rates and measurably higher at the highest level of use. For opiates, the odds ratio was about 2 – statistically significant. For barbiturates it was clearly greater than 2, whereas with triptans, the odds ratio showed a nonsignificant, slight increase in risk. And for NSAIDs, the odds ratio was, if anything, less than 1,” said Dr. Gottschalk.

He also discussed aspects of behavioral pharmacology, in which positive reinforcement associated with decreased headache may encourage repeated use of the drug. “Given these, it should be no surprise to anyone that emergency room treatment with opiates for acute migraine is clearly associated with increased recidivism for patients given those drugs,” said Dr. Gottschalk.

Opiate use is associated with increased pain sensitivity, and in the case of migraine, it may interfere with the activity of other treatments.

As for butalbital-containing compounds, they are positive-reinforcing drugs, and they are not indicated for migraine, only tension headache. There is no evidence of benefit in migraine, but butalbital is anxiolytic, which could lead an individual to increase its use.

A recent meta-analysis of therapies for episodic migraine found that hydromorphone and meperidine are less effective than standard therapies such as prochlorperazine or metoclopramide. Another study suggested that opioid use may interfere with the efficacy of NSAIDs in the emergency room environment, while a post hoc analysis of rizatriptan clinical trials found that recent opiate use was associated with a lower response rate, and the effect was more pronounced in women.

Among patients with chronic migraine, a 2004 study found that opiates were the most commonly used medication, and other studies found that chronic migraine does not arise in nonmigraine patients treated with opiates, “suggesting that migraine is specifically prone to opiate-induced hyperalgesia of migraine itself,” said Dr. Gottschalk.

Even under careful monitoring, misuse occurs in more than 50% of patients, “suggesting that even under the best circumstances, it is difficult to use this class of drugs safely in long term,” said Dr. Gottschalk.

He pointed out that the risk of drug addiction rises with various clinical and socioeconomic factors, including living in impoverished environments, adverse childhood experiences, low socioeconomic status, exposure to pollutants, and stressors. “In other words, all features associated with systemic racism are clearly associated with an increased risk of addiction,” said Dr. Gottschalk. Other factors include availability of the drug, such as whether or not a physician prescribes it, and repeated use.

These concerns, combined with positive-reinforcing properties of opiates and association with migraine progression and refractoriness, and the lack of progression risk found with use of NSAIDs and triptans, and the fact that effective acute therapy is associated with a lower risk of progression, argue against the use of opiates, said Dr. Gottschalk.

There is even a potential risk that the experience of migraine and its relief due to self-administration may become a rewarding experience that propagates the problem. It’s possible that anticipatory anxiety related to fear stressors could lead to migraine, or to physical sensations interpreted as migraine prodrome. “[It] raises the question of whether or not positive reinforcement by drugs makes migraine itself a rewarding experience and therefore more likely to occur as a cue for drug self-administration. The question I pose is: Is there any reason to test this theory in drugs of no proven benefit in the treatment of migraine? I would say very clearly, No,” said Dr. Gottschalk.
 

Clarifying the finer points of the debate

In the Q&A session after the talk, Dr. Rizzoli said that he doesn’t advocate for long-term use of opiates, except in rare cases where the diagnosis gets changed to a chronic pain syndrome. “We’re talking about intermittent use for treatment of an acute event. Do we put limits on them? I think the answer is clearly Yes, and the limits are more strict than those for triptans. My own sense as a clinician is I want all of the available tools. From a clinical perspective, there are a large number of people who do just fine with intermittent use of these medicines, and so I wouldn’t restrict them,” said Dr. Rizzoli.

Dr. Gottschalk agreed that opiates may make sense for some patients, but expressed concerns about any and all physicians prescribing them. “The part about the tools is partly a question of: Who gets to use them? In the hands of a headache specialist in those isolated cases with careful restrictions, sure. But what I’m making is a slippery slope argument: What we know is that in emergency rooms, these are used routinely, and that [those] patients are precisely the ones who are at higher risk of addiction. So in some sense, I’m just saying I think we need to have much clearer boundaries,” he said.

Dr. Rizzoli has no relevant financial disclosures. Dr. Gottschalk has been on the advisory boards of Alder, AbbVie, Amgen/Novartis, Biohaven, Theranica, Upsher-Smith, Axsome, Vorso, Currax, and Impel. He has been a consultant for Alder, Alexion, and Spherix Global Insights. He has received research support from Relivion.

            Racial and ethnic disparities in prostate cancer diagnosis and treatment are well recognized. Prostate magnetic resonance imaging (MRI) as part of a diagnostic approach for people with elevated PSA may decrease unnecessary biopsies or better direct biopsies based on results, and its use is increasing significantly. Abashidze et al examined Medicare claims between 2011 and 2017 to determine if racial disparities were present with respect to the use of prostate MRI. Compared with White men, Black, Asian, and Hispanic men were less likely to have a prostate MRI within 180 days after an elevated PSA (results stratified at 2.5, 4, or 10 ng/mL). The differences were most pronounced for patients with a PSA at 4 ng/mL or higher. The results suggest that providers should be aware of potential system and individual factors that influence racial and ethnic disparities in the use of prostate MRI.

            Studies designed to evaluate germline and somatic genomic abnormalities in prostate cancer have come to the forefront in the last decade. Lynch syndrome is an inherited cancer syndrome of abnormalities in at least one of the commonly recognized mismatch repair genes: MLH1, MSH2, MSH6, or PMS2. While testing for mismatch repair deficiency is recommended in the advanced setting where systemic therapy is being considered, such testing outside of known family history is unclear in the setting of screening for prostate cancer. Bancroft et al compared PSA levels (and prostate cancer incidence) as part of baseline screening between carriers of one of mismatch repair genes (MLH1, MSH2, MSH6) and non-carrier controls. Carriers of MLH1 and MSH6 variants had a higher incidence of prostate cancer compared with controls. While not yet recommended for standard practice, further studies will be needed to verify these compelling results.

            Racial and ethnic disparities in prostate cancer diagnosis and treatment are well recognized. Prostate magnetic resonance imaging (MRI) as part of a diagnostic approach for people with elevated PSA may decrease unnecessary biopsies or better direct biopsies based on results, and its use is increasing significantly. Abashidze et al examined Medicare claims between 2011 and 2017 to determine if racial disparities were present with respect to the use of prostate MRI. Compared with White men, Black, Asian, and Hispanic men were less likely to have a prostate MRI within 180 days after an elevated PSA (results stratified at 2.5, 4, or 10 ng/mL). The differences were most pronounced for patients with a PSA at 4 ng/mL or higher. The results suggest that providers should be aware of potential system and individual factors that influence racial and ethnic disparities in the use of prostate MRI.

            Studies designed to evaluate germline and somatic genomic abnormalities in prostate cancer have come to the forefront in the last decade. Lynch syndrome is an inherited cancer syndrome of abnormalities in at least one of the commonly recognized mismatch repair genes: MLH1, MSH2, MSH6, or PMS2. While testing for mismatch repair deficiency is recommended in the advanced setting where systemic therapy is being considered, such testing outside of known family history is unclear in the setting of screening for prostate cancer. Bancroft et al compared PSA levels (and prostate cancer incidence) as part of baseline screening between carriers of one of mismatch repair genes (MLH1, MSH2, MSH6) and non-carrier controls. Carriers of MLH1 and MSH6 variants had a higher incidence of prostate cancer compared with controls. While not yet recommended for standard practice, further studies will be needed to verify these compelling results.

            Racial and ethnic disparities in prostate cancer diagnosis and treatment are well recognized. Prostate magnetic resonance imaging (MRI) as part of a diagnostic approach for people with elevated PSA may decrease unnecessary biopsies or better direct biopsies based on results, and its use is increasing significantly. Abashidze et al examined Medicare claims between 2011 and 2017 to determine if racial disparities were present with respect to the use of prostate MRI. Compared with White men, Black, Asian, and Hispanic men were less likely to have a prostate MRI within 180 days after an elevated PSA (results stratified at 2.5, 4, or 10 ng/mL). The differences were most pronounced for patients with a PSA at 4 ng/mL or higher. The results suggest that providers should be aware of potential system and individual factors that influence racial and ethnic disparities in the use of prostate MRI.

            Studies designed to evaluate germline and somatic genomic abnormalities in prostate cancer have come to the forefront in the last decade. Lynch syndrome is an inherited cancer syndrome of abnormalities in at least one of the commonly recognized mismatch repair genes: MLH1, MSH2, MSH6, or PMS2. While testing for mismatch repair deficiency is recommended in the advanced setting where systemic therapy is being considered, such testing outside of known family history is unclear in the setting of screening for prostate cancer. Bancroft et al compared PSA levels (and prostate cancer incidence) as part of baseline screening between carriers of one of mismatch repair genes (MLH1, MSH2, MSH6) and non-carrier controls. Carriers of MLH1 and MSH6 variants had a higher incidence of prostate cancer compared with controls. While not yet recommended for standard practice, further studies will be needed to verify these compelling results.

From 2017 to 2018, the 30-day prevalence of “vaping” nicotine rose dramatically among 8th graders, 10th graders, 12th graders, college students, and young adults; the increase was the greatest among college students.¹ As vaping has become a common phenomenon in our society, it is prudent to have a basic understanding of what vaping is, and its potential health risks.

How it works

Vaping is the inhaling and exhaling of aerosol that is produced by a device.² Users can vape nicotine, tetrahydrocannabinol (THC), or synthetic drugs. The aerosol, often mistaken for water vapor, consists of fine particles that contain varying amounts of toxic chemicals and heavy metals that enter the lungs and bloodstream when vaping.² In general, vaping devices consist of a mouthpiece, a battery, a cartridge for containing the e-juice/e-liquid, and a heating component that turns the e-juice/e-liquid into vapor.² The e-juice/e-liquid usually contains a propylene glycol or vegetable glycerin-based liquid with nicotine, THC, or synthetic drugs.² The e-juice/e-liquid also contains flavorings, additives, and other chemicals and metals (but not tobacco).²

There are 4 types of vaping devices³:

E-cigarettes. This first generation of vaping devices was introduced to US markets in 2007. E-cigarettes look similar to cigarettes and come in disposable or rechargeable forms.³ They may emit a light when the user puffs. E-cigarettes have shorter battery lives and are less expensive than other vaping devices.

Vape pens. These second-generation vaping devices resemble fountain pens. Vape pens also come in disposable and rechargeable forms.³ They can be refilled with e-juice/e-liquid.³

Vaping mods. These third-generation vaping devices were created when users modified items such as flashlights to create a more powerful vaping experience; however, these self-modifications often are unsafe. Vaping mods are larger than vape pens and e-cigarettes and include modification options. They also have large-capacity batteries that are replaceable. Vaping mods are typically rechargeable and deliver more nicotine than earlier-generation vaping devices.

Pod systems. Pod systems, such as Juul, are the latest generation of vaping devices. These small, sleek devices resemble a USB drive.³ They can be recharged on a laptop or any USB charger.³ Pods combine the portability of e-cigarettes or vape pens with the power of a mod system. There are 2 types of pod systems: open and closed. Open pod systems consist of removable pods that are filled with the user’s choice of e-juice/e-liquid and then replaced after being refilled several times. Closed pod systems are purchased pre-filled with e-juice/e-liquid and are disposable, similar to single-use coffee pods. Juul is the most popular vape brand in the United States.⁴ For a visual guide of the different vaping devices, see https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/ecigarette-or-vaping-products-visual-dictionary-508.pdf
 

What are the risks?

Vaping is relatively new, so the long-term health effects are not well studied. Although less harmful than smoking cigarettes, vaping is still not safe because users are exposed to chemicals in the aerosol, such as nicotine, heavy metals such as lead, volatile organic compounds, and cancer-causing agents.³ Vaping nicotine can result in the same cardiac and pulmonary complications as smoking cigarettes. Vaping nicotine can also be more addictive than smoking cigarettes because users can buy cartridges with higher concentrations of nicotine or increase the vaping device’s voltage to get a greater “hit” of nicotine (or whatever substance the user is vaping.) Vaping devices can also cause unintentional injuries due to fires and explosions from defective batteries.³

Vaping—particularly vaping THC—has been linked to a condition called e-cigarette, or vaping, product use-associated lung injury (EVALI).⁵ As of February 18, 2020, the CDC had received reports of approximately 2,800 patients with EVALI who were hospitalized or had died.⁵ Most EVALI cases have been linked to e-cigarette or vaping products that contained THC, particularly products obtained from informal sources such as friends, family, or in-person or online dealers.⁵ Vitamin E acetate, an additive in some THC-containing vaping products, has been strongly linked to EVALI.⁵ When ingested as a vitamin supplement or applied to the skin, vitamin E usually is harmless, but when inhaled, it may interfere with normal lung functioning.⁵ The CDC recommends that individuals who vape do not use products that contain THC; avoid getting vaping products from informal sources, such as friends, family, or online dealers; and not modify or add any substances to a vaping device other than as intended by the manufacturer.⁵

From 2017 to 2018, the 30-day prevalence of “vaping” nicotine rose dramatically among 8th graders, 10th graders, 12th graders, college students, and young adults; the increase was the greatest among college students.¹ As vaping has become a common phenomenon in our society, it is prudent to have a basic understanding of what vaping is, and its potential health risks.

How it works

Vaping is the inhaling and exhaling of aerosol that is produced by a device.² Users can vape nicotine, tetrahydrocannabinol (THC), or synthetic drugs. The aerosol, often mistaken for water vapor, consists of fine particles that contain varying amounts of toxic chemicals and heavy metals that enter the lungs and bloodstream when vaping.² In general, vaping devices consist of a mouthpiece, a battery, a cartridge for containing the e-juice/e-liquid, and a heating component that turns the e-juice/e-liquid into vapor.² The e-juice/e-liquid usually contains a propylene glycol or vegetable glycerin-based liquid with nicotine, THC, or synthetic drugs.² The e-juice/e-liquid also contains flavorings, additives, and other chemicals and metals (but not tobacco).²

There are 4 types of vaping devices³:

E-cigarettes. This first generation of vaping devices was introduced to US markets in 2007. E-cigarettes look similar to cigarettes and come in disposable or rechargeable forms.³ They may emit a light when the user puffs. E-cigarettes have shorter battery lives and are less expensive than other vaping devices.

Vape pens. These second-generation vaping devices resemble fountain pens. Vape pens also come in disposable and rechargeable forms.³ They can be refilled with e-juice/e-liquid.³

Vaping mods. These third-generation vaping devices were created when users modified items such as flashlights to create a more powerful vaping experience; however, these self-modifications often are unsafe. Vaping mods are larger than vape pens and e-cigarettes and include modification options. They also have large-capacity batteries that are replaceable. Vaping mods are typically rechargeable and deliver more nicotine than earlier-generation vaping devices.

Pod systems. Pod systems, such as Juul, are the latest generation of vaping devices. These small, sleek devices resemble a USB drive.³ They can be recharged on a laptop or any USB charger.³ Pods combine the portability of e-cigarettes or vape pens with the power of a mod system. There are 2 types of pod systems: open and closed. Open pod systems consist of removable pods that are filled with the user’s choice of e-juice/e-liquid and then replaced after being refilled several times. Closed pod systems are purchased pre-filled with e-juice/e-liquid and are disposable, similar to single-use coffee pods. Juul is the most popular vape brand in the United States.⁴ For a visual guide of the different vaping devices, see https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/ecigarette-or-vaping-products-visual-dictionary-508.pdf
 

What are the risks?

Vaping is relatively new, so the long-term health effects are not well studied. Although less harmful than smoking cigarettes, vaping is still not safe because users are exposed to chemicals in the aerosol, such as nicotine, heavy metals such as lead, volatile organic compounds, and cancer-causing agents.³ Vaping nicotine can result in the same cardiac and pulmonary complications as smoking cigarettes. Vaping nicotine can also be more addictive than smoking cigarettes because users can buy cartridges with higher concentrations of nicotine or increase the vaping device’s voltage to get a greater “hit” of nicotine (or whatever substance the user is vaping.) Vaping devices can also cause unintentional injuries due to fires and explosions from defective batteries.³

Vaping—particularly vaping THC—has been linked to a condition called e-cigarette, or vaping, product use-associated lung injury (EVALI).⁵ As of February 18, 2020, the CDC had received reports of approximately 2,800 patients with EVALI who were hospitalized or had died.⁵ Most EVALI cases have been linked to e-cigarette or vaping products that contained THC, particularly products obtained from informal sources such as friends, family, or in-person or online dealers.⁵ Vitamin E acetate, an additive in some THC-containing vaping products, has been strongly linked to EVALI.⁵ When ingested as a vitamin supplement or applied to the skin, vitamin E usually is harmless, but when inhaled, it may interfere with normal lung functioning.⁵ The CDC recommends that individuals who vape do not use products that contain THC; avoid getting vaping products from informal sources, such as friends, family, or online dealers; and not modify or add any substances to a vaping device other than as intended by the manufacturer.⁵

From 2017 to 2018, the 30-day prevalence of “vaping” nicotine rose dramatically among 8th graders, 10th graders, 12th graders, college students, and young adults; the increase was the greatest among college students.¹ As vaping has become a common phenomenon in our society, it is prudent to have a basic understanding of what vaping is, and its potential health risks.

How it works

Vaping is the inhaling and exhaling of aerosol that is produced by a device.² Users can vape nicotine, tetrahydrocannabinol (THC), or synthetic drugs. The aerosol, often mistaken for water vapor, consists of fine particles that contain varying amounts of toxic chemicals and heavy metals that enter the lungs and bloodstream when vaping.² In general, vaping devices consist of a mouthpiece, a battery, a cartridge for containing the e-juice/e-liquid, and a heating component that turns the e-juice/e-liquid into vapor.² The e-juice/e-liquid usually contains a propylene glycol or vegetable glycerin-based liquid with nicotine, THC, or synthetic drugs.² The e-juice/e-liquid also contains flavorings, additives, and other chemicals and metals (but not tobacco).²

There are 4 types of vaping devices³:

E-cigarettes. This first generation of vaping devices was introduced to US markets in 2007. E-cigarettes look similar to cigarettes and come in disposable or rechargeable forms.³ They may emit a light when the user puffs. E-cigarettes have shorter battery lives and are less expensive than other vaping devices.

Vape pens. These second-generation vaping devices resemble fountain pens. Vape pens also come in disposable and rechargeable forms.³ They can be refilled with e-juice/e-liquid.³

Vaping mods. These third-generation vaping devices were created when users modified items such as flashlights to create a more powerful vaping experience; however, these self-modifications often are unsafe. Vaping mods are larger than vape pens and e-cigarettes and include modification options. They also have large-capacity batteries that are replaceable. Vaping mods are typically rechargeable and deliver more nicotine than earlier-generation vaping devices.

Pod systems. Pod systems, such as Juul, are the latest generation of vaping devices. These small, sleek devices resemble a USB drive.³ They can be recharged on a laptop or any USB charger.³ Pods combine the portability of e-cigarettes or vape pens with the power of a mod system. There are 2 types of pod systems: open and closed. Open pod systems consist of removable pods that are filled with the user’s choice of e-juice/e-liquid and then replaced after being refilled several times. Closed pod systems are purchased pre-filled with e-juice/e-liquid and are disposable, similar to single-use coffee pods. Juul is the most popular vape brand in the United States.⁴ For a visual guide of the different vaping devices, see https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/ecigarette-or-vaping-products-visual-dictionary-508.pdf
 

What are the risks?

Vaping is relatively new, so the long-term health effects are not well studied. Although less harmful than smoking cigarettes, vaping is still not safe because users are exposed to chemicals in the aerosol, such as nicotine, heavy metals such as lead, volatile organic compounds, and cancer-causing agents.³ Vaping nicotine can result in the same cardiac and pulmonary complications as smoking cigarettes. Vaping nicotine can also be more addictive than smoking cigarettes because users can buy cartridges with higher concentrations of nicotine or increase the vaping device’s voltage to get a greater “hit” of nicotine (or whatever substance the user is vaping.) Vaping devices can also cause unintentional injuries due to fires and explosions from defective batteries.³

Vaping—particularly vaping THC—has been linked to a condition called e-cigarette, or vaping, product use-associated lung injury (EVALI).⁵ As of February 18, 2020, the CDC had received reports of approximately 2,800 patients with EVALI who were hospitalized or had died.⁵ Most EVALI cases have been linked to e-cigarette or vaping products that contained THC, particularly products obtained from informal sources such as friends, family, or in-person or online dealers.⁵ Vitamin E acetate, an additive in some THC-containing vaping products, has been strongly linked to EVALI.⁵ When ingested as a vitamin supplement or applied to the skin, vitamin E usually is harmless, but when inhaled, it may interfere with normal lung functioning.⁵ The CDC recommends that individuals who vape do not use products that contain THC; avoid getting vaping products from informal sources, such as friends, family, or online dealers; and not modify or add any substances to a vaping device other than as intended by the manufacturer.⁵

Background: Naloxone is an opioid antagonist that works to treat opioid overdose. Few randomized trials have assessed the efficacy of intranasal administration, whereas more data have been published supporting use of intramuscular naloxone. This prospective trial examines the ability of the same dose (800 mcg per 1 mL solution) of intranasal naloxone vs. intramuscular naloxone at managing opioid overdose.

Dr. Welter is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.

Background: Naloxone is an opioid antagonist that works to treat opioid overdose. Few randomized trials have assessed the efficacy of intranasal administration, whereas more data have been published supporting use of intramuscular naloxone. This prospective trial examines the ability of the same dose (800 mcg per 1 mL solution) of intranasal naloxone vs. intramuscular naloxone at managing opioid overdose.

Dr. Welter is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.

Background: Naloxone is an opioid antagonist that works to treat opioid overdose. Few randomized trials have assessed the efficacy of intranasal administration, whereas more data have been published supporting use of intramuscular naloxone. This prospective trial examines the ability of the same dose (800 mcg per 1 mL solution) of intranasal naloxone vs. intramuscular naloxone at managing opioid overdose.

Dr. Welter is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.

Human papillomavirus (HPV) vaccination helps prevent cervical cancer and saves lives, new nationwide data suggest.

The analysis adds to a growing body of evidence demonstrating vaccine-associated changes in cervical cancer incidence and mortality.

Previous data from the United Kingdom, published earlier in November, showed that cervical cancer rates were 87% lower among girls who received the HPV vaccine compared to previously unvaccinated generations. Based on the analysis, the authors concluded that the UK’s HPV immunization program “almost eliminated cervical cancer” in women born since September 1995.

The latest study, published Nov. 29 in JAMA Pediatrics , reports a 38% drop in cervical cancer incidence and a 43% decline in mortality among young women and girls after HPV vaccination was introduced in the United States.

“These results are encouraging,” Peter Sasieni, MD, of King’s College London, and senior author on the U.K. study, told this news organization in an email.

The difference in incidence rates between the U.K. and U.S. studies, Dr. Sasieni explained, is likely due to HPV vaccine coverage not expanding as significantly in the United States as it has in the United Kingdom, and “thus one would anticipate a lower impact on the population in the U.S.”

In the U.S. analysis, Justin Barnes, MD, a radiation oncology resident at Washington University, St. Louis, and colleagues examined cervical cancer incidence between January 2001 and December 2017 using Surveillance, Epidemiology, and End Results and National Program of Cancer Registries data as well as mortality data from the National Center for Health Statistics.

Dr. Barnes and colleagues then compared changes in cervical cancer incidence and mortality between prevaccination years (January 2001 to December 2005) and postvaccination years (January 2010 to December 2017) among three age cohorts – 15-24 years, 25-29 years, and 30-39 years.

“The older 2 groups were included as comparison, given their low vaccination rates,” Dr. Barnes and colleagues explained.

Results show that between the prevaccination and postvaccination periods, the incidence of cervical cancer dropped by 38% in the youngest cohort and by only 16% in the middle-aged group and 8% in the oldest cohort.

Women and girls in the youngest group saw a striking drop in mortality: a 43% decline, which translated to a mortality rate of 0.6 per 100,000.

On the other hand, the authors report a 4.7% decline in mortality in the oldest group and a 4.3% increase in mortality in the middle-aged group – translating to a mortality rate of 1.89 per 100,000 and 0.57 per 100,000, respectively.

Overall, “these nationwide data showed decreased cervical cancer incidence and mortality among women and girls aged 15-24 years after HPV vaccine introduction,” Dr. Barnes and colleagues wrote. The changes in cervical cancer incidence and mortality observed in the youngest age group “were greater than changes in those aged 25 to 29 years and 30 to 39 years, suggesting possible associations with HPV vaccination.”

This analysis lines up with previous evidence from U.S. epidemiologic data, which “have shown decreased cervical cancer incidence after vaccine implementation in women and girls aged 15 to 24 years but not older women.”

Although “the number of deaths and hence the number of potentially averted deaths in young women and girls was small,” the study adds to the current literature by “providing suggestive evidence for vaccine-associated decreases in cervical cancer mortality,” investigators concluded.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Human papillomavirus (HPV) vaccination helps prevent cervical cancer and saves lives, new nationwide data suggest.

The analysis adds to a growing body of evidence demonstrating vaccine-associated changes in cervical cancer incidence and mortality.

Previous data from the United Kingdom, published earlier in November, showed that cervical cancer rates were 87% lower among girls who received the HPV vaccine compared to previously unvaccinated generations. Based on the analysis, the authors concluded that the UK’s HPV immunization program “almost eliminated cervical cancer” in women born since September 1995.

The latest study, published Nov. 29 in JAMA Pediatrics , reports a 38% drop in cervical cancer incidence and a 43% decline in mortality among young women and girls after HPV vaccination was introduced in the United States.

“These results are encouraging,” Peter Sasieni, MD, of King’s College London, and senior author on the U.K. study, told this news organization in an email.

The difference in incidence rates between the U.K. and U.S. studies, Dr. Sasieni explained, is likely due to HPV vaccine coverage not expanding as significantly in the United States as it has in the United Kingdom, and “thus one would anticipate a lower impact on the population in the U.S.”

In the U.S. analysis, Justin Barnes, MD, a radiation oncology resident at Washington University, St. Louis, and colleagues examined cervical cancer incidence between January 2001 and December 2017 using Surveillance, Epidemiology, and End Results and National Program of Cancer Registries data as well as mortality data from the National Center for Health Statistics.

Dr. Barnes and colleagues then compared changes in cervical cancer incidence and mortality between prevaccination years (January 2001 to December 2005) and postvaccination years (January 2010 to December 2017) among three age cohorts – 15-24 years, 25-29 years, and 30-39 years.

“The older 2 groups were included as comparison, given their low vaccination rates,” Dr. Barnes and colleagues explained.

Results show that between the prevaccination and postvaccination periods, the incidence of cervical cancer dropped by 38% in the youngest cohort and by only 16% in the middle-aged group and 8% in the oldest cohort.

Women and girls in the youngest group saw a striking drop in mortality: a 43% decline, which translated to a mortality rate of 0.6 per 100,000.

On the other hand, the authors report a 4.7% decline in mortality in the oldest group and a 4.3% increase in mortality in the middle-aged group – translating to a mortality rate of 1.89 per 100,000 and 0.57 per 100,000, respectively.

Overall, “these nationwide data showed decreased cervical cancer incidence and mortality among women and girls aged 15-24 years after HPV vaccine introduction,” Dr. Barnes and colleagues wrote. The changes in cervical cancer incidence and mortality observed in the youngest age group “were greater than changes in those aged 25 to 29 years and 30 to 39 years, suggesting possible associations with HPV vaccination.”

This analysis lines up with previous evidence from U.S. epidemiologic data, which “have shown decreased cervical cancer incidence after vaccine implementation in women and girls aged 15 to 24 years but not older women.”

Although “the number of deaths and hence the number of potentially averted deaths in young women and girls was small,” the study adds to the current literature by “providing suggestive evidence for vaccine-associated decreases in cervical cancer mortality,” investigators concluded.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Human papillomavirus (HPV) vaccination helps prevent cervical cancer and saves lives, new nationwide data suggest.

The analysis adds to a growing body of evidence demonstrating vaccine-associated changes in cervical cancer incidence and mortality.

Previous data from the United Kingdom, published earlier in November, showed that cervical cancer rates were 87% lower among girls who received the HPV vaccine compared to previously unvaccinated generations. Based on the analysis, the authors concluded that the UK’s HPV immunization program “almost eliminated cervical cancer” in women born since September 1995.

The latest study, published Nov. 29 in JAMA Pediatrics , reports a 38% drop in cervical cancer incidence and a 43% decline in mortality among young women and girls after HPV vaccination was introduced in the United States.

“These results are encouraging,” Peter Sasieni, MD, of King’s College London, and senior author on the U.K. study, told this news organization in an email.

The difference in incidence rates between the U.K. and U.S. studies, Dr. Sasieni explained, is likely due to HPV vaccine coverage not expanding as significantly in the United States as it has in the United Kingdom, and “thus one would anticipate a lower impact on the population in the U.S.”

In the U.S. analysis, Justin Barnes, MD, a radiation oncology resident at Washington University, St. Louis, and colleagues examined cervical cancer incidence between January 2001 and December 2017 using Surveillance, Epidemiology, and End Results and National Program of Cancer Registries data as well as mortality data from the National Center for Health Statistics.

Dr. Barnes and colleagues then compared changes in cervical cancer incidence and mortality between prevaccination years (January 2001 to December 2005) and postvaccination years (January 2010 to December 2017) among three age cohorts – 15-24 years, 25-29 years, and 30-39 years.

“The older 2 groups were included as comparison, given their low vaccination rates,” Dr. Barnes and colleagues explained.

Results show that between the prevaccination and postvaccination periods, the incidence of cervical cancer dropped by 38% in the youngest cohort and by only 16% in the middle-aged group and 8% in the oldest cohort.

Women and girls in the youngest group saw a striking drop in mortality: a 43% decline, which translated to a mortality rate of 0.6 per 100,000.

On the other hand, the authors report a 4.7% decline in mortality in the oldest group and a 4.3% increase in mortality in the middle-aged group – translating to a mortality rate of 1.89 per 100,000 and 0.57 per 100,000, respectively.

Overall, “these nationwide data showed decreased cervical cancer incidence and mortality among women and girls aged 15-24 years after HPV vaccine introduction,” Dr. Barnes and colleagues wrote. The changes in cervical cancer incidence and mortality observed in the youngest age group “were greater than changes in those aged 25 to 29 years and 30 to 39 years, suggesting possible associations with HPV vaccination.”

This analysis lines up with previous evidence from U.S. epidemiologic data, which “have shown decreased cervical cancer incidence after vaccine implementation in women and girls aged 15 to 24 years but not older women.”

Although “the number of deaths and hence the number of potentially averted deaths in young women and girls was small,” the study adds to the current literature by “providing suggestive evidence for vaccine-associated decreases in cervical cancer mortality,” investigators concluded.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A head-to-head comparison of immune checkpoint inhibitors atezolizumab and nivolumab and the chemotherapy drug docetaxel in patients with advanced non–small cell lung cancer (NSCLC), finds that atezolizumab was associated with a significantly longer overall survival than docetaxel and was on par with nivolumab.

The findings were reported in JAMA Network Open.

“Until recently, chemotherapy with platinum doublet was the standard first-line option for most patients with advanced NSCLC who did not have these genetic drivers or were not tested for them and remains the first choice in many parts of the world,” wrote the authors of the study which was led by Sreeram Ramagopalan, PhD, of F. Hoffmann-La Roche in Switzerland which funded the study.

Atezolizumab (Tecentriq, Genentech), which was approved in October by the U.S. Food and Drug Administration, is a monoclonal antibody that targets programmed cell death ligand 1 (PD-L1). It is also approved as monotherapy for patients with advanced NSCLC whose disease progressed despite treatment with platinum-based chemotherapy.

This is the first-known analysis that compares atezolizumab, nivolumab (Opdivo, Bristol Myers Squibb), and docetaxel (Taxotere, Sanofi) in patients outside of clinical trials, said Vivek Subbiah, MD, of MD Anderson Cancer Center and the study’s first author. “We have several new immune checkpoint inhibitors approved for treatment for NSCLC. Head-to-head comparison of the effectiveness of these agents in the real world are lacking,” he said.

Treatment with immune checkpoint inhibitors has shown improvement in the survival of patients with advanced NSCLC who failed chemotherapy treatment.

This study included 3,336 patients (mean age 67 years, 54.6% men) with advanced NSCLC who were treated with platinum-based chemotherapy. Data were collected from more than 1,000 clinics in the United States. Of the patients, 206 received atezolizumab, 500 received docetaxel, and 2,630 received nivolumab.

Patients were followed between May 2011 and March 2020. Atezolizumab and nivolumab showed a similar overall survival in these patients, but atezolizumab showed a longer overall survival, compared with docetaxel.

“Compared with docetaxel, atezolizumab was associated with significantly longer survival in the overall population and across all subgroups analyzed,” including patients with stage IIIB or IV cancer at diagnosis and nonsquamous NSCLC, the authors wrote. “Atezolizumab was associated with longer overall survival compared with docetaxel and was on par with nivolumab, supporting current clinical guidelines for systemic therapy for patients with advanced NSCLC in the U.S.”

Limitations of the study included its observational design and a small number of patients receiving atezolizumab. The authors suggested that studies using larger sample sizes are needed.

This study was funded by F. Hoffmann-La Roche. Genentech is a subsidiary of F. Hoffmann-La Roche.

A head-to-head comparison of immune checkpoint inhibitors atezolizumab and nivolumab and the chemotherapy drug docetaxel in patients with advanced non–small cell lung cancer (NSCLC), finds that atezolizumab was associated with a significantly longer overall survival than docetaxel and was on par with nivolumab.

The findings were reported in JAMA Network Open.

“Until recently, chemotherapy with platinum doublet was the standard first-line option for most patients with advanced NSCLC who did not have these genetic drivers or were not tested for them and remains the first choice in many parts of the world,” wrote the authors of the study which was led by Sreeram Ramagopalan, PhD, of F. Hoffmann-La Roche in Switzerland which funded the study.

Atezolizumab (Tecentriq, Genentech), which was approved in October by the U.S. Food and Drug Administration, is a monoclonal antibody that targets programmed cell death ligand 1 (PD-L1). It is also approved as monotherapy for patients with advanced NSCLC whose disease progressed despite treatment with platinum-based chemotherapy.

This is the first-known analysis that compares atezolizumab, nivolumab (Opdivo, Bristol Myers Squibb), and docetaxel (Taxotere, Sanofi) in patients outside of clinical trials, said Vivek Subbiah, MD, of MD Anderson Cancer Center and the study’s first author. “We have several new immune checkpoint inhibitors approved for treatment for NSCLC. Head-to-head comparison of the effectiveness of these agents in the real world are lacking,” he said.

Treatment with immune checkpoint inhibitors has shown improvement in the survival of patients with advanced NSCLC who failed chemotherapy treatment.

This study included 3,336 patients (mean age 67 years, 54.6% men) with advanced NSCLC who were treated with platinum-based chemotherapy. Data were collected from more than 1,000 clinics in the United States. Of the patients, 206 received atezolizumab, 500 received docetaxel, and 2,630 received nivolumab.

Patients were followed between May 2011 and March 2020. Atezolizumab and nivolumab showed a similar overall survival in these patients, but atezolizumab showed a longer overall survival, compared with docetaxel.

“Compared with docetaxel, atezolizumab was associated with significantly longer survival in the overall population and across all subgroups analyzed,” including patients with stage IIIB or IV cancer at diagnosis and nonsquamous NSCLC, the authors wrote. “Atezolizumab was associated with longer overall survival compared with docetaxel and was on par with nivolumab, supporting current clinical guidelines for systemic therapy for patients with advanced NSCLC in the U.S.”

Limitations of the study included its observational design and a small number of patients receiving atezolizumab. The authors suggested that studies using larger sample sizes are needed.

This study was funded by F. Hoffmann-La Roche. Genentech is a subsidiary of F. Hoffmann-La Roche.

A head-to-head comparison of immune checkpoint inhibitors atezolizumab and nivolumab and the chemotherapy drug docetaxel in patients with advanced non–small cell lung cancer (NSCLC), finds that atezolizumab was associated with a significantly longer overall survival than docetaxel and was on par with nivolumab.

The findings were reported in JAMA Network Open.

“Until recently, chemotherapy with platinum doublet was the standard first-line option for most patients with advanced NSCLC who did not have these genetic drivers or were not tested for them and remains the first choice in many parts of the world,” wrote the authors of the study which was led by Sreeram Ramagopalan, PhD, of F. Hoffmann-La Roche in Switzerland which funded the study.

Atezolizumab (Tecentriq, Genentech), which was approved in October by the U.S. Food and Drug Administration, is a monoclonal antibody that targets programmed cell death ligand 1 (PD-L1). It is also approved as monotherapy for patients with advanced NSCLC whose disease progressed despite treatment with platinum-based chemotherapy.

This is the first-known analysis that compares atezolizumab, nivolumab (Opdivo, Bristol Myers Squibb), and docetaxel (Taxotere, Sanofi) in patients outside of clinical trials, said Vivek Subbiah, MD, of MD Anderson Cancer Center and the study’s first author. “We have several new immune checkpoint inhibitors approved for treatment for NSCLC. Head-to-head comparison of the effectiveness of these agents in the real world are lacking,” he said.

Treatment with immune checkpoint inhibitors has shown improvement in the survival of patients with advanced NSCLC who failed chemotherapy treatment.

This study included 3,336 patients (mean age 67 years, 54.6% men) with advanced NSCLC who were treated with platinum-based chemotherapy. Data were collected from more than 1,000 clinics in the United States. Of the patients, 206 received atezolizumab, 500 received docetaxel, and 2,630 received nivolumab.

Patients were followed between May 2011 and March 2020. Atezolizumab and nivolumab showed a similar overall survival in these patients, but atezolizumab showed a longer overall survival, compared with docetaxel.

“Compared with docetaxel, atezolizumab was associated with significantly longer survival in the overall population and across all subgroups analyzed,” including patients with stage IIIB or IV cancer at diagnosis and nonsquamous NSCLC, the authors wrote. “Atezolizumab was associated with longer overall survival compared with docetaxel and was on par with nivolumab, supporting current clinical guidelines for systemic therapy for patients with advanced NSCLC in the U.S.”

Limitations of the study included its observational design and a small number of patients receiving atezolizumab. The authors suggested that studies using larger sample sizes are needed.

This study was funded by F. Hoffmann-La Roche. Genentech is a subsidiary of F. Hoffmann-La Roche.

‘Grainy’ or ‘pixelated’ vision can be an alarming symptom for patients. The phenomenon is called visual snow, and although it was first described only recently, it is fairly common.

“This is a symptom of vision where patients describe numerous flickering dots throughout their vision. Sometimes they’ll use the term grainy or pixelated vision. Many times there’s a dynamic moving component to this. Many patients will describe this as like a TV static overlay on their vision,” Carrie Robertson, MD, said during a presentation on the topic at the 2021 Scottsdale Headache Symposium. Dr. Robertson is a neurologist at the Mayo Clinic in Rochester, Minn.

“It turns out that a little over 3% of us probably see this in our vision. So even if you haven’t seen this in the clinic yet, it’s likely that you will in the future,” said Dr. Robertson.

The first report describing visual snow appeared in 1995, among migraine patients. As of 2014 there were only 10 cases described in the literature. Although the condition was initially thought of as an unusual feature of migraine, a 2014 combined chart review and survey found that 15 of 22 patients had additional visual symptoms, such as photophobia or difficulty with night vision. Twenty of the 22 patients had comorbid migraine. Other symptoms include visual ghosts that persist after looking away from an object, as well as a higher frequency of experiencing floaters.

Symptoms aren’t restricted to the visual domain. Migraine, tinnitus, dizziness, and impaired concentration also occur.

The condition is more common than many suspect. “We used to think it was very rare. Now we assume that this was just under recognized,” said Dr. Robertson. One survey in the United Kingdom found that 3.7% of respondents reported visual snow, and 2.2% met the criteria for the syndrome.
 

A common and typically benign problem

It is a common clinical problem, according to Andrew Charles, MD, professor of neurology at the University of California, Los Angeles, and director of the UCLA Goldberg Migraine Program. “Almost every week I personally see somebody and then in our group, we have a whole host of them,” he said.

“When you see these patients in clinic, it’s important to remember that this is a heterogeneous disorder,” said Dr. Robertson. “Some patients will say, ‘Oh yeah, I’ve seen visual snow for as long as I can remember, I didn’t even know it was abnormal.’ Some will describe a family history of visual snow. Others will show up in clinic panicked because their visual snow just started or sometimes it’ll start after a triggering events like a head injury or hallucinogen use, and they’re worried that they’re going to go blind.”

It’s important to rule out other potential causes. Dr. Robertson’s group examined 248 cases of visual snow and found that 89 had a comorbidity that explained the condition. Issues within the retina, cornea, and the optical nerve can cause visual snow, which makes it critical that patients be seen by an ophthalmologist.

Some patients reported improvement when they stopped a new medication. “I always ask if there was a specific medicine that they started at the onset of their symptoms,” said Dr. Robertson. Other rare conditions associated with visual snow include idiopathic intracranial hypertension, posterior cortical atrophy, and even the Heidenhain variant of Creutzfeldt-Jakob disease.

In the absence of a secondary cause, and the if condition doesn’t worsen, physicians should reassure patients that the condition is typically benign. “Many of these patients are panicked that they’re going to lose their vision, and that’s what brings them to your office. It’s important to stress that visual snow is real, that you believe them, that they’re seeing what they say that they’re seeing. It’s not a migraine aura, but it’s typically benign. I like to give the analogy that it’s similar to tinnitus because I think that that’s helpful for patients to put it in that category of benign but very annoying,” said Dr. Robertson.
 

Limited treatment options

Unfortunately, there is little evidence on medications to treat the problem. According to Dr. Robertson, the best available evidence – from case reports – is for lamotrigine. Nearly 20% of patients achieve a partial response, and complete responses are rare.

Clinical trials are a possibility, but patients should be made aware that medications have the potential to worsen visual snow.

Nonpharmaceutical approaches include visual and mental distraction, along with manipulation of lighting at work and at home. Stress reduction may help, and Dr. Robertson may send patients with dizziness for visual vestibular therapy to work on visual motion desensitization exercises.

There are visual snow relief videos available on YouTube, which may provide temporary relief. “It’s probably similar to white noise therapy for tinnitus,” said Dr. Robertson.

Colored glass lenses may be helpful. “I’m having the best success at this point with FL-41 lenses. Some prefer amber, and others prefer the rose-tinted, just like migraine. I usually start with that,” said Dr. Robertson. Yellow lenses may help with nyctalopia.

She recommends that patients avoid consuming too much caffeine, and that they avoid stimulants, especially attention-deficit disorder (ADD) medications. “I’ve had a lot of patients worsen with ADD medication,” said Dr. Robertson. She also warns patients away from marijuana and hallucinogens.

There is a large community available for patients with visual snow, including more than 60 Facebook groups, and many YouTube videos of patients describing their experiences. There is even a visual snow simulator that neurologists can show patients to confirm what they are seeing. “It’s very validating for the patient,” said Dr. Robertson.

Dr. Charles noted the relatively few treatment options and poor understanding of the mechanisms behind the condition. “It’s incredibly frustrating that we have to tell them that we have so little understanding of basic mechanisms, and no really clear therapeutic strategy that we can apply across all patients and expect results,” said Dr. Charles.

The heightened interest in the condition does represent some hope. “It’s very much reassuring to people that, number one, we’re starting to understand it – but number two, that they’re not crazy. It’s very much validating to hear that it’s now a topic of much more rigorous investigation,” said Dr. Charles.

Dr. Robertson and Dr. Charles have no relevant financial disclosures.

‘Grainy’ or ‘pixelated’ vision can be an alarming symptom for patients. The phenomenon is called visual snow, and although it was first described only recently, it is fairly common.

“This is a symptom of vision where patients describe numerous flickering dots throughout their vision. Sometimes they’ll use the term grainy or pixelated vision. Many times there’s a dynamic moving component to this. Many patients will describe this as like a TV static overlay on their vision,” Carrie Robertson, MD, said during a presentation on the topic at the 2021 Scottsdale Headache Symposium. Dr. Robertson is a neurologist at the Mayo Clinic in Rochester, Minn.

“It turns out that a little over 3% of us probably see this in our vision. So even if you haven’t seen this in the clinic yet, it’s likely that you will in the future,” said Dr. Robertson.

The first report describing visual snow appeared in 1995, among migraine patients. As of 2014 there were only 10 cases described in the literature. Although the condition was initially thought of as an unusual feature of migraine, a 2014 combined chart review and survey found that 15 of 22 patients had additional visual symptoms, such as photophobia or difficulty with night vision. Twenty of the 22 patients had comorbid migraine. Other symptoms include visual ghosts that persist after looking away from an object, as well as a higher frequency of experiencing floaters.

Symptoms aren’t restricted to the visual domain. Migraine, tinnitus, dizziness, and impaired concentration also occur.

The condition is more common than many suspect. “We used to think it was very rare. Now we assume that this was just under recognized,” said Dr. Robertson. One survey in the United Kingdom found that 3.7% of respondents reported visual snow, and 2.2% met the criteria for the syndrome.
 

A common and typically benign problem

It is a common clinical problem, according to Andrew Charles, MD, professor of neurology at the University of California, Los Angeles, and director of the UCLA Goldberg Migraine Program. “Almost every week I personally see somebody and then in our group, we have a whole host of them,” he said.

“When you see these patients in clinic, it’s important to remember that this is a heterogeneous disorder,” said Dr. Robertson. “Some patients will say, ‘Oh yeah, I’ve seen visual snow for as long as I can remember, I didn’t even know it was abnormal.’ Some will describe a family history of visual snow. Others will show up in clinic panicked because their visual snow just started or sometimes it’ll start after a triggering events like a head injury or hallucinogen use, and they’re worried that they’re going to go blind.”

It’s important to rule out other potential causes. Dr. Robertson’s group examined 248 cases of visual snow and found that 89 had a comorbidity that explained the condition. Issues within the retina, cornea, and the optical nerve can cause visual snow, which makes it critical that patients be seen by an ophthalmologist.

Some patients reported improvement when they stopped a new medication. “I always ask if there was a specific medicine that they started at the onset of their symptoms,” said Dr. Robertson. Other rare conditions associated with visual snow include idiopathic intracranial hypertension, posterior cortical atrophy, and even the Heidenhain variant of Creutzfeldt-Jakob disease.

In the absence of a secondary cause, and the if condition doesn’t worsen, physicians should reassure patients that the condition is typically benign. “Many of these patients are panicked that they’re going to lose their vision, and that’s what brings them to your office. It’s important to stress that visual snow is real, that you believe them, that they’re seeing what they say that they’re seeing. It’s not a migraine aura, but it’s typically benign. I like to give the analogy that it’s similar to tinnitus because I think that that’s helpful for patients to put it in that category of benign but very annoying,” said Dr. Robertson.
 

Limited treatment options

Unfortunately, there is little evidence on medications to treat the problem. According to Dr. Robertson, the best available evidence – from case reports – is for lamotrigine. Nearly 20% of patients achieve a partial response, and complete responses are rare.

Clinical trials are a possibility, but patients should be made aware that medications have the potential to worsen visual snow.

Nonpharmaceutical approaches include visual and mental distraction, along with manipulation of lighting at work and at home. Stress reduction may help, and Dr. Robertson may send patients with dizziness for visual vestibular therapy to work on visual motion desensitization exercises.

There are visual snow relief videos available on YouTube, which may provide temporary relief. “It’s probably similar to white noise therapy for tinnitus,” said Dr. Robertson.

Colored glass lenses may be helpful. “I’m having the best success at this point with FL-41 lenses. Some prefer amber, and others prefer the rose-tinted, just like migraine. I usually start with that,” said Dr. Robertson. Yellow lenses may help with nyctalopia.

She recommends that patients avoid consuming too much caffeine, and that they avoid stimulants, especially attention-deficit disorder (ADD) medications. “I’ve had a lot of patients worsen with ADD medication,” said Dr. Robertson. She also warns patients away from marijuana and hallucinogens.

There is a large community available for patients with visual snow, including more than 60 Facebook groups, and many YouTube videos of patients describing their experiences. There is even a visual snow simulator that neurologists can show patients to confirm what they are seeing. “It’s very validating for the patient,” said Dr. Robertson.

Dr. Charles noted the relatively few treatment options and poor understanding of the mechanisms behind the condition. “It’s incredibly frustrating that we have to tell them that we have so little understanding of basic mechanisms, and no really clear therapeutic strategy that we can apply across all patients and expect results,” said Dr. Charles.

The heightened interest in the condition does represent some hope. “It’s very much reassuring to people that, number one, we’re starting to understand it – but number two, that they’re not crazy. It’s very much validating to hear that it’s now a topic of much more rigorous investigation,” said Dr. Charles.

Dr. Robertson and Dr. Charles have no relevant financial disclosures.

‘Grainy’ or ‘pixelated’ vision can be an alarming symptom for patients. The phenomenon is called visual snow, and although it was first described only recently, it is fairly common.

“This is a symptom of vision where patients describe numerous flickering dots throughout their vision. Sometimes they’ll use the term grainy or pixelated vision. Many times there’s a dynamic moving component to this. Many patients will describe this as like a TV static overlay on their vision,” Carrie Robertson, MD, said during a presentation on the topic at the 2021 Scottsdale Headache Symposium. Dr. Robertson is a neurologist at the Mayo Clinic in Rochester, Minn.

“It turns out that a little over 3% of us probably see this in our vision. So even if you haven’t seen this in the clinic yet, it’s likely that you will in the future,” said Dr. Robertson.

The first report describing visual snow appeared in 1995, among migraine patients. As of 2014 there were only 10 cases described in the literature. Although the condition was initially thought of as an unusual feature of migraine, a 2014 combined chart review and survey found that 15 of 22 patients had additional visual symptoms, such as photophobia or difficulty with night vision. Twenty of the 22 patients had comorbid migraine. Other symptoms include visual ghosts that persist after looking away from an object, as well as a higher frequency of experiencing floaters.

Symptoms aren’t restricted to the visual domain. Migraine, tinnitus, dizziness, and impaired concentration also occur.

The condition is more common than many suspect. “We used to think it was very rare. Now we assume that this was just under recognized,” said Dr. Robertson. One survey in the United Kingdom found that 3.7% of respondents reported visual snow, and 2.2% met the criteria for the syndrome.
 

A common and typically benign problem

It is a common clinical problem, according to Andrew Charles, MD, professor of neurology at the University of California, Los Angeles, and director of the UCLA Goldberg Migraine Program. “Almost every week I personally see somebody and then in our group, we have a whole host of them,” he said.

“When you see these patients in clinic, it’s important to remember that this is a heterogeneous disorder,” said Dr. Robertson. “Some patients will say, ‘Oh yeah, I’ve seen visual snow for as long as I can remember, I didn’t even know it was abnormal.’ Some will describe a family history of visual snow. Others will show up in clinic panicked because their visual snow just started or sometimes it’ll start after a triggering events like a head injury or hallucinogen use, and they’re worried that they’re going to go blind.”

It’s important to rule out other potential causes. Dr. Robertson’s group examined 248 cases of visual snow and found that 89 had a comorbidity that explained the condition. Issues within the retina, cornea, and the optical nerve can cause visual snow, which makes it critical that patients be seen by an ophthalmologist.

Some patients reported improvement when they stopped a new medication. “I always ask if there was a specific medicine that they started at the onset of their symptoms,” said Dr. Robertson. Other rare conditions associated with visual snow include idiopathic intracranial hypertension, posterior cortical atrophy, and even the Heidenhain variant of Creutzfeldt-Jakob disease.

In the absence of a secondary cause, and the if condition doesn’t worsen, physicians should reassure patients that the condition is typically benign. “Many of these patients are panicked that they’re going to lose their vision, and that’s what brings them to your office. It’s important to stress that visual snow is real, that you believe them, that they’re seeing what they say that they’re seeing. It’s not a migraine aura, but it’s typically benign. I like to give the analogy that it’s similar to tinnitus because I think that that’s helpful for patients to put it in that category of benign but very annoying,” said Dr. Robertson.
 

Limited treatment options

Unfortunately, there is little evidence on medications to treat the problem. According to Dr. Robertson, the best available evidence – from case reports – is for lamotrigine. Nearly 20% of patients achieve a partial response, and complete responses are rare.

Clinical trials are a possibility, but patients should be made aware that medications have the potential to worsen visual snow.

Nonpharmaceutical approaches include visual and mental distraction, along with manipulation of lighting at work and at home. Stress reduction may help, and Dr. Robertson may send patients with dizziness for visual vestibular therapy to work on visual motion desensitization exercises.

There are visual snow relief videos available on YouTube, which may provide temporary relief. “It’s probably similar to white noise therapy for tinnitus,” said Dr. Robertson.

Colored glass lenses may be helpful. “I’m having the best success at this point with FL-41 lenses. Some prefer amber, and others prefer the rose-tinted, just like migraine. I usually start with that,” said Dr. Robertson. Yellow lenses may help with nyctalopia.

She recommends that patients avoid consuming too much caffeine, and that they avoid stimulants, especially attention-deficit disorder (ADD) medications. “I’ve had a lot of patients worsen with ADD medication,” said Dr. Robertson. She also warns patients away from marijuana and hallucinogens.

There is a large community available for patients with visual snow, including more than 60 Facebook groups, and many YouTube videos of patients describing their experiences. There is even a visual snow simulator that neurologists can show patients to confirm what they are seeing. “It’s very validating for the patient,” said Dr. Robertson.

Dr. Charles noted the relatively few treatment options and poor understanding of the mechanisms behind the condition. “It’s incredibly frustrating that we have to tell them that we have so little understanding of basic mechanisms, and no really clear therapeutic strategy that we can apply across all patients and expect results,” said Dr. Charles.

The heightened interest in the condition does represent some hope. “It’s very much reassuring to people that, number one, we’re starting to understand it – but number two, that they’re not crazy. It’s very much validating to hear that it’s now a topic of much more rigorous investigation,” said Dr. Charles.

Dr. Robertson and Dr. Charles have no relevant financial disclosures.

New U.S. data show that the incidence of colorectal cancer (CRC) is on the rise among people aged 50–54 years, mirroring the well-documented increases in early-onset CRC in persons younger than 50 years.

“It’s likely that the factors contributing to CRC at age 50–54 years are the same factors that contribute to early-onset CRC, which has increased in parallel,” Caitlin Murphy, PhD, MPH, with the University of Texas Health Science Center at Houston, said in an interview.

“Many studies published in just the last year show that the well-known risk factors of CRC in older adults, such as obesity or sedentary lifestyle, are risk factors of CRC in younger adults. Growing evidence also suggests that early life exposures, or exposures in childhood, infancy, or even in the womb, play an important role,” Dr. Murphy said.

The study was published online October 28 in Gastroenterology .

Dr. Murphy and colleagues examined trends in age-specific CRC incidence rates for individuals aged 45–49, 50–54, and 55–59 years using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

During the period 1992–2018, there were a total of 101,609 cases of CRC among adults aged 45–59 years.

Further analysis showed that the CRC incidence rates rose from 23.4 to 34.0 per 100,000 among people aged 45–49 years and from 46.4 to 63.8 per 100,000 among those aged 50–54 years.

Conversely, incidence rates decreased among individuals aged 55–59 years, from 81.7 to 63.7 per 100,000 persons.

“Because of this opposing trend, or decreasing rates for age 55–59 years and increasing rates for age 50–54 years, incidence rates for the two age groups were nearly identical in 2016–18,” the researchers write.

They also found a “clear pattern” of increasing CRC incidence among adults in their early 50s, supporting the hypothesis that incidence rates increase at older ages as higher-risk generations mature, the researchers note.

These data send a clear message, Dr. Murphy told this news organization.

“Don’t delay colorectal cancer screening. Encourage on-time screening by discussing screening with patients before they reach the recommended age to initiate screening. The U.S. Preventive Services Task Force now recommends initiating average-risk screening at age 45 years,” Dr. Murphy said.
 

Concerning but not surprising

Rebecca Siegel, MPH, scientific director of Surveillance Research at the American Cancer Society, in Atlanta, who wasn’t involved in the study, said the results are “not surprising” and mirror the results of a 2017 study that showed that the incidence of CRC was increasing among individuals aged 50–54 years, as reported.

What’s “concerning,” Ms. Siegel said, is that people in this age group “have been recommended to be screened for CRC for decades. Hopefully, because the age to begin screening has been lowered from 50 to 45 years, this uptick will eventually flatten.”

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, in Norfolk, Va., who also wasn’t involved in the study, said the increasing incidence is “concerning in this younger population, and similar to what is seen recently for the 45- to 49-year-old population.

“Recent data have linked dietary influences in the early development of precancerous colon polyps and colon cancer. The increased ingestion of processed foods and sugary beverages, most of which contain high fructose corn syrup, is very likely involved in the pathogenesis to explain these striking epidemiologic shifts,” Dr. Johnson said in an interview.

“These concerns will likely be compounded by the COVID-related adverse effects on people [in terms of] appropriate, timely colorectal cancer screening,” Dr. Johnson added.

The study was supported by the National Cancer Institute at the National Institutes of Health. Dr. Murphy has consulted for Freenome. Ms. Siegel and Dr. Johnson have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

New U.S. data show that the incidence of colorectal cancer (CRC) is on the rise among people aged 50–54 years, mirroring the well-documented increases in early-onset CRC in persons younger than 50 years.

“It’s likely that the factors contributing to CRC at age 50–54 years are the same factors that contribute to early-onset CRC, which has increased in parallel,” Caitlin Murphy, PhD, MPH, with the University of Texas Health Science Center at Houston, said in an interview.

“Many studies published in just the last year show that the well-known risk factors of CRC in older adults, such as obesity or sedentary lifestyle, are risk factors of CRC in younger adults. Growing evidence also suggests that early life exposures, or exposures in childhood, infancy, or even in the womb, play an important role,” Dr. Murphy said.

The study was published online October 28 in Gastroenterology .

Dr. Murphy and colleagues examined trends in age-specific CRC incidence rates for individuals aged 45–49, 50–54, and 55–59 years using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

During the period 1992–2018, there were a total of 101,609 cases of CRC among adults aged 45–59 years.

Further analysis showed that the CRC incidence rates rose from 23.4 to 34.0 per 100,000 among people aged 45–49 years and from 46.4 to 63.8 per 100,000 among those aged 50–54 years.

Conversely, incidence rates decreased among individuals aged 55–59 years, from 81.7 to 63.7 per 100,000 persons.

“Because of this opposing trend, or decreasing rates for age 55–59 years and increasing rates for age 50–54 years, incidence rates for the two age groups were nearly identical in 2016–18,” the researchers write.

They also found a “clear pattern” of increasing CRC incidence among adults in their early 50s, supporting the hypothesis that incidence rates increase at older ages as higher-risk generations mature, the researchers note.

These data send a clear message, Dr. Murphy told this news organization.

“Don’t delay colorectal cancer screening. Encourage on-time screening by discussing screening with patients before they reach the recommended age to initiate screening. The U.S. Preventive Services Task Force now recommends initiating average-risk screening at age 45 years,” Dr. Murphy said.
 

Concerning but not surprising

Rebecca Siegel, MPH, scientific director of Surveillance Research at the American Cancer Society, in Atlanta, who wasn’t involved in the study, said the results are “not surprising” and mirror the results of a 2017 study that showed that the incidence of CRC was increasing among individuals aged 50–54 years, as reported.

What’s “concerning,” Ms. Siegel said, is that people in this age group “have been recommended to be screened for CRC for decades. Hopefully, because the age to begin screening has been lowered from 50 to 45 years, this uptick will eventually flatten.”

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, in Norfolk, Va., who also wasn’t involved in the study, said the increasing incidence is “concerning in this younger population, and similar to what is seen recently for the 45- to 49-year-old population.

“Recent data have linked dietary influences in the early development of precancerous colon polyps and colon cancer. The increased ingestion of processed foods and sugary beverages, most of which contain high fructose corn syrup, is very likely involved in the pathogenesis to explain these striking epidemiologic shifts,” Dr. Johnson said in an interview.

“These concerns will likely be compounded by the COVID-related adverse effects on people [in terms of] appropriate, timely colorectal cancer screening,” Dr. Johnson added.

The study was supported by the National Cancer Institute at the National Institutes of Health. Dr. Murphy has consulted for Freenome. Ms. Siegel and Dr. Johnson have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

New U.S. data show that the incidence of colorectal cancer (CRC) is on the rise among people aged 50–54 years, mirroring the well-documented increases in early-onset CRC in persons younger than 50 years.

“It’s likely that the factors contributing to CRC at age 50–54 years are the same factors that contribute to early-onset CRC, which has increased in parallel,” Caitlin Murphy, PhD, MPH, with the University of Texas Health Science Center at Houston, said in an interview.

“Many studies published in just the last year show that the well-known risk factors of CRC in older adults, such as obesity or sedentary lifestyle, are risk factors of CRC in younger adults. Growing evidence also suggests that early life exposures, or exposures in childhood, infancy, or even in the womb, play an important role,” Dr. Murphy said.

The study was published online October 28 in Gastroenterology .

Dr. Murphy and colleagues examined trends in age-specific CRC incidence rates for individuals aged 45–49, 50–54, and 55–59 years using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program.

During the period 1992–2018, there were a total of 101,609 cases of CRC among adults aged 45–59 years.

Further analysis showed that the CRC incidence rates rose from 23.4 to 34.0 per 100,000 among people aged 45–49 years and from 46.4 to 63.8 per 100,000 among those aged 50–54 years.

Conversely, incidence rates decreased among individuals aged 55–59 years, from 81.7 to 63.7 per 100,000 persons.

“Because of this opposing trend, or decreasing rates for age 55–59 years and increasing rates for age 50–54 years, incidence rates for the two age groups were nearly identical in 2016–18,” the researchers write.

They also found a “clear pattern” of increasing CRC incidence among adults in their early 50s, supporting the hypothesis that incidence rates increase at older ages as higher-risk generations mature, the researchers note.

These data send a clear message, Dr. Murphy told this news organization.

“Don’t delay colorectal cancer screening. Encourage on-time screening by discussing screening with patients before they reach the recommended age to initiate screening. The U.S. Preventive Services Task Force now recommends initiating average-risk screening at age 45 years,” Dr. Murphy said.
 

Concerning but not surprising

Rebecca Siegel, MPH, scientific director of Surveillance Research at the American Cancer Society, in Atlanta, who wasn’t involved in the study, said the results are “not surprising” and mirror the results of a 2017 study that showed that the incidence of CRC was increasing among individuals aged 50–54 years, as reported.

What’s “concerning,” Ms. Siegel said, is that people in this age group “have been recommended to be screened for CRC for decades. Hopefully, because the age to begin screening has been lowered from 50 to 45 years, this uptick will eventually flatten.”

David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, in Norfolk, Va., who also wasn’t involved in the study, said the increasing incidence is “concerning in this younger population, and similar to what is seen recently for the 45- to 49-year-old population.

“Recent data have linked dietary influences in the early development of precancerous colon polyps and colon cancer. The increased ingestion of processed foods and sugary beverages, most of which contain high fructose corn syrup, is very likely involved in the pathogenesis to explain these striking epidemiologic shifts,” Dr. Johnson said in an interview.

“These concerns will likely be compounded by the COVID-related adverse effects on people [in terms of] appropriate, timely colorectal cancer screening,” Dr. Johnson added.

The study was supported by the National Cancer Institute at the National Institutes of Health. Dr. Murphy has consulted for Freenome. Ms. Siegel and Dr. Johnson have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.

Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.

“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.

The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.

The findings were published online Nov. 24 in JAMA Psychiatry.
 

Primary outcome met

The study included 291 patients aged 60 years and older (mean age, 70 years; 58% women) with confirmed insomnia disorder and no major depression within the previous 12 months.

All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).

CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.

SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.

Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.

The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.

Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.

After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).

Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
 

‘Remission is key’

The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).

“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.

Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.

It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.

The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.

While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.

These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.

There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
 

Convincing argument?

Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.

“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.

The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”

Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.

The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”

Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.

If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.

“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.

This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.

The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.

A version of this article first appeared on Medscape.com.

Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.

Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.

“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.

The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.

The findings were published online Nov. 24 in JAMA Psychiatry.
 

Primary outcome met

The study included 291 patients aged 60 years and older (mean age, 70 years; 58% women) with confirmed insomnia disorder and no major depression within the previous 12 months.

All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).

CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.

SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.

Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.

The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.

Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.

After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).

Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
 

‘Remission is key’

The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).

“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.

Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.

It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.

The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.

While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.

These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.

There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
 

Convincing argument?

Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.

“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.

The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”

Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.

The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”

Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.

If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.

“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.

This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.

The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.

A version of this article first appeared on Medscape.com.

Cognitive-behavioral therapy (CBT) is linked to a significantly reduced risk of depression in patients with insomnia, new research shows.

Insomnia affects over 50% of older adults, and insomnia contributes to a twofold greater risk for major depression, investigators noted.

“We show that by treating insomnia with a simple behavioral approach called Cognitive Behavioral Therapy for Insomnia, or CBT-I, you can reduce the likelihood of developing depression by over 50%,” lead author Michael R. Irwin, MD, Cousins Distinguished Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, said in an interview.

The study is unique in that the treatment “is not just reducing depression, it’s preventing depression,” Dr. Irwin added.

The findings were published online Nov. 24 in JAMA Psychiatry.
 

Primary outcome met

The study included 291 patients aged 60 years and older (mean age, 70 years; 58% women) with confirmed insomnia disorder and no major depression within the previous 12 months.

All were randomly assigned to receive either CBT-I or Sleep Education Therapy (SET).

CBT-I is a first-line treatment for insomnia that includes five components: cognitive therapy targeting dysfunctional thoughts about sleep, stimulus control, sleep restriction, sleep hygiene, and relaxation.

SET provides information on behavioral and environmental factors contributing to poor sleep. While sleep education provides tips on improving sleep, CBT-I helps patients implement those changes and behaviors, Dr. Irwin noted.

Both interventions were delivered by trained personnel in weekly 120-minute group sessions for 2 months, consistent with the format and duration of most CBT-I trials.

The primary outcome was time to incident or recurrent major depressive disorder as diagnosed by the Structured Clinical Interview of the DSM-5 every 6 months during 36 months of follow-up. A monthly Patient Health Questionnaire 9 (PHQ-9) was used to screen for depressive symptoms.

Results showed depression occurred in 12.2% of the CBT-I group versus 25.9% of the SET group. The hazard ratio (HR) for depression in the CBT-I group compared with the SET group was 0.51 (95% confidence interval, 0.29-0.88; P = .02). The number needed to treat to prevent incident or recurrent depression was 7.3.

After adjustment for factors affecting depression risk such as sex, educational level, income, comorbidity, and history of depression, the HR for depression in the CBT-I group versus the SET group was 0.45 (95% CI, 0.23-0.86; P = .02).

Treatment with CBT-I yielded an annual 4.1% incidence of depression, which is similar to the population rate and half the rate in SET, which was 8.6%.
 

‘Remission is key’

The secondary outcome was sustained remission of insomnia disorder. The investigators found a greater proportion of the CBT-I group than the SET group achieved remission after treatment (50.7% vs. 37.7%; 95% CI, 0.10-0.93; P = .02).

“Remission is really key to the benefits that we’re seeing,” said Dr. Irwin.

Inflammation may explain why insomnia raises the risk for depression, he noted. “We know sleep disturbance can lead to inflammation and we also know inflammation can produce depression,” Dr. Irwin said.

It is also possible insomnia leads to an impaired pleasure or reward system, which is linked to depression, he added.

The authors noted that because insomnia is associated with suicidal ideation and dementia, CBT-I may reduce risk for suicide or cognitive decline.

While 8-week CBT-I treatments are readily available, “unfortunately, most clinicians will prescribe medications,” said Dr. Irwin. He noted that in older adults, drugs are linked to adverse events such as falls and cognitive problems.

These new results “really argue that psychology and psychiatry need to be fully integrated into what we call collaborative care models,” Dr. Irwin said.

There were no adverse events during treatment, and none of the serious events that occurred during follow-up were attributed to the trial.
 

Convincing argument?

Commenting on the findings for this news organization, Philip R. Muskin, MD, professor of psychiatry at Columbia University Irving Medical Center, New York, said the study was “nicely written” and the authors put forward “a very convincing argument” for CBT-I to prevent depression.

“It’s eye opening in that it’s a robust study; it’s carefully done; subjects were followed for a long period of time, and it’s an accessible treatment,” said Dr. Muskin, who was not involved with the research.

The study also shows “it’s possible to intervene in something we know is a risk factor in elderly people,” he added. “We think of older people as being less malleable to these kinds of things, but they’re not. They clearly participated, and there wasn’t a huge dropout rate.”

Dr. Muskin noted that less than half of the older participants were married or had a partner. He would have liked more information on this status because being widowed or divorced, as well as when this life change occurred, could affect vulnerability to depression.

The authors of an accompanying editorial called the study “seminal,” and noted that insomnia treatment possibly preventing depressive disorders is a “major finding.”

Proving this preventive strategy is effective in older adults will be important because “insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low,” wrote Pim Cuijpers, PhD, department of clinical, neuro, and developmental psychology, Amsterdam Public Health Research Institute, and Charles F. Reynolds III, MD, department of psychiatry, University of Pittsburgh.

If the reduced rates of depression observed in the study could be generalized to the total population with insomnia, “the incidence of major depression could be reduced considerably,” they wrote.

“Can we prevent depression through interventions aimed at procrastination in college students, interventions aimed at perfectionism in perinatal women, stress management training for employees, social skills training in adolescents?” they asked.

This approach to preventing depressive disorders “offers all kinds of new opportunities to develop and test indirect interventions” for problems that are significantly associated with the onset of depression, the editorialists wrote.

The study was funded by a grant from the National Institute on Aging to the University of California, which partially supported the authors’ salaries. Dr. Irwin, Dr. Muskin, and Dr. Cuijpers have reported no relevant financial relationships. Dr. Reynolds reported being coinventor of the Pittsburgh Sleep Quality Index, for which he receives royalties.

A version of this article first appeared on Medscape.com.

Municipal budget allocations can affect severe maternal morbidity (SMM) rates, a cross-sectional study published in JAMA Network Open reported.

Led by Felix M. Muchomba, PhD, an assistant professor at Rutgers University School of Social Work in New Brunswick, N.J., the study found that local expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM. Specifically, annual per-capita expenditures of $1,000 and higher in these categories were associated with a 35.4%-67.3% lower risk of SMM: odds ratios, 0.33 (95% confidence interval, 0.15-0.72) to 0.65 (95% CI, 0.46-0.91).

In contrast, expenditures on police were positively associated with SMM: OR, 1.15 (95% CI, 1.04-1.28).

In the first study of environmental services spending and SMM done at the municipal level – others have focused on state and county funding – Dr. Muchomba’s group analyzed 2008-2018 birth files linked to maternal hospital discharge records and U.S. Census municipal expenditures data.

The study’s cohort comprised 1,001,410 mothers giving birth in New Jersey hospitals with a mean age of 29.8 years. Of these,10.9 % were Asian, 14.8% were Black, 28.0% were Hispanic, and 44.7% were White.

Per-capita municipal expenditures were reviewed for a broad range of city services: education, public health, fire and ambulance, parks, recreation, natural resources, housing, community development, public welfare; police; transportation, and libraries. “Each year municipalities spend about $600 billion nationwide on local services, investing far more than counties do,” Dr. Muchomba said.

Among developed nations, the United States has a rate of high maternal morbidity, a determinant of maternal mortality, and New Jersey has one of the highest rates in the country, although, paradoxically, it has one of the lowest state poverty rates and one of the highest state income levels, he added, said explaining the impetus for the study.

Previous research has found that state and local investment in non–health specific services can reduce infant mortality rates (IMR). Last year, for example, a national study of 2000-2016 data led by Neal D. Goldstein, PhD, MRI, an assistant professor of epidemiology and biostatistics at Drexel University in Philadelphia, reported that a $0.30 per-person increase in environmental spending was associated with a decrease of 0.03 deaths per 1,000 live births, and a $0.73 per-person increase in social services spending was associated with a decrease of 0.02 deaths per 1,000 live births. “IMR is reflective of, and amenable to broad social, economic, and health care delivery contexts within a society. State and local governments, via increased social and environmental expenditures, have the potential to reduce, albeit not eliminate, IMR disparities,” Dr. Goldstein’s group wrote in Pediatrics.

According to Aimee J. Palumbo, PhD, MPH, an assistant professor in the department of epidemiology & biostatistics in the College of Public Health at Temple University in Philadelphia, who was not involved in the study, the current study’s results are broadly consistent with those of the Goldstein study, of which she is a coauthor, in that it shows spending on public welfare is associated with better outcomes following birth.

“This analysis, however, is done at the municipality level, which allows it to evaluate variations in spending that occur at more local levels, rather than the state level like ours,” she said in an interview. “The researchers are also able to control for individual-level factors,” which is good as it is really suggestive of the impact that spending has on outcomes after controlling for some individual characteristics.”

Both studies speak to the importance of exploring funding for social services and specific programs that affect health, Dr. Palumbo added.

Services that affect nonmedical determinants of health broadly affect how people live their daily lives, Dr. Muchomba said – where they live, how they get to work and to medical appointments, where they shop, how they engage in recreation.

“Housing is very important for mothers since it provides a safe space to shelter during pregnancy and during recovery from childbirth. It’s a safe place to store medications and to prepare healthy food,” he continued. “But much of the housing in New Jersey is very expensive, and some mothers may have to decide between paying the rent and buying healthy food.”

In other benefits, local services spending provides transportation to jobs and health care, bus shelters, effective waste management, viable sidewalks, safe crosswalks, and public exercise venues that help to reduce obesity.

The category that Dr. Muchomba is most often asked about is libraries. “Why libraries? Our hypothesis is that libraries provide some low-income people with their only access to computers and the Internet. They’re a major resource for information and a proxy for the delivery of other services,” he said. In addition, many libraries offer English as a second language classes, which may increase health literacy among immigrants.

A major objective of the 2020 Maternal Health Action Plan of the U.S. Department of Health & Human Services is to better target resources by identifying problem spots for maternal morbidity and mortality. “Our findings strongly suggest that surveillance at the municipal level, a level rarely considered in studies of health outcomes, would be important for success in such efforts,” the authors wrote.

Dr. Muchomba believes doctors can have a role to play in targeting of spending for local services that can reduce maternal morbidity and mortality. “Many physicians are engaged in community health outreach efforts. As respected people in the community, they need to be aware of these other determinants of health that may be driving maternal morbidity rates in their communities.”

This research was supported by the Robert Wood Johnson Foundation, the National Center for Advancing Translational Sciences, the U.S. Department of Health & Human Services Health Resources and Service Administration and the Child Health Institute of New Jersey. Dr. Muchomba reported a grant from Eunice Kennedy Shriver National Institute of Child Health and Human Development outside of the submitted work. Dr. Palumbo had no potential competing interests to disclose.

Municipal budget allocations can affect severe maternal morbidity (SMM) rates, a cross-sectional study published in JAMA Network Open reported.

Led by Felix M. Muchomba, PhD, an assistant professor at Rutgers University School of Social Work in New Brunswick, N.J., the study found that local expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM. Specifically, annual per-capita expenditures of $1,000 and higher in these categories were associated with a 35.4%-67.3% lower risk of SMM: odds ratios, 0.33 (95% confidence interval, 0.15-0.72) to 0.65 (95% CI, 0.46-0.91).

In contrast, expenditures on police were positively associated with SMM: OR, 1.15 (95% CI, 1.04-1.28).

In the first study of environmental services spending and SMM done at the municipal level – others have focused on state and county funding – Dr. Muchomba’s group analyzed 2008-2018 birth files linked to maternal hospital discharge records and U.S. Census municipal expenditures data.

The study’s cohort comprised 1,001,410 mothers giving birth in New Jersey hospitals with a mean age of 29.8 years. Of these,10.9 % were Asian, 14.8% were Black, 28.0% were Hispanic, and 44.7% were White.

Per-capita municipal expenditures were reviewed for a broad range of city services: education, public health, fire and ambulance, parks, recreation, natural resources, housing, community development, public welfare; police; transportation, and libraries. “Each year municipalities spend about $600 billion nationwide on local services, investing far more than counties do,” Dr. Muchomba said.

Among developed nations, the United States has a rate of high maternal morbidity, a determinant of maternal mortality, and New Jersey has one of the highest rates in the country, although, paradoxically, it has one of the lowest state poverty rates and one of the highest state income levels, he added, said explaining the impetus for the study.

Previous research has found that state and local investment in non–health specific services can reduce infant mortality rates (IMR). Last year, for example, a national study of 2000-2016 data led by Neal D. Goldstein, PhD, MRI, an assistant professor of epidemiology and biostatistics at Drexel University in Philadelphia, reported that a $0.30 per-person increase in environmental spending was associated with a decrease of 0.03 deaths per 1,000 live births, and a $0.73 per-person increase in social services spending was associated with a decrease of 0.02 deaths per 1,000 live births. “IMR is reflective of, and amenable to broad social, economic, and health care delivery contexts within a society. State and local governments, via increased social and environmental expenditures, have the potential to reduce, albeit not eliminate, IMR disparities,” Dr. Goldstein’s group wrote in Pediatrics.

According to Aimee J. Palumbo, PhD, MPH, an assistant professor in the department of epidemiology & biostatistics in the College of Public Health at Temple University in Philadelphia, who was not involved in the study, the current study’s results are broadly consistent with those of the Goldstein study, of which she is a coauthor, in that it shows spending on public welfare is associated with better outcomes following birth.

“This analysis, however, is done at the municipality level, which allows it to evaluate variations in spending that occur at more local levels, rather than the state level like ours,” she said in an interview. “The researchers are also able to control for individual-level factors,” which is good as it is really suggestive of the impact that spending has on outcomes after controlling for some individual characteristics.”

Both studies speak to the importance of exploring funding for social services and specific programs that affect health, Dr. Palumbo added.

Services that affect nonmedical determinants of health broadly affect how people live their daily lives, Dr. Muchomba said – where they live, how they get to work and to medical appointments, where they shop, how they engage in recreation.

“Housing is very important for mothers since it provides a safe space to shelter during pregnancy and during recovery from childbirth. It’s a safe place to store medications and to prepare healthy food,” he continued. “But much of the housing in New Jersey is very expensive, and some mothers may have to decide between paying the rent and buying healthy food.”

In other benefits, local services spending provides transportation to jobs and health care, bus shelters, effective waste management, viable sidewalks, safe crosswalks, and public exercise venues that help to reduce obesity.

The category that Dr. Muchomba is most often asked about is libraries. “Why libraries? Our hypothesis is that libraries provide some low-income people with their only access to computers and the Internet. They’re a major resource for information and a proxy for the delivery of other services,” he said. In addition, many libraries offer English as a second language classes, which may increase health literacy among immigrants.

A major objective of the 2020 Maternal Health Action Plan of the U.S. Department of Health & Human Services is to better target resources by identifying problem spots for maternal morbidity and mortality. “Our findings strongly suggest that surveillance at the municipal level, a level rarely considered in studies of health outcomes, would be important for success in such efforts,” the authors wrote.

Dr. Muchomba believes doctors can have a role to play in targeting of spending for local services that can reduce maternal morbidity and mortality. “Many physicians are engaged in community health outreach efforts. As respected people in the community, they need to be aware of these other determinants of health that may be driving maternal morbidity rates in their communities.”

This research was supported by the Robert Wood Johnson Foundation, the National Center for Advancing Translational Sciences, the U.S. Department of Health & Human Services Health Resources and Service Administration and the Child Health Institute of New Jersey. Dr. Muchomba reported a grant from Eunice Kennedy Shriver National Institute of Child Health and Human Development outside of the submitted work. Dr. Palumbo had no potential competing interests to disclose.

Municipal budget allocations can affect severe maternal morbidity (SMM) rates, a cross-sectional study published in JAMA Network Open reported.

Led by Felix M. Muchomba, PhD, an assistant professor at Rutgers University School of Social Work in New Brunswick, N.J., the study found that local expenditures on fire and ambulance, transportation, health, housing, and libraries were negatively associated with SMM. Specifically, annual per-capita expenditures of $1,000 and higher in these categories were associated with a 35.4%-67.3% lower risk of SMM: odds ratios, 0.33 (95% confidence interval, 0.15-0.72) to 0.65 (95% CI, 0.46-0.91).

In contrast, expenditures on police were positively associated with SMM: OR, 1.15 (95% CI, 1.04-1.28).

In the first study of environmental services spending and SMM done at the municipal level – others have focused on state and county funding – Dr. Muchomba’s group analyzed 2008-2018 birth files linked to maternal hospital discharge records and U.S. Census municipal expenditures data.

The study’s cohort comprised 1,001,410 mothers giving birth in New Jersey hospitals with a mean age of 29.8 years. Of these,10.9 % were Asian, 14.8% were Black, 28.0% were Hispanic, and 44.7% were White.

Per-capita municipal expenditures were reviewed for a broad range of city services: education, public health, fire and ambulance, parks, recreation, natural resources, housing, community development, public welfare; police; transportation, and libraries. “Each year municipalities spend about $600 billion nationwide on local services, investing far more than counties do,” Dr. Muchomba said.

Among developed nations, the United States has a rate of high maternal morbidity, a determinant of maternal mortality, and New Jersey has one of the highest rates in the country, although, paradoxically, it has one of the lowest state poverty rates and one of the highest state income levels, he added, said explaining the impetus for the study.

Previous research has found that state and local investment in non–health specific services can reduce infant mortality rates (IMR). Last year, for example, a national study of 2000-2016 data led by Neal D. Goldstein, PhD, MRI, an assistant professor of epidemiology and biostatistics at Drexel University in Philadelphia, reported that a $0.30 per-person increase in environmental spending was associated with a decrease of 0.03 deaths per 1,000 live births, and a $0.73 per-person increase in social services spending was associated with a decrease of 0.02 deaths per 1,000 live births. “IMR is reflective of, and amenable to broad social, economic, and health care delivery contexts within a society. State and local governments, via increased social and environmental expenditures, have the potential to reduce, albeit not eliminate, IMR disparities,” Dr. Goldstein’s group wrote in Pediatrics.

According to Aimee J. Palumbo, PhD, MPH, an assistant professor in the department of epidemiology & biostatistics in the College of Public Health at Temple University in Philadelphia, who was not involved in the study, the current study’s results are broadly consistent with those of the Goldstein study, of which she is a coauthor, in that it shows spending on public welfare is associated with better outcomes following birth.

“This analysis, however, is done at the municipality level, which allows it to evaluate variations in spending that occur at more local levels, rather than the state level like ours,” she said in an interview. “The researchers are also able to control for individual-level factors,” which is good as it is really suggestive of the impact that spending has on outcomes after controlling for some individual characteristics.”

Both studies speak to the importance of exploring funding for social services and specific programs that affect health, Dr. Palumbo added.

Services that affect nonmedical determinants of health broadly affect how people live their daily lives, Dr. Muchomba said – where they live, how they get to work and to medical appointments, where they shop, how they engage in recreation.

“Housing is very important for mothers since it provides a safe space to shelter during pregnancy and during recovery from childbirth. It’s a safe place to store medications and to prepare healthy food,” he continued. “But much of the housing in New Jersey is very expensive, and some mothers may have to decide between paying the rent and buying healthy food.”

In other benefits, local services spending provides transportation to jobs and health care, bus shelters, effective waste management, viable sidewalks, safe crosswalks, and public exercise venues that help to reduce obesity.

The category that Dr. Muchomba is most often asked about is libraries. “Why libraries? Our hypothesis is that libraries provide some low-income people with their only access to computers and the Internet. They’re a major resource for information and a proxy for the delivery of other services,” he said. In addition, many libraries offer English as a second language classes, which may increase health literacy among immigrants.

A major objective of the 2020 Maternal Health Action Plan of the U.S. Department of Health & Human Services is to better target resources by identifying problem spots for maternal morbidity and mortality. “Our findings strongly suggest that surveillance at the municipal level, a level rarely considered in studies of health outcomes, would be important for success in such efforts,” the authors wrote.

Dr. Muchomba believes doctors can have a role to play in targeting of spending for local services that can reduce maternal morbidity and mortality. “Many physicians are engaged in community health outreach efforts. As respected people in the community, they need to be aware of these other determinants of health that may be driving maternal morbidity rates in their communities.”

This research was supported by the Robert Wood Johnson Foundation, the National Center for Advancing Translational Sciences, the U.S. Department of Health & Human Services Health Resources and Service Administration and the Child Health Institute of New Jersey. Dr. Muchomba reported a grant from Eunice Kennedy Shriver National Institute of Child Health and Human Development outside of the submitted work. Dr. Palumbo had no potential competing interests to disclose.