Panel at health policy forum cites alternatives to opioids for pain, and the need for a culture shift on the topic

By Melissa Patrick
Kentucky Health News

Kentucky has a new law restricting painkiller prescriptions to three days for acute pain, but an anecdotal story from one of the state's leading doctors suggests that it has a ways to go: the child of a friend recently got wisdom teeth extracted and was given a 30-day supply of pain medicine.

"They don't need that many. They may only need -- zero!" said Dr. Philip Chang, chief medical officer at UK HealthCare. "I don't know how well that [law] is followed, to be honest with you."

Chang also discussed proven ways to reduce opioid use, and still relieve pain, during the "Alternatives to Opioids" panel at the Howard L. Bost Memorial Health Policy Forum held Sept. 24 in Lexington by the Foundation for a Healthy Kentucky. The meeting's theme was "Kentucky's Substance Use Epidemic: A Solutions Update."

Comprehensive EAP photo

The law, passed in 2017, limits painkillers to a three-day supply if prescribed for acute pain, but doesn't apply to chronic pain and has a long list of other exemptions -- and allows a prescriber to override the new rule by documenting a justification.

At the end of the session, Dr. Mel Pohl, chief medical officer of Las Vegas Recovery Center, noted that Nevada doesn't have this problem because its laws on opioid prescriptions are very strict.

"If people prescribe opioids for more than three days for a minor and seven days for a major surgical procedure, they will be brought before the medical board," he said. "It's too bad that we had to be punished and threatened into changing our behavior as prescribers, but we did. And now it's happening and I think that the paradigm shift is in place."

Chang said it was important for providers to get on board with the new law because opioids have adverse consequences. He pointed to research that shows a one-week prescription of opioids to patients who have never used pain pills before increases their risk of becoming addicted by 15 percent in one year, and a 30-day prescription increases that risk to 35 percent.

He also cited research that found a combination therapy of ibuprofen and acetaminophen is much more effective for treating pain than opioids. "This is the information we need to get out there, so they know that this doesn't come without a costs," he said. "The misconception that opioids are always better is not true."

Chang, a trauma surgeon, also noted a pilot study that he led, which basically didn't allow providers to prescribe any pain-medication prescriptions unless the patient had exhausted all other means of pain-control medications available to them, like ibuprofen, Tylenol and muscle relaxers.

He said that in just two years' time, they were able to drop the overall opioid-prescribing rates for trauma patients 50 percent, with the best results in the "opioid naive" patients.

The pilot was so promising that the policy has been implemented hospital-wide, with results over the last two years showing a steady decline in the amount of daily morphine prescribed, resulting in 250,000 fewer pills per year, and no changes in patient-described pain scores. "None at all!" he said.

"We can do this," Chang said. "We can get away from this trend of prescribing opioids and more opioids and more frequent and different kinds of opioids. We can get away from it."

Dr. Danesh Mazloomdoost, medical director at Wellward Regenerative Medicine in Lexington, told the group that we need a culture change when it comes to pain management and that the question shouldn't be how can we manage opioids more effectively, but to ask if they are even effective.

"That's really the key to understanding how we're going to fix this pain issue," he said. "We've got to stop thinking that we can cure everything or symptom-manage everything with a pill, and start getting an understanding of what the physiology of our bodies is, how our bodies function and how we're going to get healthy to feel better."

Mona Carper, a physical therapist and professor at UK, said it is long past time for her profession to have a seat at the table when it comes to discussing pain management.

She said access to physical therapy within the first 14 days of injury is critical for decreasing the need for opioids and for decreasing the long-term cost of care.

Pohl, an addiction specialist who treats co-occurring pain and addictions with the goal of getting patients off opioids, said, "When we take people off opioids, guess what happens to their pain? It goes down."

Pohl gave several suggestions for alternatives to opioids, including several specific types of therapy, including cognitive behavioral therapy, complementary alternative therapies like nutritional interventions and acupuncture, and mindfulness practices.

He spent much of his time talking about the benefits of practicing mindfulness daily, which he said is a type of meditation that involves focusing on an object, like breathing. He said the practice of mindfulness allows people to "detach from thoughts, feelings and physical sensations" and thus better tolerate or manage their pain.

Pohl noted two studies that spoke to the effectiveness of the practice, including a three-month study of adults 27 and older that found practicing mindfulness, or meditation, resulted in less pain, improved attention, enhanced well-being, and improved quality of life. The second one found that just four days of mindfulness training decreased pain and feelings of unpleasantness by half.

He added that results from his own clinic show a 20 percent reduction in pain scores among his patients who practice mindfulness. He said, "That is efficacious as most opioids."

Red Bird dental clinic fixes teeth of people in drug treatment, preparing them for work and cutting need for painkillers

Dr. Bill Collins works on a patient. (Photo by Deborah Yetter)

A dental clinic in southeastern Kentucky, with help from dental-school students, is pulling teeth and providing dentures for residents of drug-treatment centers "in hopes of building their self-confidence and putting them in a better position to get jobs," Deborah Yetter reports for the Louisville Courier Journal.

"In a state that already suffers from high poverty and poor dental health, addiction is adding to the toll on teeth — and that is holding back some people in drug treatment programs," Yetter writes, quoting Dr. Bill Collins, dental director at the Red Bird Mission of the United Methodist Church: "People do well when they complete treatment. But when they smile and they have no teeth, it's hard for them to get employment. And if they can't find work, they go back to drug use."

Students from the state's two dental schools are helping. "The Red Bird dental clinic shows what institutions of higher education should do," University of Louisville President Neeli Bendapudi said at an open house at the clinic, in far southern Clay County.

Sharon Turner, retired dental dean at the University of Kentucky, who volunteers at the clinic, "said it's important to treat all patients with respect and provide quality dental care she said is offered at Red Bird," Yetter reports.

Turner said there's another reason to fix the teeth of people coming out of drug treatment, Yetter writes: "Chronic pain from untreated dental problems can lead people to resort to painkillers, causing them to relapse."

Patients pay only $25 a visit for treatment, "which can run up to five visits for cases that require extraction of all teeth and having dentures made," Yetter reports. "The actual costs of dentures is about $2,000, Collins said. The clinic works with people who can't pay, and Collins said several outside grants help cover costs for low-income and uninsured patients and the mobile services." The grants are $50,000 from Delta Dental, an insurance company; $37,250 from the Methodist Church's Good Samaritan Foundation; and $20,000 from Avesis, a dental managed-care company.

"The best part for everyone is the reaction of patients they've helped, such as a woman's exclamation of delight recently when staff at the clinic handed her a mirror to admire her new dentures," Yetter reports, quoting Turner: "It's changing their world."

Share of uninsured Kentuckians in rural areas and small towns dropped to 13 percent from 40 percent after Medicaid expansion

OPINION By Emily Beauregard
Executive director, Kentucky Voices for Health

Medicaid expansion has made an overwhelmingly positive impact on rural Kentucky. Our state was among the top three leaders in lowering our uninsured rate for low-income adults in rural areas and small towns.

That rate dropped from 40 percent to 13 percent between 2008-09 and 2015-16, according to a new report from researchers at Georgetown University and the University of North Carolina. This may be the first time Kentucky has been a leader in anything other than cancer deaths and poor health outcomes.

Compare the dramatic dip in uninsured to our neighbors in Tennessee, where the uninsured rate for low-income adults in rural communities is 35 percent, down just 6 percentage points from 2008-09. In Mississippi, it’s 35 percent, down about 5 percentage points. In Kentucky, we saw a 27-percentage-point improvement.

What is Kentucky doing that our neighbors aren’t? It’s simple; our leaders agreed to expand Medicaid to adults who earn up to 138 percent of the federal poverty line, and that has been one of the keys to this successful reduction in our uninsured rates. This was a provision of the Patient Protection and Affordable Care Act that some of our neighboring states chose to reject.

Kentucky bet that expanding the benefit to more working families would be a good investment for our residents and would help rural hospitals and clinics keep their doors open. That bet is paying off for our state; hardworking Kentuckians without employer-sponsored health insurance have been able to seek care, some for the first time in their lives.

Not only was the decision to expand Medicaid in Kentucky beneficial to low-wage workers and those in rural communities with few job opportunities, it also likely saved some rural hospitals from closing their doors. Hospitals in states that expanded Medicaid are six times less likely to close their doors than those in non-expansion states.

Kentuckians have made clear their desire to retain Medicaid expansion as it is, without changes to benefits or the addition of barriers. In recent comments to the Centers for Medicare and Medicaid Services, Kentuckians spoke out 20 to 1 against a waiver that would alter Medicaid from its current state.

The decision to expand Medicaid is giving residents in our small towns and rural communities a reliable source of health coverage. It is giving rural hospitals and community health centers a reliable stream of revenue for treating people who get sick. And it is fueling the economic vitality of these communities.

Workers with health coverage are better able to show up for work regularly. They are less likely to fall into medical debt or bankruptcy. And their children are more likely to have their health needs met, giving the next generation a better chance at success in school and life.

U.S. Medicaid boss defends work rules and other 'community engagement' requirements, says they will thwart dependency

By Al Cross
Kentucky Health News

The director of the Centers for Medicare and Medicaid Services gave a spirited defense of work rules and other "community engagement" requirements in state Medicaid programs, such as the one Kentucky officials have proposed.

Seema Verma

"We are committed to this issue," Seema Verma said Sept. 27 at a meeting of insurers who manage care of Medicaid beneficiaries for state governments.

She didn't mention that the plan has been blocked by a federal judge, who said federal officials didn't adequately consider the state's prediction that thousands would be dropped from the rolls for failure to follow the rules or report their income and activity. But she did address those concerns.

"These policies are not blunt instruments," Verma said. "We’ve worked carefully to design important protections to ensure that states exempt individuals who have disabilities, are medically frail, serve as primary caregivers, or have an acute medical condition that prevent them from successfully meeting the requirement."

Kentucky's plan would require non-exempt, "able-bodied adults" to spend 80 hours a month at work, in school, volunteering or, if needed, in drug treatment. Arkansas has adopted similar rules, and 1,000 Medicaid beneficiaries have gone to work, Verma said.

Verma cast the policies as an effort to thwart dependency on government, and cited statistics to argue that it is growing "The overall work rate for non-disabled working-age adults" has fallen by 3.4 percentage points since 2000, and the work rate of childless, working-age adults is only 2.6 points higher than the overall rate, she said. "In 1979, the employment rate for childless adults under 50 was almost 10 percentage points higher than the overall rate," and "Not surprisingly, this group also experienced the largest increase in welfare."

Verma said, "It is not compassionate to trap people on government programs, or create greater dependency on public assistance as we expand programs like Medicaid. True compassion is giving people the tools necessary for self-sufficiency . . . Community engagement requirements are not some subversive attempt to just kick people off of Medicaid. Instead, their aim is to put beneficiaries in control with the right incentives to live healthier, independent lives."

Federal judge strikes down state law Bevin cited, requiring abortion clinics to have agreements for ambulance service

Kentucky abortion clinics do not need to have written agreements with an ambulance service and hospital for patient care in the event of an emergency, because such restrictions are unconstitutional, a federal judge ruled Friday. The ruling by U.S. District Judge Greg Stivers undercuts Gov. Matt Bevin's efforts to eliminate legal abortion in the state.

Abortion providers argued Bevin "was using the law unfairly to try to shut down the state's only abortion clinic and block another from opening," reports Deborah Yetter of the Louisville Courier Journal. "The ruling involves a 1998 state law requiring abortion clinics to have so-called 'transfer' agreements with an ambulance service and hospital in the event of a medical emergency at the clinic, a provision opponents argued was unnecessary but one that lawyers for Bevin said is necessary for patient safety."

Kentucky loses a health champion who advocated for health equity and community-based solutions; Dr. Gil Friedell was 91

Dr. Gilbert "Gil" Friedell

By Melissa Patrick
Kentucky Health News

Dr. Gilbert Friedell, who was a fierce advocate for health equity and finding community-based solutions to the many health issues that plague Kentucky, died Sept. 23 at the age of 91.

His mantra,"If the problems are in the community, the solutions are in the community," was a drumbeat message that will continue to guide the efforts of many who knew him.

"It is difficult to imagine a more selfless man of medicine," said veteran journalist Al Smith.

Friedell was described in his obituary as an "avid student," attending Harvard College in 1943 at the age of 16 and graduating from the University of Minnesota Medical School in 1950. He then went on to receive his medical training in pathology in Boston and served as a physician in the Navy reserves for two plus years.

He was a medical faculty member at Harvard, Boston University, the University of Massachusetts and the University of Kentucky, where he became the first director of the Lucille Parker Markey Cancer Center in 1983, with a focus on cancer prevention.

He stepped down as the director in 1990 to run Markey Cancer Control Program, where he worked to convey breast-cancer information to the public and health professionals through the Kentucky Cancer Program, the Kentucky Cancer Registry and a regional information service for Kentucky, Tennessee and Arkansas -- all organizations that he helped to create. He retired from this position in 1998.

Friedell was an unwavering advocate for increasing health care access to Kentucky's underserved citizens, especially those who lived in Eastern Kentucky. To that end, he co-founded Kentucky Homeplace, a lay health-worker program funded by the Kentucky General Assembly that facilitates access to health-care services in 30 Eastern Kentucky counties.

Since 1994, the program has served over 161,968 people who have received access to more than 4.9 million services valued at $324.4 million, according to Fran Feltner, director of UK's Center for Excellence in Rural Health, where the program is based.

"Gil was a true friend and mentor," Feltner said. "He truly understood the community."

Feltner recalled how they testified to lawmakers in Washington and Frankfort about the value of community health workers and helped pass the national Patient Navigator Bill, which recognizes the need for improving access to care.

"His legacy will never be forgotten and his love for the community will live in my heart and in our work as we continue the lessons learned," Feltner said.

Friedell's legacy will also continue in the work of the Friedell Committee on Health System Transformation, which he founded. He asked that it not bear his name, but the other members unanimously overruled him. The committees' mission is "to improve the health of Kentuckians by promoting an effective, values-based health system, advocating for community action, and measuring the system's performance."

"Gil indeed touched each of us deeply," said Carolyn Dennis, executive director of the committee. "His determination for a just healthcare system that respects the inherent right of every individual to receive the best care possible was contagious; everyone associated with the Friedell Committee carries that same passion and sorrow in his passing. . . . He will be sorely missed but his legacy will live on by all who knew and loved him."

Dennis described Friedell as a "consummate gentleman," partial to wearing a "jaunty bow tie and beret," who was "tireless in his quest to engage leaders in every geographic corner of the state to improve the health of their communities."

Friedell was the recipient of numerous awards, authored more than 200 articles in medical publications, served on many state and national public-health committees, and co-authored The Great Diabetes Epidemic: A Manifesto for Control and Prevention that published in 2014.

"The very vibrant Big Sandy Diabetes Coalition . . . is a testament to Gil, who was really its founder with his periodic trips here to encourage us and educate us about the diabetes epidemic," said Prestonsburg lawyer John Rosenberg. "He infected us with the belief that the solution to better health care was in the community, and that took hold. He was a wonderful man, in his quiet way, a great leader and a great spirit!"

Friedell's obituary said, "To those who knew him, Gil will be remembered for his wise personal and professional counsel, incisive questions, wit, infectious chuckle, poetic annual holiday letters and fondness for bow ties. Gil dedicated his life to transforming inequitable systems to make the world a better place."

Smith, a Friedell Committee member, said, "We remember him best when we do all we can for the good health of Kentucky."

Friedell is survived by Jan, his wife of 67 years, four of their five children, seven grandchildren, and one great-granddaughter. A memorial service will be held in Charleston, S.C. in the fall with details to follow. In lieu of flowers, donations may be made to the Gilbert H. Friedell Resident Scholar in Cancer Prevention and Control Fund, University of Kentucky, Markey Cancer Center, 800 Rose Street, Lexington KY 40536, to the attention of Elisha Maxson.

Herald-Leader goes after understaffing at Ky. nursing homes

"At Sunrise Manor Nursing Home in Hodgenville, a frail woman spent a night in 2015 sitting precariously on her bathroom toilet, shouting uselessly for help, shivering with cold, because nobody remembered to return and assist her to bed. The nurse’s aide for that unit later told state inspectors that she had been overwhelmed trying to monitor 26 residents during the graveyard shift."

That's the first paragraph of one of the stories from John Cheves of the Lexington Herald-Leader about understaffing at Kentucky nursing homes. It goes on:

"At Stonecreek Health and Rehabilitation in Paducah that same year, harried nursing staff dealt with a resident screaming about excruciating pain from a neglected urinary catheter — he had an infection that soon would require emergency hospitalization — by removing his speaking valve, a plastic prosthesis in his throat, to render him mute. At Woodcrest Nursing and Rehabilitation Center in Elsemere this year, a resident told state inspectors that he was ordered to empty his bowels in bed when nobody on staff was available to take him to the bathroom."

The report has several videos. Here's one on how to pick a nursing home for a loved one: https://www.kentucky.com/news/local/watchdog/article214646475.html

An angry mother recalls her son's death in a nursing home: https://www.kentucky.com/news/local/watchdog/article218394420.html

Sen. Ralph Alvarado, R-Winchester, "works at nearly a half-dozen substandard nursing homes while he fights in Frankfort to protect the nursing home industry from personal injury and wrongful death lawsuits," and opposes bills to require more staff, Cheves reports. Here's a video:

Congress agrees on bipartisan opioid package

Congress has agreed on a comprehensive package to address the opioid epidemic, which includes both law-enforcement and public-health measures. President Trump is expected to sign it.

The 653-page bill has a provision to fight importation of fentanyl through the mail, one that allows more health-care providers to prescribe medication for opioid addiction, and another to make it easier for Medicaid recipients to get inpatient care for substance abuse over the next five years.

“While there is more work to be done, this bipartisan legislation takes an important step forward and will save lives,” a group of Republican and Democratic committee leaders said in a statement.

Opioid overdoses were responsible for nearly 50,000 U.S. deaths last year, 1,565 in Kentucky.

One of the most expensive items in the new law is the partial removal of a decades-old federal rule that prevented states from using federal Medicaid dollars on inpatient addiction treatment facilities with more than 16 beds, called the IMD exclusion (for "institution for mental disease").

For the next five years, the new law allows states to amend their Medicaid programs to obtain federal funds to cover up to 30 days of residential treatment for individuals receiving substance-abuse treatment per calendar year.

Mental-health advocates have said this provision doesn't go far enough because it doesn't cover treatment for mental illness that isn't related to substance use. Others have voiced concerns that the relaxation of the exclusion will divert money away from other community-based programs.

Some addiction specialist are also concerned that it will create a shift to these inpatient facilities and away from longer-term outpatient programs that focus on medication-assisted treatments, which is the gold standard for treating opioid addiction. "Many residential programs for opioid addiction still don't offer such treatment as part of their protocol, and the bill does nothing to address that," Abby Goodnough of the New York Times reports.

The package also will permanently allow nurse practitioners and physician assistants to prescribe buprenorphine, an anti-addiction medication that requires a special license. It also allows nurse anesthetists, nurse midwives and clinical nurse specialists to prescribe buprenorphine for a trial period of five years.

It also includes a provision to help stop the flow of illicit opioids into the country by mail, especially synthetic fentanyl. Goodnough writes, "It will require the United States Postal Service to start collecting information on international mail shipments, just as private carriers like FedEx and DHL already have to do. By the end of this year, the Postal Service will need to provide the name and address of the sender and the contents of the package, as described by the sender, for at least 70 percent of all international packages, including all of those from China. It will have to provide the information on all such shipments by the end of 2020. The Postal Service could block or destroy shipments for which the information is not provided."

The package will provide funds for the research and development of new, non-addictive painkillers and allow the U.S. Food and Drug Administration to require certain opioids be dispensed in packaging that limits their abuse potential.

Critics of the bill say it's not enough to fully combat the opioid crisis and what is needed is an infusion of money similar to the billions of dollars that has been spent on HIV/AIDS.

Inside Health Policy reports that a House-backed measure that sought to loosen privacy restrictions on medical records containing information about substance abuse was dropped from the final package.

Also missing, Goodnough writes, is a provision that the pharmaceutical industry pushed hard for that "would have softened a requirement for drug manufacturers to start providing larger discounts next year to Medicare beneficiaries whose spending on prescription drugs falls in a coverage gap called the “doughnut hole."

Panel acknowledges medical benefits of medical marijuana but also concerns, including potency of a possible 'Trojan horse'

By Melissa Patrick
Kentucky Health News

Research shows conclusively that medical marijuana has some health benefits, but also comes with some adverse risks that would likely be exacerbated by the increasing potency of the plants, and some think a medical marijuana law in Kentucky would be a "Trojan horse" for recreational use.

Meanwhile, teen vaping of high-potency marijuana products is increasing. And some wonder why Kentucky should follow states that have passed laws approving certain drugs, when that's the job of the U.S. Food and Drug Administration.

Those were the some major messages Sept. 24 during a breakout session at the Foundation for a Healthy Kentucky's Howard L. Bost Memorial Health Policy Forum, the theme of which was "Kentucky's Substance Use Epidemic: A Solutions Update."

Ed Shemelya

Ed Shemelya, a 30-year veteran of the Kentucky State Police and coordinator of the federal government's National Marijuana Initiative, said we need to be talking more about the potency of marijuana, which he said "exploded" after states began legalizing its recreational use.

The initiative works in the officially designated 33 High Intensity Drug Trafficking Areas areas. Its duties include disrupting domestic trafficking and production of, and reducing demand for, marijuana and derivative products.

Shemelya said he is seeing marijuana plants that can produce as much as 22 pounds of processed product, with more than 40 percent tetrahydrocannabinol (THC), the plant's psychoactive product. Before recreational use was made legal in a few states, marijuana plants typically produced one to two pounds of product and were much less potent, he said.

Also of great concern are the dabbing products, which he said are showing up with THC potency as high as 80 percent. Dabbing is the catch-all phrase for marijuana concentrates that are used in e-cigarettes, like "shatter," "budder" or "wax."

"This is what scares me, the vaping," he said. "The fastest growing youth segment is vaping because of the stealth component of it."

Stealth vaping allows a person to vape in secret. Rather than exhaling the vapor, a person simply holds it in so that it has almost disappeared by the time he or she exhales.

David Bradford

From another point of view, a professor of public administration and policy at the University of Georgia came with a handful of research papers to support both the heath and financial effectiveness of medical marijuana.

David Bradford shared findings from a 2017 National Academies of Sciences Engineering and Medicine review of more than 10,000 studies on the health effects of recreational and therapeutic use of cannabis (marijuana's biological genus).

The review found conclusive evidence for the effectiveness of medical cannabis in treatment of chronic pain, chemotherapy-induced nausea, and spasticity associated with multiple sclerosis; and moderate evidence of its effectiveness in treating sleep disorders, Bradford said.

Bradford also shared his own research that, using data on all Medicare Part D patients between 2010 and 2013, showed that prescription drugs for conditions like anxiety, depression and chronic pain had dropped in states that had legalized medical cannabis.

"We are seeing substantial substitutions away from prescription drugs when cannabis is available," he said. "But the big ticket item here is pain medications," such as ibuprofen and other non-steroidal, anti-inflammatory drugs "as well as oxycodone," an addictive painkiller.

Bradford estimated that Medicare could save $1.2 to $1.7 billion a year if every state passed a law allowing medical marijuana to be obtained from dispensaries, presuming Medicare Part D enrollees would buy their medical marijuana without any subsidies. He said other research showed a 14.4 percent decrease in Part D opioid use in states with a dispensary based law.

Bradford said an update of his study, which has been peer-reviewed but not published, found that dispensary laws are twice as effective as home-cultivation based laws in diverting people away from pain medications -- in urban counties, but not rural ones. Much of Kentucky's population is in rural areas where marijuana is raised.

He concluded, "We do think there is evidence that appropriately devised medical cannabis laws can be one tool in helping optimize policies to save lives, which is the most important thing, and on the way you might be able to save a little bit of money too."

Jason Hockenberry

Jason Hockenberry, associate professor at Emory University's School of Public Health in Atlanta, said his research shows fewer prescriptions being written for Medicaid patients in medical-marijuana states. He added that the widely cited National Survey of Drug Use and Health has found "no translation between passing a medical marijuana law and any of the uses in other substance-use behaviors over the subsequent years."

But "It's not just about those health things," he added. He showed a graph that showed how incarceration rates had dropped in four states with major marijuana reforms. Among African Americans, the rates dropped from 742.1 per 100,000 before reforms to 251.9 per 100,000 afterward. Among all other races taken together, that number dropped from 167.7 to 51.1.

Dr. Scott Teitelbaum

Dr. Scott Teitelbaum, medical director of the Florida Recovery Center, argued that we shouldn't be passing laws to legalize a drug because that is the responsibility of the FDA.

"I would argue vehemently, and will continue, that there are two things we don't do with medications: smoke them or vote on them," said Teitelbaum, a psychiatry professor at the University of Florida and chief of its Division of Addiction Medicine.

Teitelbaum acknowledged research shows marijuana's medical benefits, but said it also shows there are risks that must also be considered, including addiction, psychiatric disorders, traffic accidents and cognitive deficits.

In addition, he said it's important to remember that the movement to revive cannabis as a medicine is driven by many factors other than science -- namely money. He concluded by asking, "Do we want to legalize it or do we want to decriminalize it? That's a more real conversation than this Trojan horse: medicalization."

All the speakers agreed that we need more longitudinal studies, which look at effects over time.

The topic was timely. The 2013 Kentucky Health Issues Poll found that 78 percent of Kentucky adults favored legalization of marijuana for medicinal purposes, and members of the Kentucky General Assembly are seriously considering a medical-marijuana law.

During the last legislative session, they spent three straight days in discussion of such a bill, but ended up shelving it on a 14-4 committee vote, with not enough time left in the session to find a way to pass it.

And though a new bill hasn't yet been submitted for the short session that begins Jan. 8, the Interim Joint Committee on Licensing, Occupations & Administrative Regulations has devoted two meetings to the topic this summer, presenting arguments both for and against it. Committee Co-Chair John Schickel, R-Union, said in a Sept. 14 news release that he expects some type of marijuana legislation to be introduced.

So far, 31 states and the District of Columbia have legalized medical marijuana. Nine states and the district have legalized recreational marijuana, and 17 states, including Kentucky, have legalized cannabidiol extracts with low THC.

McCreary and Wayne counties win Health Policy Champion award from Foundation for a Healthy Ky. for being 'bright spots'

Foundation for a Healthy Kentucky CEO Ben Chandler announced the award as nominees listened.

By Al Cross
Kentucky Health News

Wayne and McCreary counties won the first overall Health Policy Champion award presented by the Foundation for a Healthy Kentucky, for being "bright spots" of progress on health issues in Appalachian Kentucky.

"We have a tie," Foundation President and CEO Ben Chandler said as he announced the award at the foundation's annual Howard L. Bost Memorial Health Policy Forum in Lexington on Monday.

The adjoining counties on the Tennessee border were two of eight nominees for the award, which spotlights "those folks who are advocating the policy changes that will make Kentucky healthier," Chandler said. The $5,000 award was divided equally between the McCreary County Health Coalition and the Wayne County Health Council.

"They show us there' s always somewhere to start when it comes to working to improve health," Chandler said.

The two counties were among nine in Kentucky and 42 in Appalachia that the Appalachian Regional Commission and the Robert Wood Johnson Foundation named "bright spots" because they had better than expected health outcomes given their resources and health indicators.

McCreary and Wayne were among 10 counties in a case study that took a deeper dive into what they were doing to improve the health of their citizens, despite their many challenges.

The Lake Cumberland district, with Wayne and
McCreary outlined. Taylor is not in Appalachia.

The other "bright spots" in Kentucky were Green, Adair, Russell, Wayne, McCreary, Pulaski and Lincoln counties, like McCreary and Wayne part of the Lake Cumberland District Health Department, and Lewis and Morgan counties.

The other Health Policy Champion award nominees were Dr. Van Breeding of Whitesburg, for fighting substance abuse; and Murray Mayor Jack Rose, Paducah cardiologist Pat Withrow, Paducah Mayor Brandi Harless, the Casey County Youth Coalition and, jointly, Lexington Mayor Jim Gray and Lexington Legends owner Andy Shea, all for efforts against tobacco use.

Appalachian health researchers discuss work, with three sessions on drugs, and are urged to engage more closely with communities

By Melissa Patrick
Kentucky Health News

A big step toward improving health in Appalachia would be closer relationships between residents of the region and researchers -- who often drop in, gather data and leave.

That's what researchers were told last week as they gathered in Lexington to talk about their work in Appalachia, ranging from opioid disposal programs to air and water quality.

Joyce Bells-Berry of the Mayo Clinic, keynote at the
Appalachian Translational Research Network Summit

Joyce Bells-Berry of the Mayo Clinic said at the eighth annual Appalachian Translational Research Network Summit that it was time for Appalachian researchers to stop "helicopter" research and truly engage with communities in the region.

"Community engagement allows us to get to the why so that we can answer our research questions in a way that is pivotal for changing the lives of those around us, in a way that builds partnerships and mutual respect, while taking into consideration the needs of those around us, not just our needs as the academics," said Bells-Berry, a professor of epidemiology.

Scott Lockard, director of the Kentucky River Health Department, who is collaborating on a syringe-exchange project with the University of Kentucky, said he agreed.

"We don't like helicopter researchers," said Lockard, a native of Wolfe County. "We've been studied enough."

Lockard said Appalachian Kentucky is "ripe for collaboration" with researchers who will come to the region to work with residents and help communities find their own solutions to health issues, and be prepared to answer this question: "At the end of the day, does our research improve the lives of everyday Kentuckians?"

And, for that matter, all Appalachians. The Appalachian Translational Research Network is nine institutions in the major Appalachian states (Kentucky, Ohio, Pennsylvania, North Carolina and Tennessee) that collaborate to strengthen research and training efforts in the region. Its stated mission is to "catalyze translational research among partnering institutions serving Appalachian communities to synergistically improve the health of these communities."

Drug disposal programs questioned

One of the many presentations at the summit, held Sept. 20-21, involved researchers from UK and Wake Forest University who are working on finding ways to improve prescription-drug disposal programs in Appalachia. These programs include drop boxes, organized take-back events and drug-deactivation products that can be used at home.

Mark Wolfson, co-director of Wake Forest's Center for Research on Substance Abuse and Addiction, told the group that "best estimates" show that only 30 percent of all medications with abuse potential are used as prescribed, leaving 70 percent either unused or inappropriately used.

Kentucky has embraced organized drug-disposal programs as part of its strategy to curb the opioid epidemic. The state Office of Drug Control Policy says Kentucky has 198 drop boxes in 116 counties, with sites being added daily; many locations participate in twice-yearly national take-back days for prescription drugs, with the next one on Oct. 27.

A new state law requires pharmacists to tell customers how to safely dispose of controlled substances, and either provide or offer to sell them a product designed to neutralize drugs for disposal -- or provide on-site disposal. Kentucky is participating in a pilot program to provide drug deactivation pouches in Floyd, Henderson, McCracken and Perry counties.

But research indicates that the program is not effective. Wolfson said a study by East Carolina University, using Kentucky data, found that less than 1 percent of controlled medications that were unused were being collected in drop boxes.

Donald Helme, professor in the UK College of Communication and Information, is working with Wolfson. He has found through focus groups, moderated discussions of a few people, that hardly anyone knows about the drop boxes -- and even if they do, there is great skepticism about handing over drugs to government agencies, which house most of the drop boxes. 

"One of the main things that came up" in the focus groups, Helme said, is "Do not use law enforcement, do not use EMS, do not use the fire department to promote this, because they don't trust them."

Helme and Wolfson will design and test a drug-disposal messaging campaign for the five counties in the study, in hopes of justifying a bigger campaign in the future. It is being conducted in conjunction with health departments in Bell, Whitley and Floyd counties in Kentucky and Burke and Wilkes counties in North Carolina.

Environmental health issues explored

Along the theme of community-engaged research, Ellen Hahn, deputy director and community-engagement core leader at UK's Center for Appalachian Research in Environmental Sciences, or UK-CARES, talked about her efforts to "match-make" researchers who are working on air and water quality issues with Appalachian communities.

Hahn, a nursing professor and director of BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments), said part of their efforts involve citizen science projects. As an example, she pointed to an air-quality project conducted by students and teachers at Perry County Central High School and UK, described in a video:



Keeping pre-diabetes from becoming diabetes

Dr. James Keck, assistant professor in UK's Department of Family & Community Medicine, talked about his research around increasing access to the Diabetes Prevention Program, an evidence-based lifestyle program that helps people with pre-diabetes to keep the disease from progressing.

Keck said that like the rest of the nation, about one in three Kentuckians have pre-diabetes, a condition that increases the likelihood that a person will eventually be diagnosed with diabetes without preventive intervention.

He said the one-year prevention program has been hamstrung by a general lack of knowledge about it by both patients and clinicians, as well as its cost, which runs about $700 a year. But he added that more and more insurance plans, including UK health insurance and Medicare, now pay for it.

Recognizing the challenges of bringing such a program to rural Kentucky, Keck said his next project will be to to determine if a free, six-week diabetes program offered by Kentucky Homeplace community health workers is as effective as his year-long program.

Studying syringe exchanges

Hilary Surratt, associate professor at UK's College of Medicine, is researching syringe-exchange programs in Appalachian Kentucky.

In collaboration with the Clark, Knox and Pike county health departments, Surratt's research includes  injection-drug users who use the exchanges as well as those who don't. It will also include interviews with community stakeholders, who are both for and against the exchanges. The goal of the research is to understand the many barriers to access and to identify strategies to increase uptake.

Surratt found that among 175 exchange participants, 46 percent said their primary drug of injection was crystal methamphetamine; 27 percent said buprenorphine ( a drug typically used to combat drug addiction), and 17 percent said heroin.

Of particular concern was that more than one in three said they had shared needles and syringes with other injection-drug users in the past three months. And the average number of times they said they had injected in the past month was 80, while the median number of syringes they reported getting was only 50.

One of the main purposes of a syringe-exchange program is to prevent the spread of HIV and hepatitis C, which are commonly spread by the sharing of needles among injection-drug users.

Surratt also found that nearly 40 percent of the exchange participants said they had a personal history of overdose, but only 14 percent said they had access to Narcan, an anti-overdose drug.

She showed a map with the ZIP codes of the interviewees, representing 10 counties, illustrating the great distances drug users must travel to get clean needles.

"When I see something like this, it says to me that we need to think of innovative kinds of solutions to keep engaging people," she said. "Because we know over time that distance is a barrier to consistent use of these programs."

Members of the Appalachian Translational Research Network are UK, Wake Forest, East Tennessee State University, The Pennsylvania State University, The Ohio State University, Ohio University, the University of Cincinnati and Marshall University in Huntington, W.Va.

65 kids a day are abused or neglected in Ky., third in nation; officials urge safe sleep practices, care about who provides care

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – When it comes to keeping babies safe, three of the most important things are safe sleep practices, recognizing that bruising in non-mobile infants is not normal, and choosing an appropriate caregiver.

So said members of the state's Child Fatality and Near Fatality External Review Panel, who told legislators at the Sept. 19 joint health committee meeting that three-fourths of cases they reviewed in 2017 were "potentially preventable."

They lawmakers also heard the executive director of Prevent Child Abuse Kentucky say the state ranked No. 3 for "child maltreatment" in 2016. Jill Seyfred added that 23,827 Kentucky children were confirmed victims of child abuse or neglect in 2017, about 65 a day.

The ABCs – and D – of safe sleep

Dr. Jaime Pittenger, a review-panel member and the president of Prevent Child Abuse Kentucky, told the committee that 39 percent of the deaths the panel reviewed in 2017 involved sudden unexpected deaths in infancy, or SUDI, a broad term that covers both sudden infant death syndrome and other fatal sleeping accidents. That number is "on the rise this year," she warned.

Pittenger, who heads the pediatric residency program at the University of Kentucky, stressed the importance of following the ABC's of safe sleep to prevent injury or infant deaths – Alone, on their Back, and in a Clean, Clear Crib.

Safe Sleep Kentucky website graphic; for a larger version, click on it

And because so many of the fatalities or near-fatalities are connected to substance abuse, Kentucky has added a D to that list to point out the Danger of sharing a bed with a child, especially when under the influence of alcohol or other drugs.

Almost two-thirds of last year's SUDI cases in Kentucky involved an impaired caregiver who slept with their baby and the baby died from suffocation or asphyxiation, the review panel found.

Pittenger pointed out that many Kentucky infants don't have a safe place to sleep: "We can make it sound like everybody has a bassinet, a crib, but they don't."

Rep. Joni Jenkins, D-Louisville, suggested that the state look into providing children who don't have a crib with a "baby box" with instructions on safe sleep, as some other states and countries do.

"Some years ago we decided that every child that left the hospital ought to have the appropriate car seat," Jenkins said. "It seems to me that a logical [solution] is that every child that leaves the hospital after birth should have an appropriate place to sleep as well."

CDC photo

"Those who don't cruise, don't bruise": Pittenger offered this rhyme as a way to remember that bruising in infants not old enough to be mobile "is not normal." She was quick to point out that bruising doesn't always mean abuse, but "should raise a red flag to make you ask questions."

Paula Sherlock, a retired Family Court judge, stressed the importance of reporting bruising in non-mobile infants: "We don't want to think that our kids are abusing our grandkids, so we believe things that we shouldn't believe."

"Don't leave your child with someone you wouldn't leave a puppy with": This was Sherlock's advice for choosing a caregiver. She added, "People who have violent tempers, who have histories of domestic violence, should not be left in a care-giving role with children who can't defend themselves or tell anybody what happened," she said. "The vast majority of the kids we see are under the age of 4 and a huge portion of them are under the age of 2."

Happiest Baby blog photo

Sherlock said 41 percent of Kentucky children determined to have abusive head trauma in 2017 were left with a caregiver to whom they were not related. "Typical of that is the boyfriend who is watching the baby while mom goes to work," she said. "Mom has no affordable daycare, she has no good support system and so a completely inappropriate person is left with the child, who is not his child. We see a really startling number of these cases."

Abusive head trauma is also called "shaken baby syndrome." It can be caused by a direct blow to the head, dropping or throwing a child, or shaking a child resulting in an injury to the child's brain.

Seyfred said the top risk for these children are substance abuse and family violence. "Substance abuse was documented as a risk factor in 65 percent of the reports, with family violence as a risk factor in 42 percent," she said.

There are other dangers. Pittenger said people who have a history of crime or mental illness have also been connected to the majority of these abused and neglected children. The panel report found that 85 percent of the 2017 cases reviewed had a prior history with child protective services.

What's Kentucky doing to protect its children?

Sherlock and others stressed the importance of the review panel, which she said works to identify gaps in the system and to find ways to fix them.

She also stressed the need to get quick, efficient, affordable and non-punitive help for Kentucky parents who are suffering from addiction.

"These parents need help," she said. "These kids are very vulnerable and if they are being born to drug-addicted parents and then going home to be cared for by these parents, that is a recipe for disaster." Sherlock said, "My experience in court: drug addicted parents did not by and large beat their children to death . . . but the neglect is so gross and so widespread that these children are not fed, they are not supervised."

Rep. Kim Moser, R-Taylor Mill, and Sen. Reginald Thomas, D-Lexington, praised the HANDS program as a tool to help at-risk families learn how to better care for children. HANDS, for Health Access Nurturing Development Services, is a home-visitation program for new and expectant parents that works toward healthy pregnancies and births, healthy child growth and development, safe homes and self-sufficient families.

Thomas said he thought every parent would benefit from this program, but especially those at high risk. "The reality is that children don't come with a how-to manual," he said.

Moser also praised the START program, which integrates addiction services and other wrap-around services to families with at least one child under 6 years of age who is in the child-welfare system and has a parent with a substance-use disorder that puts that child at risk. START stands for Sobriety Treatment and Recovery Team. Moser said she would love to see both of these programs expanded.

Seyfred told the panel that Prevent Child Abuse Kentucky had recently partnered with WellCare and the Kentucky Hospital Association to create a video focusing on safe sleep, abusive head trauma, and choosing an appropriate caregiver to show new parents before they leave the hospital.

Pittenger spoke to the importance of this education: "One of the saddest stories I ever heard was a dad who just didn't understand that shaking would hurt his child. He never knew, he never thought that what he was doing when he lost his temper would hurt the child. Some people just don't know."

Kentucky has also passed laws to require caregivers and professionals who serve children to receive training on pediatric abusive head trauma.

Sen. David Givens, R-Greensburg, charged everyone at the meeting to tell at least one person with a newborn or who is pregnant about what they had learned about the importance of safe-sleep practices and quality caregivers.

"We could save one child's life just through that conversation," he said. "So let's do that. Let's all leave here today charged in the course of the next two weeks to have that conversation with at least one person. We may make a difference."

To report suspected child abuse in Kentucky, call 877-KYSAFE1 (597-2331) or online at https://prd.chfs.ky.gov/ReportAbuse/OutofHours.aspx. The national abuse hotline can be reached at 1-800-422-4453.

Lexington has 100+ restaurants on probation for health violations; hepatitis A raises concern, but no cases have been related to food

Amid a nearly statewide outbreak of hepatitis A, the Lexington-Fayette County Health Department is monitoring more than 100 restaurants that it has placed on probation for violation of public-health standards, Janet Patton reports for the Lexington Herald-Leader.

"Spoiled food. Soiled equipment. Dirty floors, dirty walls. Live roaches and flies inside kitchens. Dead ducks hanging outside. Lexington’s restaurant inspectors have seen it all," Patton writes. "Since 2015, they’ve compiled a list of restaurants and other food service providers to target for heightened scrutiny."

The cleanliness of restaurants has taken on fresh importance since the hepatitis A outbreak started in about a year ago. The Lexington health department recently recommended that everyone in Fayette County be vaccinated against the liver disease because some food service workers had tested positive for the virus. No Kentucky cases of the disease have been attributed to food service.

A restaurant goes on probation if it has an inspection score below 85 or a critical violation that can’t be corrected immediately, including "employee hygiene practices such as a lack of hand washing, cold food being too hot or hot food being too cold, dishwashers not sanitizing properly, or evidence of rodents or insects," Patton reports. The most common violation is incompletely cleaned dishes and utensils, "either because the dishwasher isn’t dispensing sanitizer or the water isn’t hot enough to kill germs."

Kitchens at two Lexington hospitals are on probation. The one that serves patients and the cafeteria at UK Good Samaritan Hospital, went on probation when a May inspection "found live flies throughout the kitchen, and dirty walls, ceiling and equipment," Patton reports. UK spokeswoman Kristi Willett said the kitchen scored 98 in a follow-up inspection May 30. She said the hospital "has passed all other health department inspections in the past five years with a score of 98 or above.”

The cafeteria at St. Joseph Hospital "has been on probation since June, when an inspection found live roaches in the kitchen in the reach-in cooler, as well as unclean floors, walls, soda and juice dispensers," Patton writes. Kentucky One Health spokeswoman Mary Branham said the inspection was “not reflective of the scores our food service typically receives,” and the follow-up score was 99.

Patton reports that several "high profile" restaurant operators said the label "probation" is misleading. “People don’t understand … that upon reinspection the score was good,” said Rob Ramsey, who operates several restaurants with his family name in Lexington. “As far as I’m aware of we’ve never had a food-safety hazard that has been passed to the public.”

Deal to sell Jewish Hospital may be falling apart, raising the possibility that it might be closed, with big ramifications

KentuckyOne Health photo

The future of Louisville's Jewish Hospital is in doubt. Its owner, KentuckyOne Health, "continues to lose money after months of negotiating to sell it and other local facilities to a hedge fund, according to a doctor who has written about the local health care industry."

So reports the Louisville Courier Journal, which interviewed Dr. Peter Hasselbacher, a retired University of Louisville medical professor. "I would not be surprised for Jewish Hospital to close its doors within a matter of months," he said. "I wish the best for them, but I think the odds are stacked against them."

"Hasselbacher's concerns are shared by five other doctors and five current KentuckyOne staff members in a variety of roles, as well as a former administrator with knowledge of the negotiations," the CJ's Grace Schneider and Morgan Watkins report. "They shared information with the Courier Journal on the condition of anonymity because they aren't authorized to discuss the matter and due to their employment with or other professional ties to KentuckyOne and the university," which has an organ-transplant program at Jewish.

The CJ's sources and Hasselbacher doubt that KentuckyOne will be able to sell Jewish to BlueMountain Capital Management, a New York hedge fund that has formed a hospital-management firm with a Los Angeles billionaire. Its first acquisition, of "a failing non-profit Catholic hospital chain in California, has failed – the hospital system has filed for bankruptcy," Hasselbacher reported on his Kentucky Health Policy Institute blog on Sept. 5. He said that is "casting a very dark curtain over this potential transaction in Louisville."

The deal was expected to include Jewish's several satellites, including one in Shelbyville, and their doctors' practices; Sts. Mary & Elizabeth Hospital in southwest Louisville; and Saint Joseph Martin, a small hospital in Eastern Kentucky's Floyd County. But St. Joseph was sold to Appalachian Regional Health in June, and "Our Lady of Peace Hospital, a profitable psychiatric hospital that KentuckyOne initially intended to keep, is now part of what's on the block with BlueMountain," the newspaper reports. "But the hedge fund now wants Jewish out of the bundle, according to the longtime doctor with ties to Jewish and U of L and a local health care executive."

The CJ notes, "KentuckyOne and BlueMountain announced in December that they were entering negotiations, but have set new deadlines for closing the transaction." KentuckyOne interim president and CEO Chuck Neumann said through a spokesman that "a complex due diligence and transaction process" has delayed the deal. A BlueMountain spokesman said negotiations are continuing.

"Neumann told employees Friday that executives have no plans to close Jewish, but added that they're making contingency plans in case they can't reach an agreement," the CJ reports. University President Neeli Bendapudi told the newspaper, "We really are trying to be prepared for everything." Jewish has 462 beds, so its closure would have serious ramifications..

"The remaining downtown hospitals (University Hospital and Norton Heathcare) will be swamped if not overwhelmed," Hasselbacher wrote. "Sharing with the outlying hospitals is not likely sufficient to take up much if any of the load. University Hospital is already full. Without a landing pad for transplant, rehab, cardiology, and other specialty services historically housed at Jewish, the University will lose access to those teaching services."

KentuckyOne's Denver parent, Catholic Health Initiatives, is heavily in debt. It said 16 months ago that it would sell its Louisville properties, "in a bid to shed facilities that were losing money," the CJ notes. "KentuckyOne and BlueMountain's announcement of negotiations in December allayed fears that the health system couldn't find a buyer. But several signs point to trouble for Jewish, which needs more than $200 million in upgrades. Worse, it's received D ratings in recent years from a nonprofit health care watchdog that evaluates patient safety."

UPDATE, Sept. 24: Insider Louisville reports, "Jewish Hospital for years has been losing money and until recently had been propped up financially by the profitable University Hospital, which KentuckyOne managed. However, the University Hospital’s management — and profit — have reverted to the University of Louisville, leaving Jewish in a more precarious financial situation and its owner with greater incentives to sell it."

Addict who writes column for Appalachian papers publishes book

Phillip Lee, a recovering drug addict who writes a column for newspapers in Appalachian Kentucky and Tennessee, has published a book, The Journey of an Addict.

"Through overdoses and many hospitalizations, through nursing homes and rehabilitation centers, through drug treatment programs and prisons, I survived through it all only by the grace of my higher power," Lee writes on Amazon. "This book is part of a complete dedication in my life to helping others reach recovery. Not being easy at all, I tell how it's the hardest thing I've ever done in life. I tell you about the personal rewards of recovery. The freedom and calm that is gained is second best to nothing. Looking back on some of the insane and dangerous situations, I can even laugh at some of the stories now."

Lee began writing a column for the weekly Clinton County News in his hometown of Albany in May 2017. For a while it bore the name of the book as well as the title "An Addict's Corner." Now only the book carries the name.

"The Journey of an Addict is a series of stories and personal experiences I have gone through in active addiction, my experiences now, and what it takes to remain drug-free today," Lee writes. "I give all the credit to my higher power, who is Jesus Christ, whom without today I am nothing. As an addict, I know you will gain understanding of your own addiction through reading this book. As a family member of an addict, you will gain real world knowledge of what we as addicts go through on a constant basis."

National Medicaid boss defends work and 'community engagement' rules as measures to thwart dependence

By Al Cross
Kentucky Health News

The director of the Center for Medicare and Medicaid Services gave a spirited defense of work requirements like Kentucky has proposed for its Medicaid program, saying "We are committed to this issue."

Seema Verma spoke Thursday to a conference of insurers who managed care for state Medicaid programs. She did not mention that a federal judge has blocked the Kentucky plan, which is being re-evaluated by her agency, but addressed fears that the "community engagement" and reporting requirements would lead to loss of coverage for thousands of Kentuckians.

"These policies are not blunt instruments," Verma said. "We’ve worked carefully to design important protections to ensure that states exempt individuals who have disabilities, are medically frail, serve as primary caregivers, or have an acute medical condition that prevent them from successfully meeting the requirement."

Kentucky's plan would require "able-bodied" Medicaid beneficiaries to spend 80 hours a week at work, in school, volunteering or, if needed, drug treatment. Verma cast the rules as an attempt to thwart a culture of dependency, and noted that the percentage of childless adults under 50 who are not in the workfrce has dropped 3.4 percentage points since 2000, mostly before the Great Recession.

"It is not compassionate to trap people on government programs, or create greater dependency on public assistance as we expand programs like Medicaid," she said. "True compassion is giving people the tools necessary for self-sufficiency… allowing able-bodied, working age adults to experience the dignity of a job, of contributing to their own care, and gaining a foothold on the path to independence.

"And there is clear evidence that people are happier and healthier when they are working and leading independent, self-sufficient lives. . . . The problem too often is that the most well-meaning government policies trap people in a hopeless cycle of poverty, making it too difficult to escape, and too easy to become more dependent. Instead, we ought to insist that the able-bodied participate in earning benefits."

FDA goes to war against teenagers' 'epidemic' use of electronic cigarettes, says another generation is at risk of nicotine addiction

By Melissa Patrick
Kentucky Health News

The U.S. Food and Drug Administration is launching a new anti-vaping campaign aimed at teens.

The campaign, "The Real Cost," will target nearly 10.7 million students through hard-hitting advertising on digital and social media sites that are popular among teens, like You Tube and Instagram, and by placing ads at least 10,000 high-school bathrooms.

The ads will educate teens on the risk of nicotine addiction and the dangerous chemicals in the products; an estimated 80 percent of them don't see a great risk of harm from regular use of e-cigs, according to the latest "Monitoring the Future" survey, which tracks substance use by students in 12th, 10th and 8th grades.

In 2017, more than 2 million youth were current users of e-cigarettes. Kentucky's high-school students use traditional cigarettes and e-cigarettes at about the same rate, 14 percent, according to the 2017 Youth Risk Behavior Survey. However, the same report shows that more high school students have ever tried e-cigs, compared to ever trying the traditional ones: 45 percent and 40.5 percent, respectively.

FDA Commissioner Scott Gottlieb called teens' use of e-cigs "epidemic" and said it "jeopardizes the extraordinary public health gains we've made in reducing smoking rates in the nation."

“We have data to show that use of e-cigarettes, while potentially posing much less harm than combusting tobacco, is not benign. It causes its own health effects. And nicotine use by kids is dangerous. It causes direct effects on their health and their brains,” Gottlieb said in a written statement. "Not to mention the risk of lifelong addiction. There’s a large pool of nicotine users that’s being created among kids by these products. And some portion of them are at risk of transitioning to and risking addiction to cigarettes.”

Gottlieb stressed that while the FDA recognizes e-cigarettes can play a role in helping adults quit smoking, there is no reason for teens to use them.

“Even as we consider the potential benefits of innovative tobacco products and the role that some such products may play in reducing harm to current adult smokers, the FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products," he said.

The nearly $60 million campaign efforts will be funded by user fees collected from the tobacco industry, not by taxpayer dollars, says the news release.

The campaign comes just days after Gottlieb announced a major crackdown on e-cig sales to minors, including the issuance of more than 1,300 warning letters and civil money-penalty complaints to retailers who illegally sold e-cig products to minors; a request to the five top-selling e-cig companies (Juul, Vuse, MarkTen, blu e-cigarettes and Logic) to submit plans describing how they will address the widespread youth use of their products; and warning companies that have misleading labels and ads that resemble kid-friendly foods such as juice boxes, candy and cookies, that they must stop.

"Making sure e-cigs aren't being marketed to, sold to, or used by kids is a core priority and the guiding principle behind our efforts," Gottlieb said.

A federal judge in Boston has said these efforts haven't moved fast enough and has ordered the FDA to quickly finish writing a rule requiring graphic warnings on cigarette packages and advertisements, The Associated Press reports. On Sept. 5, Judge Indira Talwani gave the FDA until later this month to provide an expedited schedule for finalizing the graphic warnings rule.

An FDA spokesman told AP that the agency continues "to move forward on the work to support a new rulemaking," is analyzing the judge's decision, and will comply.

To defend against another flu epidemic in Kentucky: 'Get the shot. Consult your doc. Stop the spread," campaign says

Nurse practitioner Sara Wellman gives Ben Chandler his shot;
Health Commissioner Jeffrey Howard looks on.(Photo by Al Cross)

By Al Cross

Kentucky Health News

Influenza killed 325 people in Kentucky last flu season, when only 40 percent of Kentuckians got a flu shot. The state's doctors, health agencies and the Foundation for a Healthy Kentucky aim to keep such things from happening this season.

The foundation, the Cabinet for Health and Family Services and the Kentucky Medical Association staged an event in the state Capitol rotunda Tuesday to urge Kentuckians to get a flu shot on Wednesday, Sept. 26 or at least by the end of October.

Flu cases have already been reported, and "Last year was one of the worst years ever for the flu," which can be at lot worse than an inconvenience, said KMA President Bruce Scott said. He said he can't understand why some people still think you can get the flu from a flu shot, because "The virus is not live." He called it "a myth."

There is no guarantee that any one shot will prevent the flu in any one patient, because viruses, vaccines and patients vary. But every shot is likely to help reduce the effects of the flu. "Even if you get sick you’re going to have an easier time of it if you get your shot," Foundation CEO Ben Chandler said. "The sad thing is, Kentuckians who live on very low incomes are less likely to get the shot, but are more likely to have the kinds of chronic conditions that make them more vulnerable to serious flu complications."

The writer's bandage after his flu shot

Chandler said flu shots are inexpensive and "easy to get," and to illustrate the point, he, Scott and others got their shots during a break in the press conference. They got "Focus on Flu" bandages that carry the theme of the campaign. He and other speakers urged Kentuckians to post a selfie photo of their arm with the bandage on social media, writing #gotmyshot and #focusonflu.

Flu shots are not available to infants under 6 months and people with compromised immune systems, but the "herd immunity" created by vaccinations of their neighbors gives them some protection, said Dr. Brent Wright, associate dean for rural health innovation at the University of Louisville and a director of KMA's Kentucky Foundation for Medical Care, which is supporting the effort.

Wright added that you can be a carrier of the flu virus and not get sick, but not if you get the shot.

Allison Adams, president of the Kentucky Health Departments Association, said the agencies will offer vaccinations and education campaigns. The "Focus on Flu" campaign includes public service announcements, education materials, social media messages, and partnerships to make flu shots. 

Speakers also noted measures to take if you think you have the flu. Studies show that flu antiviral drugs work best when they're started within two days of getting sick. 

And if you do have the flu, rest at home. "No need to be a stoic," Chandler said. "You’re just putting others at risk." People with flu should washing their hands frequently with soap and water, cover their mouth and nose when they cough or sneeze, and limiting contact with others.

The three points of the campaign are "Get the shot. Consult your doc. Stop the spread." For resources on the flu, see this blog post from the Association of Health Care Journalists.