• Antibiotic Resistance: What Can You Do?

    The impact of antibiotics on human health cannot be overstated. They are a big deal. And thanks to evolution, more and more bacteria are becoming resistant to antibiotics. Is there anything we can do? Yes. Let’s talk about it.



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  • Buprenorphine for Opioid Use Disorder Lowers Overdose Risk in Commercially Insured Individuals

    The following originally appeared on the University of Pennsylvania Leonard Davis Institute Health Police$ense blog and the CHERISH blog. It is coauthored by Sarah Gutkind and Janet Weiner. 

    “Medications for opioid use disorder saves lives.” That’s the title and conclusion of a recent report by the National Academies of Sciences, Engineering and Medicine, based on a review of the scientific evidence. In a new study in Drug and Alcohol Dependence, CHERISH investigators Jake Morgan [also affiliated with Department of Health Law, Policy & Management at Boston University School of Public Health], Bruce Schackman and Benjamin Linas add to this evidence base by examining the real-world effectiveness of medications in preventing overdoses once treatment for opioid use disorder has begun.

    Using a database of commercially insured individuals, CHERISH investigators examined overdose risk on and off treatment with three federally approved medications for opioid use disorders–buprenorphine, extended-release injectable naltrexone, and oral naltrexone. (Methadone was excluded because it is not reliably reported in commercial claims.) From 2010-2016, they identified nearly 47,000 individuals diagnosed with an opioid use disorder and prescribed medication with an average follow up of 1.5 years per person. During that time, 1,805 individuals experienced 2,755 opioid-related overdoses (both fatal and non-fatal) as indicated by ICD-9 and ICD-10 inpatient and outpatient codes. The authors used pharmacy claims to determine whether an individual was on or off treatment in a given week.

    Most overdoses (2,020) occurred while individuals were not on treatment, resulting in a rate of 4.98 overdoses per 100 person years (PY). Individuals currently on buprenorphine experienced fewer overdoses (2.08 overdoses/ 100 PY) than those on injectable naltrexone (3.85 overdoses/ 100 PY) or oral naltrexone (6.18 overdoses/ 100 PY).  After controlling for other factors such as age, sex, region of residence, insurance coverage, polypharmacy prescriptions, and visits to a treatment facility, individuals receiving buprenorphine were 60% less likely to overdose in a given week than individuals not on treatment. The overdose risk for those on naltrexone was not significantly different from those not on treatment.

    To assess the risk of a “rebound” overdose after treatment was discontinued, CHERISH investigators looked at overdoses within a four-week window after discontinuation. They did not find a higher risk of overdose within four weeks after discontinuation of either buprenorphine or naltrexone. The relatively small sample of individuals on oral and injectable naltrexone made estimating the associations between overdose and naltrexone treatment and discontinuation challenging, but the lack of clear evidence of a protective effect of naltrexone is useful information for patients and prescribers.

    The authors found that risk of overdose was associated with multiple prescribed drugs and a concurrent diagnosis for another substance use disorder such as alcohol, cannabis, cocaine and sedatives. They also found geographic variation in overdose risk, with patients in the Northeast and Midwest experiencing a higher risk of overdose. Being a child or dependent of a primary beneficiary was also associated with a higher risk of overdose, after controlling for age, and suggests there may be a group of emerging adults at high risk who will age out of parental insurance coverage.

    The findings suggest that buprenorphine reduces overdose risk and supports the expansion of medication treatment for opioid use disorder. In 2017, about 47,000 people died from opioid-related overdoses. Less than 20% of those with an opioid use disorder receive treatment, and even fewer receive medication treatment. Increased access and use of evidence-based medications is critical to addressing the opioid overdose epidemic. Further research is needed to improve our understanding of the risks and benefits unique to each treatment in order to better tailor treatment to individual patient needs.

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  • Measles Infections Can Wipe Out Immunity to OTHER Diseases

    We’re very clearly in favor of vaccines here, because they save a LOT of lives. Did you know the measles vaccine does more than protect you from measles? Getting infected with measles doesn’t only make you sick (and carry a risk of death) it can also wipe out pre-existing immunity to other illnesses, making you more susceptible to other infections. In fact, data suggest that the majority of measles-associated deaths are due NOT to measles, but to infections taking root after measles has run its course!




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  • Recent publications from Boston University’s Department of Health Law, Policy and Management: November 2019 Edition

    Below are recent publications from me and my colleagues from Boston University’s Department of Health Law, Policy and Management. You can find all posts in this series here.

    November 2019 Edition

    Brady KJS, Kazis LE, Sheldrick RC, Ni P, Trockel MT. Selecting physician well-being measures to assess health system performance and screen for distress: Conceptual and methodological considerations. Curr Probl Pediatr Adolesc Health Care. 2019 Sep 24; 100662. PMID: 31562054.

    Carey K, Morgan JR, Lin MY, Kain MS, Creevy WR. Patient Outcomes Following Total Joint Replacement Surgery: A Comparison of Hospitals and Ambulatory Surgery Centers. J Arthroplasty. 2019 Aug 23. PMID: 31526700.

    Chang FH, Ni P. Responsiveness and Predictive Validity of the Participation Measure-3 Domains, 4 Dimensions in Survivors of Stroke. Arch Phys Med Rehabil. 2019 Aug 14. PMID: 31421097.

    Cohen AB. In the September 2019 Issue of the Quarterly. Milbank Q. 2019 Sep; 97(3):627-630. PMID: 31512294.

    Cole MB, Galárraga O, Wilson IB. The Impact of Rhode Island’s Multipayer Patient-centered Medical Home Program on Utilization and Cost of Care. Med Care. 2019 Oct; 57(10):801-808. PMID: 31464841.

    Eggleston B, Dismuke-Greer CE, Pogoda TK, Denning JH, Eapen BC, Carlson KF, Bhatnagar S, Nakase-Richardson R, Troyanskaya M, Nolen T, Walker WC. A prediction model of military combat and training exposures on VA service-connected disability: a CENC study. Brain Inj. 2019 Sep 02; 1-13. PMID: 31476880.

    George J, Parker VA, Sullivan JL, Greenan MA, Chan J, Shin MH, Chen Q, Shwartz M, Rosen AK. How hospitals select their patient safety priorities: An exploratory study of four Veterans Health Administration hospitals. Health Care Manage Rev. 2019 Sep 06. PMID: 31498164.

    Gluck AR, Huberfeld N. Health Care Federalism and Next Steps in Health Reform. J. L. Med. & Ethics 2019, Vol. 46(4) 841-845.

    Griffith KN, Li D, Davies ML, Pizer SD, Prentice JC. Call center performance affects patient perceptions of access and satisfaction. Am J Manag Care. 2019 Sep 01; 25(9):e282-e287. PMID: 31518100.

    Huberfeld N. Holes in the Safety Net: Federalism and Poverty. Health Care Reform. Cambridge University Press. 2019.

    Huberfeld N. Rural Health, Universality, and Legislative Targeting. 12 Harvard Law & Policy Review. 241. 2019.

    Huberfeld N. Stewart v. Azar and the Purpose of Medicaid: Work as a Condition of Enrollment, Public Health Reports 2019, Vol. 134(2) 197-200.

    Huberfeld N. Texas v. U.S.: Another Day, Another Threat to the Affordable Care Act. ACS Expert Forum. July 8, 2019.

    Jasuja GK, Engle RL, Skolnik A, Rose AJ, Male A, Reisman JI, Bokhour BG. Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study. J Gen Intern Med. 2019 Sep 11. PMID: 31512188.

    Kazis LE, Ameli O, Rothendler J, Garrity B, Cabral H, McDonough C, Carey K, Stein M, Sanghavi D, Elton D, Fritz J, Saper R. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open. 2019 Sep 20; 9(9):e028633. PMID: 31542740.

    Kilbourne AM, Braganza MZ, Bowersox NW, Goodrich DE, Miake-Lye I, Floyd N, Garrido MM, Frakt AB, Bever CT, Vega R, Ramoni R. Research Lifecycle to Increase the Substantial Real-world Impact of Research: Accelerating Innovations to Application. Med Care. 2019 Oct; 57 Suppl 10 Suppl 3:S206-S212. PMID: 31517789.

    Lipson SK, Raifman J, Abelson S, Reisner SL. Gender Minority Mental Health in the U.S.: Results of a National Survey on College Campuses. Am J Prev Med. 2019 Sep; 57(3):293-301. PMID: 31427032.

    Mariner WK, Annas GJ, Huberfeld N, Ulrich MR. Public Health Law. 3rd Edition. Carolina Academic Press. Durham, NC. 2019.

    Pimentel CB, Hartmann CW, Okyere D, Carnes SL, Loup JR, Vallejo-Luces TM, Sloup SN, Snow AL. Use of huddles among frontline staff in clinical settings: a scoping review protocol. JBI Database System Rev Implement Rep. 2019 Sep 02. PMID: 31483341.

    Rossheim ME, Greene KM, Yurasek AM, Barry AE, Gonzalez-Pons KM, Trangenstein PJ, Cavazos T, Nelson C, Treffers RD, Thombs DL, Jernigan DH. Underage drinkers’ first experience consuming a popular brand of supersized alcopop. Am J Drug Alcohol Abuse. 2019 Aug 23; 1-9. PMID: 31442085.

    Sachs R, Huberfeld N. The Problematic Law And Policy Of Medicaid Block Grants. Health Affairs Blog, July 23, 2019.

    Stein M, Herman D, Conti M, Anderson B, Bailey G. Initiating buprenorphine treatment for opioid use disorder during short-term in-patient ‘detoxification’: a randomized clinical trial. Addiction. 2019 Aug 20. PMID: 31430414.

    Trangenstein PJ, Whitehill JM, Jenkins MC, Jernigan DH, Moreno MA. Active cannabis marketing and adolescent past-year cannabis use. Drug Alcohol Depend. 2019 Sep 04; 204:107548. PMID: 31550611.

    Uebelacker LA, Van Noppen D, Tremont G, Bailey G, Abrantes A, Stein M. A pilot study assessing acceptability and feasibility of hatha yoga for chronic pain in people receiving opioid agonist therapy for opioid use disorder. J Subst Abuse Treat. 2019 Oct; 105:19-27. PMID: 31443887.

    Yakovchenko V, Hogan TP, Houston TK, Richardson L, Lipschitz J, Petrakis BA, Gillespie C, McInnes DK. Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial. J Med Internet Res. 2019 Aug 04; 21(8):e14750. PMID: 31444872.


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  • Even a Modest Co-Payment Can Cause People to Skip Drug Doses

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company)


    There’s a logic to out-of-pocket medical payments. They’re supposed to make patients think twice before spending money on unnecessary health care.

    When it comes to drugs, however, they’re often preventing people from getting necessary care.

    A recent data brief from the National Center for Health Statistics said about a quarter of adults who had diagnosed diabetes asked their physician if there was a lower-cost medication they could try, even if things were working for them.

    Thirteen percent of them had not taken their medication as prescribed because of the cost.

    Some of these patients were uninsured. More than a third of such patients had not taken their medication as prescribed because of the cost; that was also the case for about 18 percent of those with Medicaid. What might be surprising, though, is that 14 percent of patients with private insurance went without their medication as well.

    A study in Diabetes Research and Clinical Practice last year examined data on cost-related skipping of diabetes medication. They found that more than 16 percent of those with diabetes engaged in this practice. Those who used insulin and those who earned less than $50,000 per year were more likely to do so.

    Such behavior isn’t localized to diabetes. Multiple studies have shown that when more cost sharing is involved, patients are less likely to stick to drug therapy. This is true when considering birth control, as well as the treatment of high cholesterol, high blood pressure and other chronic care medications.

    It’s even true in cancer.

    Before the introduction of tyrosine kinase inhibitors (T.K.I.s), patients with chronic myeloid leukemia could expect to live five to six years after diagnosis. These medications, taken orally every day, can lead to full life spans. They are costly, however, and need to be taken for the rest of a patient’s life.

    In 2013, Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine, and colleagues published a study in which they looked at health plan claims from 2002 through 2011. They wanted to examine adults who had chronic myelogenous leukemia and who initiated therapy with imatinib, the first tyrosine kinase inhibitor. These were all patients with private insurance.

    The researchers found that patients with relatively higher monthly co-payments ($53) were more likely to discontinue therapy within six months than those with lower co-payments (17 percent versus 10 percent).

    Stopping the therapy can lead to recurrence, even death. “One of the biggest concerns about cutting back on medications due to cost is that some medications only work well if you take them exactly as prescribed,” Dr. Dusetzina said. “Even worse than that, in some cases if you take only part of what you are prescribed, your disease can change so the drugs no longer work for you. This can happen in the type of cancer that imatinib and other T.K.I.s are used to treat.”

    More than 8 percent of all Americans between 18 and 64 have not taken medication as prescribed because of the cost to them. Even 6 percent of those with private insurance haven’t taken recommended drugs because of what they still had to pay.


    This is mainly an American problem. A study published two years ago in BMJ Open compared rates of cost-related skipping of drugs among people 55 and older in 11 high-income countries. Most countries had a prevalence lower than 4 percent. The second-to-highest rate was in Canada, at 8 percent. (This was still less than half the prevalence we see in the United States, at almost 17 percent.)

    Canada’s single-payer system is sometimes held up as the preferred “other” model to the American status quo. But its drug coverage isn’t so good compared with the rest of the world. Pharmaceutical coverage is not part of Canada’s Medicare system, and differs from province to province. Still, Canadians do better than Americans.

    A study in Clinical Therapeutics about a decade ago specifically compared the rates of cost-related nonadherence in the United States and Canada. Uninsured Americans were seven times as likely to skip doses of medication. Those with public or private insurance were more than twice as likely.

    Insurance isn’t enough, it seems clear. In 2015, researchers published a study in the Journal of General Internal Medicine that looked at medication adherence and cost-saving strategies of those who have Medicare. About 40 percent of this population took actions to try to cut their costs. Some are relatively innocuous — asking for free samples, for example. But more than 3 percent of those surveyed admitted to buying their drugs from another country, and almost 3 percent bought drugs over the internet.

    Almost 13 percent split their pills or took less than the prescribed amount to make medications last longer. But this is not how medications work. With many drugs, like imatinib, it can even make things worse.

    Most of the discussions around the cost of drugs focus on the extreme amounts that the system will have to pay drug companies so that people can get them. Relatively few discussions focus on the relatively smaller amounts we still require of patients to receive them. These smaller amounts are still a major barrier to care.

    “Unfortunately, we — as a society — don’t do a good job of making it easier to afford care with clear benefit and harder to pay for care that is more questionable,” Dr. Dusetzina said. “If we weighed those trade-offs more, I think we could get to a place where drugs that worked were affordable for patients, and companies were paid for their very high-value products.”

    Cost sharing is supposed to lower spending without sacrificing quality. It was not meant to prevent patients who need drugs from receiving them.


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  • Some of Trump’s Most Devious Lies Are About Health Care

    Coming hot on the heels of my appearance on This American Life, I’ve got an op-ed in the New York Times today.

    As Democrats debate the best way to achieve universal coverage and lower health care costs, the Trump administration has a different approach to the challenges of our current system. It’s working overtime to make the system more fragile for the sick and the poor, even as it misrepresents to Congress and the American public what it’s up to.

    Speaking to reporters in late October, President Trump said that “we have a great Republican plan” to replace the Affordable Care Act. “Much less expensive. Deductibles will be much lower.” His statements came on the heels of a congressional hearing in which one of his top health officials, Seema Verma, said that the administration would do “everything we can” for Americans with pre-existing conditions. Under oath, she swore that the administration was aiming to help people find a pathway out of poverty.

    None of this is true.

    You can read the whole thing here.


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  • This American Life

    In one of those “wait, this really happened?” moments, I made an appearance on This American Life to discuss Texas v. United States. The story came from David Kestenbaum, who framed the case around the idea of dividing by zero. “Mathematicians,” he said, “call this kind of situation a singularity, where the math is not well-behaved.” So too with the weird possibility that eliminating the mandate penalty could bring the whole Affordable Care Act crashing down.

    Here’s my favorite part of the story:

    David Kestenbaum

    I talked to Bagley back in July on the day that the appeals court heard the case. We listened together online. The arguments the lawyers made were all about standing, severability doctrine, the meaning of the word shall. What did Congress intend when it set the tax to zero? It did not go well for the Affordable Care Act, for Bagley’s side. You could tell from the judge’s questions. Bagley’s exact words while we listened included things like–

    Nick Bagley

    Oh, Jesus.

    David Kestenbaum


    Nick Bagley

    This is really bad. This is really bad.

    David Kestenbaum

    And finally–

    Nick Bagley

    This is about as bad as you could expect from an oral argument.

    David Kestenbaum

    He was truly surprised. He thought the legal argument that zero could take down the whole law was, quote, “weak to the point of frivolousness.”

    I remain of that view, of course. The Fifth Circuit could decide the case any day. I’m waiting with bated breath.


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  • Does Poor Sleep Contribute to Alzheimer’s Disease?

    Alzheimer’s disease is no stranger in the news cycle. The latest headlines are dedicated to a new study on how the brain keeps itself clean, a process which scientists have long suspected to be involved in the disease. Let’s take a look.



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  • JAMA Forum: Making Health Care More Productive

    With a staggering amount of waste, as documented in the recent JAMA study, a key question is whether our health care system can produce the same or better outcomes for less money—in other words, can it become more productive or efficient? Until recently, the answer seemed to be “no.” But things may be changing.

    That’s me on the JAMA Forum attempting to put an optimistic spin on the future of U.S. health care. The rest of the piece points to areas where we have good evidence or reasonable expectation of increasing productivity. But, I’d be first to point out that they won’t purge all or even most of the waste from the system. Indeed, the piece ends,

    None of this means there isn’t waste in the health care system. The latest estimate suggests as much as 25% of spending in this area is wasteful. Even if the health care system is becoming more efficient in some ways, that doesn’t mean it’s as efficient as it could be or that we’re definitively on the road to driving out all the waste. History suggests that improving productivity in health care is extremely hard and extremely rare.

    Go read the whole thing. (Background research for the piece was supported by the Laura and John Arnold Foundation.)


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  • Food Insecurity and Health

    About 50 million people in the United States don’t have access to enough food to support a healthy lifestyle. The technical term for this is food insecurity, and over 40% of people in the United States will experience it during their adult lives. This pervasive problem has a lot of associated health effects, too.




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