VA OIG — Healthcare Inspection: Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center
Healthcare Inspection: Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center
Source: U.S. Department of Veterans Affairs, Office of Inspector General
The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to complaints concerning improper opioid prescription renewal practices in the Medical Practice Clinic at the San Francisco VA Medical Center (facility), San Francisco, CA. We reviewed the following allegations: (1) attendings on-duty are tasked with evaluating numerous opioid renewal requests for patients with whom they are unfamiliar, (2) providers do not routinely document patients’ opioid prescription renewal problems in the electronic health record, and (3) there have been patient hospitalizations and deaths related to opioid misuse.
We substantiated that attendings on-duty are tasked with evaluating numerous opioid renewal requests for patients with whom they are unfamiliar; however, Veterans Health Administration regulations and local policy do not prohibit such practice.
We partially substantiated that providers do not routinely document patients’ opioid prescription renewal problems in the electronic health record. The providers did not consistently document an assessment for adherence with appropriate use of opioids and monitor patients for misuse, abuse, or addiction. The primary care providers did not consistently complete the templated Narcotic Instructions Note for patients with opioid prescription renewal problems.
We partially substantiated that there have been hospitalizations and deaths of patients related to opioid misuse. Seven patients were hospitalized for opioid overdose; however, the primary care provider, Psychiatry Service, and/or the facility’s Substance Abuse Program assessed and appropriately monitored the patients for misuse. There were no deaths related to opioid overdose.
We recommended that the Facility Director (1) ensure that providers comply with all elements of the management of opioid therapy for chronic pain, as required by Veterans Health Administration and the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, and (2) ensure that the Narcotic Instructions Note is reevaluated for appropriate use in the Medical Practice Clinic and that providers comply with established protocol.
The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan. (See Appendixes A and B, pages 6–9 for the Director’s comments.) We will follow up on the planned actions until they are completed.
National Action Alliance for Suicide Prevention Releases Life-Saving Juvenile Justice System Resources
National Action Alliance for Suicide Prevention Releases Life-Saving Juvenile Justice System Resources (PDF)
Source: National Action Alliance for Suicide Prevention
The National Action Alliance for Suicide Prevention ( Action Alliance) today released a set of comprehensive suicide prevention resources to support professionals who work with youth in the juvenile justice system. The newly developed educational tools advance the National Strategy for Suicide Prevention, which guides efforts to prevent suicide across the nation. Online versions of the nine resources are now available to the juvenile justice workforce and the general public…
Early Stage Animal Hoarders: Are These Owners of Large Numbers of Adequately Cared for Cats?
Source: Human-Animal Interaction Bulletin
Animal hoarding is a spectrum-based condition in which hoarders are often reported to have had normal and appropriate pet-keeping habits in childhood and early adulthood. Historically, research has focused largely on well-established clinical animal hoarders with little work targeted towards the onset and development of animal hoarding. This study investigated whether a Brazilian population of owners of what might typically be considered an excessive number (20 or more) of cats were more likely to share the commonly reported psychological and demographic profile of animal hoarders than owners of 1-2 cats drawn from the same population. Psychological traits measured were attachment to pets (Lexington Pet Attachment Scale, LAPS), anxiety and depression (Hospitalized Anxiety and Depression Scale, HADS), and hoarding behavior (Saving Inventory-Revised, SI-R). Owners of 20 or more cats were significantly older, scored significantly higher pet attachment scores, and displayed significant positive relationships between hoarding behavior and anxiety. Such a profile demonstrates greater similarities to clinical animal hoarders than to typical cat owners on these particular measures, although additional disparities with clinical animal hoarders exist in the areas of functioning, veterinary care and home organization. Taking this information together, the studied population may represent the understudied group of early stage animal hoarders. However, external factors such as culture and societal animal control policies should not be overlooked as alternative explanations for pet keeping at levels that might be considered excessive.
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Update on Drug-Related Emergency Department Visits Attributed to Intentional Poisoning: 2011
Source: Substance Abuse and Mental Health Services Administration
- In 2011, there were an estimated 15,471 emergency department (ED) visits attributed to intentional drug poisoning
- About three quarters (77 percent) of drug-related ED visits attributed to intentional poisoning were made by patients aged 21 or older
- Females accounted for two thirds of drug-related ED visits attributed to intentional poisoning (66 percent)
- Approximately 65 percent of drug-related ED visits attributed to intentional poisoning in 2011 involved unidentified drugs, and a similar percentage involved alcohol in combination with other drugs (62 percent)
Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis
The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration’s (FDA) regulatory impact analysis (RIA), required by law as part of its rule-making process. However, evidence on the impact of GWLs on smoking prevalence is scarce.
The goal of this paper is to critically analyse FDA’s approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence.
A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control.
We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87–4.68 percentage points, a relative reduction of 12.1–19.6%; 33–53 times larger than FDA’s estimates of a 0.088 percentage point reduction. We also demonstrated that FDA’s estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed.
Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3–8.6 million in 2013. Our analysis demonstrates that FDA’s approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA’s effective regulation of tobacco products.
Behaviors that pose risks for an individual’s health and that also represent important threats for public health, such as drug use, smoking, alcohol, unhealthy eating causing obesity, and unsafe sex, are highly prevalent in low income countries, even though they are traditionally associated with richer countries.
Individual choices are an important part of the risky behaviors. Risking Your Health: Causes, Consequences, and Interventions to Prevent Risky Behaviors explore how those choices are formed and what are their consequences. Why do people engage in risky behaviors? Many different explanations have been proposed by psychology, sociology, economics or public health. One trait common to all these behaviors is that there is a disconnect – a function of both delay and uncertainty – between the pleasure or satisfaction provided by them and their consequences.
Another characteristic of risky behaviors is that they rarely occur in isolation. Peer-pressure, parental influences, networks and social norms often play an important role in initiating, continuing, or quitting those behaviors. Even if they might often be the first to suffer, the consequences of risky behaviors are also rarely limited to the individuals engaging in them. In certain cases, such as second-hand smoking or HIV transmission, the link is direct. In other cases, the link is less direct but not necessarily less real: the long term health consequences of many of these behaviors are costly to treat and could stretch households’ finances and worsen poverty. Finally, these risky behaviors have consequences for society as a whole since they often trigger a non-trivial amount of public health expenditures and lead to declines in aggregate productivity through premature death and morbidity.
Changing behaviors is tricky — public health interventions via legislation with strong enforcement mechanisms can be more effective than simple communication campaigns informing consumers about the risks associated with certain behaviors, since translating knowledge into concrete changes in behavior seems to be hard to achieve. Economic mechanisms such as taxes (especially on alcohol and tobacco products), subsidies (such as free condoms), and conditional/unconditional cash transfers are also used to reduce risky behaviors (for example in HIV prevention). Of great interest to policy makers, academics and practitioners, this book assesses the efficiency of those interventions designed to reduce the prevalence of behaviors that endanger health.
Impact of a mobile phone and web program on symptom and functional outcomes for people with mild-to-moderate depression, anxiety and stress: a randomised controlled trial
Mobile phone-based psychological interventions enable real time self-monitoring and self-management, and large-scale dissemination. However, few studies have focussed on mild-to-moderate symptoms where public health need is greatest, and none have targeted work and social functioning. This study reports outcomes of a CONSORT-compliant randomised controlled trial (RCT) to evaluate the efficacy of myCompass, a self-guided psychological treatment delivered via mobile phone and computer, designed to reduce mild-to-moderate depression, anxiety and stress, and improve work and social functioning.
Community-based volunteers with mild-to-moderate depression, anxiety and/or stress (N = 720) were randomly assigned to the myCompass program, an attention control intervention, or to a waitlist condition for seven weeks. The interventions were fully automated, without any human input or guidance. Participants’ symptoms and functioning were assessed at baseline, post-intervention and 3-month follow-up, using the Depression, Anxiety and Stress Scale and the Work and Social Adjustment Scale.
Retention rates at post-intervention and follow-up for the study sample were 72.1% (n = 449) and 48.6% (n = 350) respectively. The myCompass group showed significantly greater improvement in symptoms of depression, anxiety and stress and in work and social functioning relative to both control conditions at the end of the 7-week intervention phase (between-group effect sizes ranged from d = .22 to d = .55 based on the observed means). Symptom scores remained at near normal levels at 3-month follow-up. Participants in the attention control condition showed gradual symptom improvement during the post-intervention phase and their scores did not differ from the myCompass group at 3-month follow-up.
The myCompass program is an effective public health program, facilitating rapid improvements in symptoms and in work and social functioning for individuals with mild-to-moderate mental health problems.
New GAO Reports and Testimony
Source: Government Accountability Office
1. Civil Support: Actions Are Needed to Improve DOD’s Planning for a Complex Catastrophe. GAO-13-763, September 30.
Highlights - http://www.gao.gov/assets/660/658407.pdf
2. Federal Autism Activities: Better Data and More Coordination Needed to Help Avoid the Potential for Unnecessary Duplication. GAO-14-16, November 20.
Highlights - http://www.gao.gov/assets/660/659148.pdf
3. Immigration Detention: Additional Actions Could Strengthen DHS Efforts to Address Sexual Abuse. GAO-14-38, November 20.
Highlights - http://www.gao.gov/assets/660/659146.pdf
1. Personnel Security Clearances: Actions Needed to Help Ensure Correct Designations of National Security Positions, by Brenda S. Farrell, director, defense capabilities and management, before the Subcommittee on the Efficiency and Effectiveness of Federal Programs and the Federal Workforce, Senate Committee on Homeland Security and Governmental Affairs. GAO-14-139T, November 20.
Highlights - http://www.gao.gov/assets/660/659120.pdf
Police Shootings of People With a Mental Illness
Source: Australian Institute of Criminology
The decision to use a firearm in a police operation is one of the most critical a police officer can make and ‘no other single issue has the potential to destroy the relationship between the police and the community like the use by police of deadly force’ (McCulloch 1991: 160).
All fatal police shootings are subject to internal review, a mandatory coronial inquest and are also monitored by the Australian Institute of Criminology’s (AIC) National Deaths in Custody Program (NDICP). The NDICP collects detailed information about the circumstances and nature of such incidents, with the view to informing the ongoing development of policy and procedure.
The AIC has recently released a special monitoring report that commemorates the twentieth anniversary of the Royal Commission into Aboriginal Deaths in Custody. This report contains detailed analysis of the 2,325 deaths in custody since 1 January 1980 (which includes 905 deaths in police custody and custody-related operations). This report also examines fatal police shootings that have occurred in Australia since monitoring of these incidents began in 1989–90.
One issue that frequently arises with regard to police shootings is proportionality, or more simply, whether the threat or potential threat posed by the alleged offender was sufficient to warrant police using a firearm. This issue is tested through coronial inquests in which the presiding coroner will make a determination about whether the shooting was justified.
This issue becomes much harder to resolve when the mental capacity of the alleged offender is impaired, such as by drugs and/or alcohol, a mental illness or both, as the ability to understand or appreciate the consequences of potentially life-threatening actions may be undermined.
Emerging tobacco products gaining popularity among youth
Source: Morbidity and Mortality Weekly Report (CDC)
Emerging tobacco products such as e-cigarettes and hookahs are quickly gaining popularity among middle- and high-school students, according to a report in this week’s Morbidity and Mortality Weekly Report.
While use of these newer products increased, there was no significant decline in students’ cigarette smoking or overall tobacco use. Data from the 2012 National Youth Tobacco Survey (NYTS) show that recent electronic cigarette use rose among middle school students from 0.6 percent in 2011 to 1.1 percent in 2012 and among high school students from 1.5 percent to 2.8 percent. Hookah use among high school students rose from 4.1 percent to 5.4 percent from 2011 to 2012.
The report notes that the increase in the use of electronic cigarettes and hookahs could be due to an increase in marketing, availability, and visibility of these tobacco products and the perception that they may be safer alternatives to cigarettes. Electronic cigarettes, hookahs, cigars and certain other new types of tobacco products are not currently subject to FDA regulation. FDA has stated it intends to issue a proposed rule that would deem products meeting the statutory definition of a “tobacco product” to be subject to the Federal Food, Drug, and Cosmetic Act.
Male Survivors of Sexual Abuse and Assault (PDF)
Source: Department of Justice (CA)
Over the past three decades, the Canadian criminal law on sexual assault and other sexual offences has changed quite significantly through both the courts and parliament. It is now recognized that males, both as children and as adults, can be victims and survivors of sexual abuse and sexual assault. The majority of victims of sexual assault are female and there is a significant body of research from many disciplines examining the criminal and civil justice system responses, impacts, treatment, etc. The body of research on male victims is much more limited likely due to the smaller numbers and challenges recruiting representative samples. This research study examines the experiences of male survivors of both child sexual abuse (CSA) and adult sexual assault (ASA).
Prescription Drug Abuse: Strategies to Stop the Epidemic
Source: Trust for America’s Health
Prescription Drug Abuse: Strategies to Stop the Epidemic finds that 28 states and Washington, D.C. scored six or less out of 10 possible indicators of promising strategies to help curb prescription drug abuse. Two states, New Mexico and Vermont, got the highest score, receiving all 10 possible indicators, while South Dakota scored the lowest with two out of 10.
According to the report, prescription drug abuse has quickly become a top public health concern, as the number of drug overdose deaths – a majority of which are from prescription drugs – doubled in 29 states since 1999. The rates quadrupled in four of these states and tripled in 10 more of these states.
Prescription drug related deaths now outnumber those from heroin and cocaine combined, and drug overdose deaths exceed motor vehicle-related deaths in 29 states and Washington, D.C. Misuse and abuse of prescription drugs costs the country an estimated $53.4 billion a year in lost productivity, medical costs and criminal justice costs, and currently only one in 10 Americans with a substance abuse disorder receives treatment.
Railway Suicides in the UK: risk factors and prevention strategies (PDF)
Source: National Health Service and British Transport Police
From press release:
The lack of research on the gender and ethnicity of people who take their own lives on the UK railway system obscures an urgent need for more effective preventive strategies, a new report has claimed.
‘Railway Suicides in the UK: Risk factors and prevention strategies’, commissioned by NHS England, and produced by mental health charity Careif and the Cultural Consultation Service, reveals inconsistencies in how data on suicide is collected and the way emergency services, government agencies and the police collaborate.
In addition, the widely reported association between mental illness and railway suicide, believed to be due to a station’s proximity to in-patient psychiatric units and severe forms of mental illness such as schizophrenia, requires further research, according to the study.
Among the report’s recommendations is:
• The need for a standardised framework to collect information on suicide, including ethnicity and previous contact with care services
• Better coordination between emergency services to help prevent railway suicides
• More effective intervention in high-risk groups with steps to improve public awareness and public mental health and wellbeing in general
• Implementation of an emergency pathway across all agencies nationally to enable a consistent and coherent response.
Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review
Source: Neuropsychiatric Disease and Treatment
This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide.
We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients.
The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis.
It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition.
The Perfect Storm: Veterans, culture and the criminal justice system (PDF)
Source: Justice Policy Journal
In 2008 an article was published that suggested an Emerging Storm, relative to veteran entanglement in criminal justice, was approaching (Brown, 2008). Well, that storm appears to have hit land. The actual/ potential damage is likely to depend upon the responses of the legal system and the American public at large. There are many veterans who appear to return to the civilian culture and manage to hold their own without significant problems. Other veterans experience socio-cultural problems, along with psychological issues, but are able to camouflage those problems and issues. Some veterans are less fortunate and they find themselves confronting criminal charges. Some end up behind bars for extended periods of time. This article addresses the complexities associated with understanding why some veterans appear normal while other veterans become entangled in our criminal justice system. Specifically, we will be addressing issues related to socio-cultural differences and irregularities between civilian and military cultures, cultural competency in relation to psychology and the court system.
Battle for Benefits: VA Discrimination Against Survivors of Military Sexual Trauma
Source: American Civil Liberties Union, Service Women’s Action Network, Yale Law School
Sexual assault and harassment are serious problems in the United States armed forces. Thousands of service members each year are estimated to have experienced some form of military sexual trauma (MST), including rape, sexual assault, and sexual harassment.
Less well known is the second battle that many veterans who survive sexual violence must fight with the U.S. Department of Veterans Affairs (VA) when they return to civilian life.
“Battle for Benefits: VA Discrimination Against Survivors of Military Sexual Trauma,” a report released by Service Women’s Action Network (SWAN), the American Civil Liberties Union Women’s Rights Project (ACLU), and the American Civil Liberties Union of Connecticut (ACLU-CT), with assistance by the Yale Law School Veterans Legal Services Clinic, reveals that the process of obtaining VA disability benefits for the enduring mental health effects of military sexual trauma (MST) is an unfair fight in which veterans are often unsuccessful. Veterans who survive in-service sexual trauma face discrimination in seeking compensation.
Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010
Depressive disorders were a leading cause of burden in the Global Burden of Disease (GBD) 1990 and 2000 studies. Here, we analyze the burden of depressive disorders in GBD 2010 and present severity proportions, burden by country, region, age, sex, and year, as well as burden of depressive disorders as a risk factor for suicide and ischemic heart disease.
Methods and Findings
Burden was calculated for major depressive disorder (MDD) and dysthymia. A systematic review of epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data quantified the severity of health loss from depressive disorders. These weights were used to calculate years lived with disability (YLDs) and disability adjusted life years (DALYs). Separate DALYs were estimated for suicide and ischemic heart disease attributable to depressive disorders.
Depressive disorders were the second leading cause of YLDs in 2010. MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and dysthymia for 1.4% (0.9%–2.0%). Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause. MDD accounted for 2.5% (1.9%–3.2%) of global DALYs and dysthymia for 0.5% (0.3%–0.6%). There was more regional variation in burden for MDD than for dysthymia; with higher estimates in females, and adults of working age. Whilst burden increased by 37.5% between 1990 and 2010, this was due to population growth and ageing. MDD explained 16 million suicide DALYs and almost 4 million ischemic heart disease DALYs. This attributable burden would increase the overall burden of depressive disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.
GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden allocated to suicide and ischemic heart disease. These findings emphasize the importance of including depressive disorders as a public-health priority and implementing cost-effective interventions to reduce its burden.