A Broadened Scope of Practice

http://www.wcvb.com/health/more-school-nurses-carrying-narcan/36687064

Gerry Tout

In the past year, communities across the nation have had an astonishing rise in opiate abuse, predominantly heroin. Massachusetts and New Hampshire are several of the states with a greater percentage of opiate-caused deaths in the form of overdose and deterioration of the body’s functions from consistent use of heroin. With an overdose, assuming 9-1-1 has been called and pre-hospital intervention is available, a necessary, often life saving step for an EMT is to administer Narcan to the patient. Narcan is a narcotic antagonist, meaning it works through effectively blocking opiate receptor sites, thus reversing or preventing the toxic effects of particular opioid analgesics. Among the techniques used to save an overdosed patient in an ambulance, administration of Narcan is a quick, seemingly simple step, yet its effects are a critical precursor to further care in saving the individual.

Over the Counter, Over the Line

In the article “Over-the Counter Medicines’ Benefits and Dangers” Jane Brody discusses Americans use of OTC drugs and how we go wrong. Last year Americans spent 44 billion dollars on OTC medications so it is safe to say that they are part of every day life. We have all at least glanced at the label on a bottle of Tylenol and somewhere it says “consult your doctor” or “consult your pharmacist”. Brody points out a fact that we probably already knew which is almost no one consults their healthcare providers about taking OTC’s. We have all become self proclaimed experts in taking common medications. 

Clueless (*As IF*)

Many Doctors Unaware of Truvada, Drug for Preventing H.I.V.

By Donald G. McNeil Jr.

http://www.nytimes.com/2015/11/26/health/many-doctors-unaware-of-truvada-drug-for-preventing-hiv.html?ref=health 

Kudos to you if you actually got the reference I was making in the title.

But in all seriousness, this article frustrates me a lot. One of my good friends from high school is a campus advocate for Truvada (a.k.a. “PrEP”, or Pre-Exposure Prophylaxis) at NYU and I can already imagine how upset the information in this article would make him.

Pharmaceutical Price Hike: Only 66,566%

Cancer. It is a word the strikes fear in the hearts of many as many still equate being told one has cancer with one being given a death sentence. From that point on, one becomes somewhat of a living time bomb. However, for you, the cancer has been caught early on enough that you can still get treatment to combat the deadly illness. Immediately, one’s thoughts then go to how much will this treatment cost? For someone without insurance, the costs could be crippling. Imatinib is from a class of drugs commonly used to combat cancer. In the United States, a single year’s worth of treatment can cost upwards of $106,000. Luckily, you live in India.

In India, a year’s worth of treatment using Imatinib costs around $159. The difference between the costs for this type of drug between India and the United States is a price hike of over 66,566%. That’s right, five digits. A recent review of drug production costs and pricing presented this past September at the 2015 European Cancer Congress mapped out the money an individual would spend for a year’s treatment of three classes of drugs commonly used to combat cancer: Imatinibs, Erlotinibs, and Lapatinibs. In addition, these prices are already allowing for a 50% profit margin for pharmaceutical companies. The main reason why these life-saving drugs are cheaper in both India and in Europe (the price hike between Europe and the United States for Imatinib hovering at around 231%) is because generic versions of the drugs using Imatinibs are so much more readily available in India. The article takes the specific example of Gleevec, a drug used by people with leukemia and gastric cancer. Its patent, first approved by the FDA in 2001, should have expired this year. However, Novartis, the pharmaceutical company who has the patent, has managed to keep other companies trying to make generic version at bay by making the large amounts the drug needed to synthesize a generic version hard to attain by these other companies. This is a problem faced by many pharmaceutical companies as they try to produce cheaper generic versions of much more expensive drugs. The reason why expensive drugs are able to stay expensive is because there are no other competitors. As a result, people with these illnesses (usually more rare and not as researched) are forced to buy these expensive drugs as they have to alternative drug to turn to.

Why then, are these cancer drugs so much cheaper in India? With not as many restrictions within drug production and with drugs being so readily available, companies are able to attain enough samples to create many different generic versions of a single drug. As a result, the buying medication in India is more of a true free market as consumers can see how expensive each drug that would do the same thing is. Companies are then either forced to lower prices to beat out their competition or risk going out of business. As it would not really be beneficial for anyone (but Pharmaceutical companies) to lower drug production restrictions, the more feasible solution for the United States would be to put a cap on prices for each specific type of drug. Adopting something similar to Canada’s pharmaceutical policy where certain drugs cannot be sold within the county unless the price can be negotiated to a suitable arrangement would get affordable life-saving medication to those who need it the most without making them have to move halfway across the world to receive it.

http://www.forbes.com/sites/elaineschattner/2015/11/24/why-many-new-cancer-drugs-dont-have-to-cost-so-much/

Hepatitis C: Is curing the most vulnerable worth the price tag?

http://www.npr.org/sections/health-shots/2015/11/23/457145471/treating-prisoners-with-hepatitis-c-may-be-worth-the-hefty-price

Hepatitis C is a bloodborne virus most commonly spread through intravenous drug use, that persists in the liver and causes eventual liver failure in 85% of patients. One of the most heavily affected populations in the U.S. are prison inmates, with 15% infected with Hep C. Up until early 2014 there was no treatment, but after decades of research a drug was discovered that has a 90% cure rate. However, ledipasvir-sofosbuvir, the breakthrough Hep C medication, runs at $1,125 per pill. The minimum length of treatment is 12 weeks, which costs upwards of $90,000 per patient.

The health of prisoners is the responsibility of the government, and the liver failure associated with chronic Hep C requires incredibly costly treatments that often include liver transplants. Because of the high cost of letting the disease progress, a new study shows that the high upfront cost of screening U.S. prisoners for Hep C and treating them now will lead to longterm healthcare savings. Just treating those in prison would save $750 million over 30 years. Additionally, treating prisoners also prevents them from transmitting Hep C to the rest of the community upon their release.  

Analytical Posting : Treating A.D.H.D

http://well.blogs.nytimes.com/2015/11/23/video-game-is-built-to-be-prescribed-to-children-with-a-d-h-d/?ref=health

Earlier this month, the New York Times published an article describing a new method to treat A.D.H. D. in children. Basically, Akili Interactive Labs is a company that develops “electronic medicine” using high-quality, interactive video games. Recently, they came out with Project: EVO, a computer program “created to improve attention and reduce impulsivity in children with attention deficit hyperactivity disorder.” However, while the creation of a treatment that doesn’t force children as young as three and four to be medicated seems to be a wonderful new development, Project: EVO already sparks some concerns.

On one hand, it’s remarkable that there is a group of cognitive neuroscientists, biomedical scientists and experts in medical devices that is committed to treating children with A.D.H.D. without using drugs in a culture that is constantly using medication solve problems. The theory behind the whole brain training industry that targets children with A.D.H.D. along with adults who are trying to prevent dementia and other age-related cognitive ailments, is that people will be able to improve cognitive functions by using interactive, repetitive, and increasingly difficult exercises to strengthen the brain the same way lifting weights at the gym strengths other muscles in the body. “Electronic medicine,” as opposed to drugs could be a great alternative for parents who worry about side effects of drugs like amphetamine and methylphenidate that are typically used to treat A.D.H.D.

However, the problem with that last point is that doctors are not being encouraged to prescribe electronic treatment over standard drugs; rather, they are to prescribe both to children. Especially considering the video games are recommended for half an hour a day, five times a week for four weeks, they could be more stigmatizing for children and they wouldn’t actually replace the potentially harmful side effects from drugs. Kids who use Project: EVO could also later have an increased dependence on screen time, which is proven to, at times, end up being harmful to the development and health of children.

Also, I can’t help but worry about one more thing in the context of our discussions about the ways in which pharmaceutical companies medicalize illnesses. According to the article, “Shire, which manufactures Adderall, was an early investor in Akili and helped design the recent pilot study.” Shire has a vested interest in seeing increased treatment of A.D.H.D. in order to sell more Adderall. This is clear conflict of interest that could skew reports on the true effectiveness of Project: EVO. Unfortunately, what could be happening here is that a franchise is being made out of the treatment of A.D.H.D. And when business gets in the way of medicine, it is the patients who suffer.

Ethics in Prescribing Drugs

In Groopman’s chapter titled “Marketing, Money, and Medical Decisions,” Groopman discusses the medicalizing of normal conditions done by the pharmaceutical companies. Gropper states ‘in the past decade or so, marketing directly to the public prompts people like aging men or postmenopausal women to ask their doctor for a drug even if the drug has not been proven to work for their problem.” One particular account that stood out was the prescribing of testosterone replacement products to men. Research found that “ treatment does not significantly increase strength in most muscle groups; compared to a placebo, it neither boost libido nor increases energy.”Groopman then goes on to say “nonetheless, the number of prescriptions for testosterone replacement products continue to rise sharply.” How is it ethical for doctors to prescribe drugs that are not specifically proven to target treatment of the condition the patient presents to them? Many drugs have serious side effects such as stroke and heart attack so what if the patient taking a drug that is not beneficial to their condition is harmed significantly due to the side effects of this drug? What role does ethics play in the prescription decision-making process for doctors?

Daraprim Part 2: Competitors Don’t Mean Competition

After last month’s famous story of how Martin Shkreli, the CEO of Pharmaceutical Company Turing Pharmaceuticals raised the price of an AIDS drug from $13.50 to $750 overnight, a new story has emerged of a competitor company coming out with a $1 version of the drug. This competitor is Imprimis Pharmaceuticals, a pharmaceutical company that mixes approved drug ingredients to fill individualized patient prescriptions. Imprimis Pharmaceuticals Chief Executive Mark Baum announced last week that they would be supplying pills containing Daraprim’s active ingredients, pyrimethamine and leucovorin, in 100 pill count bottles for $99. Baum has also announced that they will be developing generic alternatives to many other drugs that have sky rocketed recently over the years- mainly drugs treating cancer and other rare diseases that the general public does not take much notice of.

However, as much as Imprimis Pharmaceuticals is championed as a hero of the people (as they should be), it turns out that Turing Pharmaceuticals really will not lose much from this competition. Imprimis’ ability to compete with Turing is greatly limited as it is a compounding pharmacy which means it can only provide medicine after a doctor requests it, meaning that doctors have to specifically be requesting their version of the pill. As we have learned in class, there are many ways for Turing Pharmaceuticals to take advantage of this system as they may begin to incentivize doctors (whether they do it over or under the table, monetarily or otherwise) to continue prescribing their version of Daraprim. In addition, rather than pharmacies having to specifically order the new version of Daraprim every time someone asks for it, it is much easier for pharmacies to dispense a drug they already readily have on hand such as the original version of Daraprim. There is already a system set in place where if the pharmacy cannot get the insurer to pay for the medicine but cannot, the pharmacy will usually dispense the drug regardless, using either charities or –where legally possible- by making the drug maker itself cover the difference in cost. Due to these reasons, despite the fact that a $1 competitor would trigger the notion of a free market happening where the people will choose the most cost-effective drug for them –where that company would make profit and the other would go out of business because no one would buy that drug, – there is really no free-market at all. Until these loopholes are closed and something like a standard price for drugs are set, these practices will continue unchallenged, and Americans will continue to bear the consequences.

http://www.usatoday.com/story/money/2015/10/23/imprimis-pharmaceuticals-turing-pharmaceuticals-daraprim/74452030/

http://www.forbes.com/sites/matthewherper/2015/10/23/suckers-that-1-a-pill-competitor-wont-hurt-martin-shkreli-one-bit/2/

Process Reflection 1

Through the readings and conversations in both lecture and discussion, the apparently “flawed” US healthcare system has now become apparent to me. The biggest eye opener of this course thus far is the fact the US healthcare is revolved mostly around money, that being either how is the doctor or how is the institution being paid. When I say eye opener I should clarify; I knew that US healthcare, being a private sector, was mostly about money but after the readings and discussions I never thought it was this bad.

Red Tape in Our Bureaucratic Healthcare System

In the article “Trapped in the System: A Sick Doctor’s Story” published in the New York Times is a doctor’s anecdote about his experience in getting  medication through a tedious process with the different institutions involved such as his doctor, insurance company, pharmaceutical and laboratory personnel. Given that he knows how the system works in terms on the processing, paperwork and documentation in order to ensure that the bills get subsidized by insurance companies, and to obtain the pills itself, he still finds it difficult to get medication for his illness. It is noteworthy that because he is a doctor, he knows which medication is a better option and the side effects. This knowledge is not something that can be easily learnt to the general public. If he finds it difficult as an individual patient in this system, the question is how else is the general public coping? More importantly, the question of how are the people with more urgent illnesses coping?

He argues that while much discussion has been revolving around the quality of and access to healthcare, the obstacles in which people face with dealing the healthcare system have oftentimes been neglected. Thus, the article provokes us to think further about the ways and indicators we consider when measuring the quality of and access to healthcare in a holistic way. This article has reminded me that not only are the groups of the uninsured, or the precariously insured citizens, or the poor are susceptible to fall from the cracks of our healthcare system, the educated, well-informed in terms of resources and power are also victims of a system, which has room of improvement in terms of delivering care. Besides its unaffordability and the unproductive outcomes (given how much we have spent on healthcare), this article reminds us to look into the red tape produced by our bureaucratic healthcare system, and how individuals, with varying power and social positions, negotiate with the many different institutions (insurance company, employers, pharmaceutical companies, doctors etc.). More importantly, how their outcomes vary depending on their social positions and power, which then varies along class lines, race, age, gender, profession, socio-economic statuses. I believe that we need to integrate these social factors in order to understand the healthcare system sociologically.

http://www.nytimes.com/2015/09/22/upshot/trapped-in-the-system-a-sick-doctors-story.html?ref=topics&_r=0