Mystery Solved: Why That ‘Opioid-Induced Constipation’ Super Bowl Ad?


I imagined 100 million people all scratching their heads at the same time and saying, “Huh?”

The source of their bafflement: Why, among all the usual Super Bowl ads for cars and beers, is there a minute-long tale (watch it above) of a man who envies others — even a dog — their digestive regularity?

The voice-over describes his plight: “If you need an opioid to manage your chronic pain, you may be so constipated it feels like everyone can go…except you. Tried many things? Still struggling to find relief? You may have opioid induced constipation — OIC.”

The condition sounds straightforward enough, and the social media poop jokes were predictable enough. The mystery was: How does something that looks like a public service announcement about opioid constipation show up on the most expensive advertising real-estate around?

A skeptical friend sent over these queries: “Are there really enough people on opioids that they can justify paying for a Super Bowl commercial? Isn’t anyone on legitimate opioids in a doctor’s care and getting info about anti-constipation meds?”

First of all, yes, there are enough people on opioids. The U.S. Pain Foundation estimates on its OIC page that nearly 8 million people who are on opioids suffer from related constipation. And that estimate may well be low, said the foundation’s founder, Paul Gileno, because people don’t tend to seek care for constipation, they often just try to treat it with over-the-counter and natural remedies. The U.S. Pain Foundation is one of a half-dozen groups listed at the end of the ad as co-sponsors, and some of its funding comes from pharmaceutical companies.

Secondly, Gileno said, no, many doctors are not on top of opioid-related constipation. “We’d all love to assume it’s being take care of, but it’s really not,” he said — to the point that some patients even skip their opioid doses despite the added pain, just to try to cope with the constipation.

About three-quarters of pain management happens in primary care doctors’ offices, he said, and those typically brief visits are often so focused on alleviating pain that they do not delve into side effects. Patients may also fail to connect their pain medication with their constipation.

“Early on in my pain journey, I didn’t realize that was a side effect, and quite honestly, my primary care doctor didn’t know either, he didn’t bring it up to me,” Gileno said. “It was only when I was able to see a good pain management doctor that he knew that was a side effect.”

The point of the Super Bowl ad was to get a conversation going about this embarrassing but important aspect of pain treatment, Gileno said.

But Super Bowl conversation-starters do not come cheap. USA Today reports that a 30-second ad costs up to $5 million. On this list of sponsors, who has that kind of money? Yes, it’s the two pharmaceutical companies at the bottom: Continue reading

A $1 Pill That Could Save Thousands Of Lives: Research Suggests Cheap Way To Avoid U.N.-Caused Cholera

(United Nations Photo/Flickr)

(United Nations Photo/Flickr)

By Richard Knox

Here’s a way to get a big bang for a buck:

If a few hundred United Nations peacekeeping troops had taken a $1 antibiotic pill five years ago before they were deployed to Haiti, it may well have prevented a cholera outbreak that has so far sickened 753,000 Haitians and killed more than 9,000.

That’s the takeaway of a new study by Yale University researchers in the journal PLoS.

The authors believe their evidence should prompt the U.N. to adopt a simple and incredibly cost-effective strategy: Make sure all the 150,000 peacekeepers it sends out into the world each year from cholera-afflicted countries get preventive doses of antibiotics before deployment.

It’s not the first time the U.N. has gotten that advice. It was first suggested by a panel of outside experts the agency appointed back in 2011 to investigate the Haitian epidemic. But so far the U.N. has rejected the panel’s recommendation on preventive antibiotics.

It’s not clear whether that will change. The U.N.’s chief medical officer, Dr. Jillian Farmer, said in an interview Friday that she welcomes the new study. But she noted it does not address “the biggest barrier to implementing the antibiotic recommendation” — a concern that what she calls “mass administration” of antibiotics would give rise to antibiotic-resistant strains of cholera.

“It may be we will be able to do this [administer pre-deployment antibiotics to U.N. peacekeepers],” Farmer said. “I don’t have a closed mind.”

The Yale researchers and others argue that the concern about generating resistant cholera strains is overblown because the antibiotics would be targeted — not administered massively. They further argue that the U.N. should sponsor research to answer that question, given the urgency of the question.

“When we have a case as extreme as Haiti showing the status quo doesn’t work, we should be working to build evidence for a solution that does, not using a lack of proven solutions as an excuse not to act,” said Adam Houston, who works with the Boston-based Institute for Justice and Democracy in Haiti.

The new study is the latest chapter in a tragic story that’s been unfolding since mid-October of 2010, when, researchers say, a single U.N. peacekeeper from Nepal most likely introduced cholera to Haiti, touching off the most explosive cholera epidemic in modern times. Before the outbreak. Haiti had been cholera-free for at least a century; thus, its citizens had no immunity to the disease.

“Based on DNA evidence, this outbreak was probably started by one or very few infected, asymptomatic individuals — I would guess one,” said Daniele Lantagne, a Tufts University environmental engineer who was one of four independent experts appointed by the U.N. in 2011 to investigate the outbreak.

Since none of the 454 Nepalese peacekeeping troops deployed to Haiti in late 2010 showed any symptoms of cholera, all of them would have had to take a prophylactic dose of antibiotic to prevent any one of them from starting the outbreak. That would have cost around $500 — a tiny price to pay to avoid a devastating epidemic that — absent the investment of billions of dollars in clean water and sanitation — will continue into Haiti’s indefinite future.

The new analysis finds that prophylactic antibiotics would have reduced the chances of the Haitian epidemic by 91 percent. When antibiotics are combined with cholera vaccination, the risk of an outbreak goes down by 98 percent.

The U.N. began requiring cholera vaccination of all its field personnel late last year. But the new study says vaccination by itself isn’t very effective; it reduces the risk of an outbreak by only 60 percent at best.

That’s because vaccination can prevent someone from falling ill from cholera, but it doesn’t prevent infection — so a vaccinated person can still carry the cholera bacterium and pass it on to others.

“Vaccination alone is not enough,” said Virginia Pitzer, who led the Yale research team. “Vaccination plus antibiotic prophylaxis would be best.”

“Antibiotics are far and away the most effective and the least expensive,” added epidemiologist Joseph Lewnard, the study’s first author. “It hits the problem from two angles. It not only prevents those exposed to cholera from experiencing an infection, but if they do get infected it shortens the duration of shedding the bacteria. So once they arrive [at their deployment destination] they would no longer have bacteria in their stools.” Continue reading

Calls For Better Pain Relief Measures For Newborns, Premature Infants

In this file photo, an infant is seen in the neonatal intensive care unit of the Swedish Medical Center in Seattle. (Paul Joseph Brown/AP)

In this file photo, an infant is seen in the neonatal intensive care unit of the Swedish Medical Center in Seattle. (Paul Joseph Brown/AP)

What could be more heartbreaking than witnessing some of the smallest, sickest babies undergoing painful medical procedures?

Yet that’s precisely the population subject to some of the most intrusive prodding and pricking, the “greatest number of painful stimuli” in the neonatal intensive care unit, or NICU.

Now the American Association of Pediatricians is calling for better, more comprehensive pain relief measures for newborns, including those born prematurely — both with medications and through alternative, non-drug measures — and for more research on effective treatments.

The AAP’s updated policy statement, published in the journal Pediatrics, asserts that “although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures.”

The AAP calls for new measures, specifically:

Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

If you’ve ever been in a NICU, you may have seen these types of procedures take place: suctioning of various secretions from the nose and throat; blood draws from veins, arteries, feet or heels; IVs being placed; adhesive tape — used to keep all those tubes and IVs in place — removed.

A landmark 2008 study from France found that the vast majority of newborns in the NICU didn’t get pain relief; researchers found only about 21 percent of infants were given either pain medication or non-drug pain relief before undergoing a painful procedure.

Why is this important? Continue reading

Opinion: How To Understand The WHO’s Zika ‘Emergency’ (And Not Be Terrified By It)

Jaqueline Vieira, left, watches as her 3-month-old son Daniel, who was born with microcephaly, undergoes physical therapy at the Altino Ventura foundation in Recife, Brazil. (AP Photo/Felipe Dana)

Jaqueline Vieira, left, watches as her 3-month-old son Daniel, who was born with microcephaly, undergoes physical therapy at the Altino Ventura foundation in Recife, Brazil. (Felipe Dana/AP)

The director-general of the World Health Organization has declared Zika virus a “public health emergency of international concern” — a PHEIC, pronounced “fike,” rhymes with spike, if you want to sound like a member of the WHO emergency committee.

It’s natural to be concerned when the WHO declares an epidemic — it has only done so three other times in its history: the 2009 influenza outbreak, an upswing in polio cases in 2014, and the West African Ebola outbreak in 2015. The question is: What makes the WHO concerned and how concerned should we be?

In this case, the disease itself is not as scary as the complications that have been linked to the virus — associations that have not yet been confirmed. Declaring a PHEIC allows the WHO to coordinate the international response, release emergency funds to better study the virus and confirm those potential complications as quickly as possible.

Here’s what we know. First, we know the virus is spreading quickly. The mosquito that carries the virus can be found from South America up to our hot and humid southeastern states in the U.S. And because the virus only arrived in the Western Hemisphere in 2014 — perhaps because of the World Cup or other sporting events — no one here has immunity to it, making it easy for mosquitoes to spread the virus. Some experts believe the virus can spread throughout the Americas, wherever the mosquito lives.

All this makes Zika sound scary, but we also know that up to 80 percent of people who catch the virus do not even display any symptoms. Those that do tend to have a mild illness with joint pain, a rash, red eyes and a fever, all of which resolve in four to seven days. No deaths have been reported so far that directly link to the virus. This is a far cry from Ebola, which causes a hemorrhagic syndrome that leads to death in as many as 50 percent of cases. Zika virus is worrisome in that it may cause horrible birth defects, but, put simply, it is not as scary as Ebola.

Still, it is the unknown that also concerns the WHO. Continue reading

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CDC Warns Of Fetal Alcohol Exposure, Says Drinking Any Time In Pregnancy Is Risky

(Source: “Vital Signs: Alcohol-Exposed Pregnancies — United States, 2011–2013")

(Source: “Vital Signs: Alcohol-Exposed Pregnancies — United States, 2011–2013″)

If you’re a sexually active woman of childbearing age and not using birth control, public health officials say you should stop drinking alcohol — completely. That includes beer, wine or any other alcoholic beverage you might be considering.

In a report out Tuesday,  the U.S. Centers for Disease Control and Prevention notes that exposure to alcohol, even in the first weeks of pregnancy, puts developing babies at risk for fetal alcohol spectrum disorders, “characterized by lifelong physical, behavioral, and intellectual disabilities.” Because these disorders are completely preventable by abstaining from alcohol, and because officials say there is “no known safe amount of alcohol” that women can drink at any time during pregnancy, their basic message is: “Why take the risk?”

“Women wanting a pregnancy should be advised to stop drinking at the same time contraception is discontinued,” the report concludes. “Health care providers should advise women not to drink at all if they are pregnant or there is any chance they might be pregnant.”

Here’s more from the CDC news release:

An estimated 3.3 million U.S. women between the ages of 15 and 44 years are at risk for exposing their developing baby to alcohol because they are drinking, sexually active, and not using birth control to prevent pregnancy, according to a new CDC Vital Signs report. The report also found that 3 in 4 women who want to get pregnant as soon as possible do not stop drinking alcohol.

Alcohol use during pregnancy, even within the first few weeks and before a woman knows she is pregnant, can cause lasting physical, behavioral, and intellectual disabilities that can last for a child’s lifetime. These disabilities are known as fetal alcohol spectrum disorders (FASDs). There is no known safe amount of alcohol – even beer or wine – that is safe for a woman to drink at any stage of pregnancy.

About half of all pregnancies in the U.S. are unplanned and, even if planned, most women will not know they are pregnant until they are 4-6 weeks into the pregnancy when they still might be drinking.

During a telephone briefing with reporters, Anne Schuchat, the CDC’s deputy director, said:

What we’re recommending is women who are not trying to get pregnant make sure they have a conversation about birth control and how to avoid becoming pregnant. If they are not using contraception and are fertile and are drinking they could be at risk… One in two deliveries in this country occurs to someone who wasn’t actually trying to get pregnant when they got pregnant. So we do think that fertile woman that are not using contraception ought to be aware that they may become pregnant and that drinking during even that first couple of weeks of pregnancy can be risky.

Continue reading

Zika Virus Prompts ‘Global Emergency,’ So Why Don’t U.S. Officials Sound Worried?

A doctor draws blood from Luana, who was born with microcephaly, at the Oswaldo Cruz Hospital in Recife, Brazil. Brazilian officials believe there's a sharp increase in cases of microcephaly and strongly suspect the Zika virus, which first appeared in the country last year, is to blame. (Felipe Dana/AP)

A doctor draws blood from Luana, who was born with microcephaly, at the Oswaldo Cruz Hospital in Recife, Brazil. Brazilian officials believe there’s a sharp increase in cases of microcephaly and strongly suspect the Zika virus, which first appeared in the country last year, is to blame. (Felipe Dana/AP)

By Richard Knox

The World Health Organization on Monday declared a “Public Health Emergency of International Concern” because of a fast-moving outbreak of serious birth defects and some cases of adult paralysis that appear to be connected to the Zika virus.

WHO Director-General Margaret Chan said the situation represents “an extraordinary event and a public health threat to other parts of the world.” The agency says the previously obscure virus has spread to 25 countries and territories in this hemisphere so far.

The declaration comes before definitive proof that the birth defects and neurological illness, called Guillain-Barre syndrome, are caused by the mosquito-borne virus. But Chan said it would be a mistake to wait until a causative link has been proven — or disproven.

“Can you imagine if we did not do all this work now, and waited until the scientific evidence comes out, then people would say…’Why didn’t you take action? Because the mosquito is ubiquitous,’ ” Chan said.

The WHO declared a similar emergency last year because of Ebola in West Africa — but was heavily criticized for waiting too long in that case.

About 4,000 children have been born in Brazil recently with microcephaly, a stunting of the brain and skull associated with severe cognitive defects — a 20-fold increase over the past year. Of these affected infants, 270 were born to mothers who had confirmed exposure to the virus. Brazilian officials estimate that 4 million people there could be infected with Zika in the coming year.

A declaration of public health emergency allows the WHO to release contingency funds to help affected countries track and count cases, explore the possible viral link, help develop a diagnostic test and possibly a vaccine, and intensify efforts to control the mosquitoes that transmit the Zika virus. The WHO does not recommend restricting travel to affected areas, though the Geneva-based agency reiterated its advice to pregnant women to avoid travel to areas where Zika virus is spreading.

Experts say it could take six to nine months to determine if Zika virus is responsible for the explosive increase in microcephaly and occasional cases of Guillain-Barre syndrome. That’s too long to be certain before next July’s Olympics in Brazil, ground zero of the Zika outbreak.

But increasingly few experts doubt that link. There appears to be no other good explanation why Brazil’s tally of microcephaly cases has ballooned from fewer than 200 in 2014 to more than 4,000 since then, while Zika infections in Brazil soared from zero to 1.5 million.

The rapidly evolving picture is not simple. On one hand, the World Health Organization calls the spread “explosive.” In just a few months, the virus has infiltrated 23 Latin and Central American countries. And there seems every prospect that Zika could become endemic in this hemisphere — that is, that it could be around for years to come.

“Zika is here to stay in the Western Hemisphere,” Michael Osterholm, of the Center for Infectious Disease Research and Policy at the University of Minnesota, wrote in The New York Times this weekend. “It will be part of life for many years to come.” Continue reading

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Investigating High C-Section Rates, Researchers To Examine Floor Plans

A woman’s chance of having a C-section can be almost three times higher from one hospital to the next in Massachusetts. But why? No one has the definitive answer. Researchers have looked at the ratio of doctors to nurses or midwives, at payment rates, at medical malpractice policies, at on-call schedules — and still the question lingers.

Could it be the layout of the labor and delivery unit?

Dr. Neel Shah, an associate faculty member at Ariadne Labs, began asking himself this question a little more than a year ago during a tour of hospitals. He watched nurses run down long hallways, from patient to patient. He noticed walls that divided patients, but also decision makers who might benefit from collaboration. And, he was struck by all the ways a labor and delivery floor mirrored an intensive care unit: one nurse per patient for women in active labor, machines that track vital signs in real time and medicines that are titrated minute to minute.

“The only difference between an ICU and a labor floor is that on the labor floor the ORs are attached,” Shah said. “So you’ve got the most intense treatment area in the entire hospital for the healthiest patients. It doesn’t take a rocket scientist to figure out why we overdo it.”

Lighting, furniture placement and waiting areas are not typically the focus of health care quality improvement projects, but maybe they should be.

Shah, working with architects at Mass Design Group, has a one-year grant from the Robert Wood Johnson Foundation to study how the design of a maternity ward affects C-section rates at 12 hospitals around the country. Continue reading

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Study: Maternal Obesity And Diabetes Bring ‘Multiple Hits,’ May Raise Autism Risk In Children

A provocative new study finds that children born to mothers with a combination of obesity and diabetes before and during pregnancy may have up to four times the risk of developing autism spectrum disorder.

On their own, obesity as well as pre-pregnancy diabetes or gestational diabetes increase the risk of autism slightly, researchers report. But the study suggests that co-occurring obesity and diabetes may bring “multiple hits” to the developing fetal brain, conferring an even higher risk of autism in the offspring than either condition on its own.

According to the U.S. Centers for Disease Control and Prevention, about 1 in 68 children has autism spectrum disorder, which also includes Asperger syndrome and other pervasive developmental disorders.

This new study — led by researchers at the Johns Hopkins Bloomberg School of Public Health and published in the journal Pediatrics — was based on analyzing the medical records of 2,734 children who have been followed from birth at the Boston Medical Center between 1998 and 2014. (Of that group, 102 of the children had a diagnosis of an autism spectrum disorder. )

So what might be leading to this increased autism risk? Researchers don’t really know, but they raise several theories in the paper. In general, the possible mechanisms relate to immune and metabolic system disturbances associated with maternal obesity and diabetes that might cause inflammation and other problems for the developing fetus.

One of the study authors, Daniele Fallin, an epidemiologist and chair of the Department of Mental Health at Hopkins’ public health school, said in an interview: “We know that both diabetes and obesity create stress on the body, generally, and a lot of that stress manifests in disruption of immune processes and inflammation. Once you have the disruption in the mom, that may lead to inflammation problems in the developing fetus, and inflammation during neurodevelopment can create problems that manifest as autism.” Continue reading

Why To Exercise Today: Minimizing ‘Menopause Misery’

(pennstatelive/Flickr)

(pennstatelive/Flickr)

A new report suggests a path toward reducing “menopause misery”: Give up your sedentary lifestyle.

A paper — titled “Sedentary lifestyle in middle-aged women is associated with severe menopausal symptoms and obesity,” and published online in the journal Menopause — looks at more than 6,000 women across Latin America ages 40-59. Researchers found that compared to active women, sedentary women (who made up about 63 percent of participants) reported more “severe” menopause symptoms, including hot flashes, joint pain, depressed mood and anxiety and other symptoms like sex problems, vaginal dryness and bladder problems.

Sedentary lifestyle was self-reported (always a possible red flag in a study like this) as less than three 30-minute sessions of physical activity per week; activities included walking, biking, running, jogging, swimming or working out.

Continue reading

Dr. Donald Thea On What We Know About The Zika Virus

For the first time, a Massachusetts resident has been diagnosed with the Zika virus.

He or she is from Boston and traveled in a country where the virus is being transmitted. The symptoms were mild, the patient did not have to be hospitalized, and is expected to make a full recovery.

Dr. Donald Thea, professor of global health and director of the Center for Global Health & Development at Boston University, joined WBUR’s Morning Edition to discuss the virus and this case in Boston.

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