By Robert W. Vera, MD, FACOG LCSW/LCDC – email: firstname.lastname@example.org
Our health is largely linked to our behavior. A recent article in City Beat dealt with how risky behaviors affect our health. Alcohol and drug abuse is risky behavior. It costs us our health and it costs society in broken families, homelessness, crime, poverty, the spread of infectious disease, human trafficking, and, in the big picture, it even affects governments through the influence of big money and cartel influence.
This City Beat issue will feature opioid use and addiction and what it is costing our communities.
Opioids are used to relieve the pain that comes with toothaches and dental work, injuries such as bone fractures, surgeries, and pain from chronic conditions(cancer, for example). Opioids work by altering the brain by creating artificial endorphins which are hormones produced by the brain and nerves. The body has opioid receptors for these naturally produced endorphins. Endorphins cause an analgesic action; they reduce pain. By creating ARTIFICIAL endorphins, opioids block pain and can also cause a euphoric good feeling.
Opioids, then, are a class of chemically related drugs. This class includes opium and heroin. It also includes legal pain relievers like oxycodone(Oxycontin), hydrocodone(Vicodin), codeine, morphine, fentanyl, paregoric, sufentanil, and tramadol. All of these interact with the natural opioid receptors in the brain. They are safe when taken for a brief time to relieve pain, but because they cause a person to feel good, to feel euphoric, they can be misused and taken in a different way, in a different dose, and taken without a prescription. Using the opioid often, daily, or regularly can lead to dependence. When abuse of the opioid continues to get that euphoric feeling, it can lead to needing higher doses to get the same feeling, addiction, overdose and even death. We hear about these deaths almost daily in our own community and nationwide. Affording this addiction can lead to family breakdown, loss of work, poverty, homelessness; all of this is a huge loss to the family and the community.
Symptoms of opioid use or addiction can be recognized. Many times the one abusing the drug does not realize that others recognize that there is something wrong. The changes one can see in opioid addiction include both physical and behavioral alterations and affect family life and employment. The clear sign for the user is not being able to stop from using more than the recommended amount of medication. Physical signs of addiction include poor coordination, sleepiness, shallow breathing which can progress to not being able to breathe at all. Other symptoms can be nausea, vomiting, constipation, moodiness, inability to make good decisions, irresponsible behavior(neglecting family or work), slurred speech, inability to sleep or sleeping too much, euphoria(a “high” feeling), depression, poor motivation for anything other than getting more drug, and anxiety attacks.
Overdosing on opioids can be, and often is, fatal. In an overdose situation, call 911. Overdose findings include unresponsiveness, slow breathing that can be irregular, no breathing noted at all, slow heart beat that can be irregular or no pulse at all, vomiting, conscientiousness, constricted(small)pupils. If there is Narcan available, spray it into the nostrils of the overdose victim. Narcan is an opioid antagonist; it will revive the overdose victim if given in time.
Treatment for the addiction is individualized. The objective is to help the addict stop using the drug and to avoid using it again in the future(avoiding relapse). This is called undergoing detox. Medications are used to relieve the withdrawal symptoms and to control the strong desire for the drug. Methadone, buprenorphine, and naltrexone are drugs used for these purposes. After undergoing detox, psychiatric management of depression is needed as are strategies to avoid opioids, to avoid cravings, and to heal the damaged family and other relationships. The addict has to realize eventually that he or she is in control of their own behavior, not the opioid. The addict must commit to stop using the drug and to get help from the doctor or counselors to get support. Help is also available from organizations dedicated to those with addictions.
The costs to society from opioid addiction and all the collateral damage caused by the addiction, is enormous. Nationwide the cost of addiction in 2015 was $504 billion. This information is from the Council of Economic Advisers, which is an agency that is part of the Executive Office of the President of the United States. In 2015:
50,000 people died of drug overdose
66%, or about 33, 000, were opioid overdose deaths.
This is four times the opioid overdose deaths reported in 1999(from the C.D.C.)
Health care, criminal justice, and lost productivity costs of opioid abuse run into billions of dollars per year. In 2013, two million Americans were abusing and dependent on opioids. In that same year, 16,000 died from prescription overdoses. In this year(2016), the National Center for Injury prevention and Control estimated opioid overdose costs, costs of abusing opioids, and opioid dependence costs, totaled $78.5 billion. In comparison, the Supplemental Nutrition Assistance Program(SNAP) cost $79.9 billion that same year.
In an article in the American Journal of Pharmacy Benefits, it was reported that patients with untreated opioid problems incurred $18,000 more in health care costs annually compared to those that had no such problem.
A study from Beth Israel Hospital Deaconess Medical Center in Boston showed that the cost of treating a patient with an opioid overdose in the Intensive Care Unit increased 58% from 2009 to 2015. In 2015, 162 academic hospitals cared for opioid overdose victims in Intensive Care Units at an average cost of $92, 400 per patient.
The Criminal Justice in our country is, obviously, having to deal with the opioid abuse. Illegal selling and use of opioids cost the United States Criminal Justice $8 billion on related costs. This information comes from the 2015 study by the National Center for Injury Prevention and Control. It is disappointing to know that recidivism runs as high as 45% within 3 years of release from prison.
Perhaps, business loses the most from workers that abuse opioids. In 2015 alone, $20 billion was wasted in lost production. Seven out of ten employers have noted some effect of prescription drug usage among their employees, which includes being absent from work and decreased work performance, according to a study by the nonprofit National Safety Council in Illinois. Overdoses that are fatal cost nearly $22 billion in health care costs and lost productivity.
There are, obviously, unseen costs. These costs consist of the impact on the quality of life of the opioid user and the effect that abusing the opioid has on the family and the community. I will leave you with this link to a video that will illustrate this more clearly than words on a page: www.stopthespiral.com.
In summary, opioid abuse and addiction is a national tragedy and a national emergency. Lives are being lost at an alarming rate and communities are being impacted by the care for those that are addicted. There is help available if the individuals will submit to treatment by first admitting that there is a serious threat to their health, welfare, family life, and financial well being because of the control the opioid has over them. President Donald Trump sympathizes with the damage that is happening in our country due to opioid abuse and addiction. He has stated, “No part of our society, not young or old, rich or poor, urban or rural, has been spared this plague of drug addiction.”
LaMagna, Maria. The Opioid Epidemic is Costing the U.S. More Than $500 Billion Per Year. March 11, 2018.
So much has been accomplished to help you lead a long productive life. Vaccinations protect you against disease that once killed many. Our plumbing system protects you against many contagious diseases. Research and development has led to medications that can cure disease or prolong life. Surgery and anesthesia have been expanded to areas not feasible before and have been made safe. The country has expanded its education and training programs to provide enough doctors, nurses and other health professionals to be available. Trauma centers have been set up to save those with serious injuries.
With all this available to the individual for their protection against disease or injury that would otherwise cut life short, why do certain individuals engage in risky behavior that places health in danger? It is a question that puzzles the medical community because there is no prevention for someone wanting to endanger their life through activities or habits in which they willingly engage. Obviously, diseases and injury arising from risky behavior are completely preventable for the most part.
Behaviors that endanger health include: smoking, driving too fast, not using seat belts in the car, drinking alcohol to excess, poor diets, poor dental care, careless sexual activity, not getting enough rest, using drugs and poor hygiene. Engaging in risky behavior can result in poor health or worse, premature death. Addressing all these issues cannot be done in this space. However, let us turn our attention to the leading causes of death and disability in the United States to see just how huge risky behavior costs us as a nation. It makes us poorer not only economically, but affects us by decreasing our quality of life, and in some cases, causing loss of productivity or premature death.
The leading causes of death and disability are heart disease and stroke, cancer, diabetes, obesity and arthritis. These causes are largely preventable. There may be a small percentage of the population that will have genetic tendencies, but a lifelong commitment to a good diet, omitting smoking, using alcohol in moderation, getting enough exercise would go a long way to prevent a person from acquiring the these diseases. It seems simple enough, yet these are the leading causes of death and disability. Obesity and breast cancer were discussed in detail in the previous issues of City Beat Magazine. Those articles will be referenced here.
Data from 2012 shows us that about 50% of all adults had one or more of these chronic diseases mentioned above. These diseases made up for about 70% of all causes of death in 2014 with heart disease and cancer as leading causes.
These diseases do not exist in isolation by themselves. Most are linked to each other. For example, diabetes can lead to heart disease or stroke. Obesity can lead to diabetes, certain cancers and arthritic joint conditions. Obesity itself, then, can lead to diabetes, heart disease, stroke, cancer and arthritis. Obesity is, obviously, preventable by taking in the same amount of calories that the body expends. To lose weight, then, one would have to take in less calories than one expends or to expend more calories than one takes in. In other words, you need to exercise and eat right. There is no other way around this. Stop reading about diets and special fat burning foods.
Obesity, the amount of body fat, can be estimated by using charts based on height and weight. A Body Mass Index of up to 24.9 is normal. A Body Mass Index of 25-29.9 is overweight. A Body Mass Index of 30+ is obese. A Body Mass Index of 40+ is extreme obesity. Body Mass Index calculators are available online.
We know what will happen to the health of an obese person. It is not a mystery. Heart disease, stroke, diabetes, dangerous clots in the veins, joint disease, metabolic syndrome, infertility and certain cancers are all linked to being overweight. Other health issues arise such as obesity complicating surgery and postoperative poor wound healing and increase risk for postoperative infections. The cancers linked to obesity are numerous; 14 types of cancer have been linked to obesity: meningioma, thyroid, esophageal, liver, gallbladder, stomach, kidney, pancreatic, colon, rectal, prostate, multiple myeloma, endometrial (cancer of the uterus), ovarian and postmenopausal breast. There is a huge risk to a healthy life from being obese, yet 79% of Hispanics are overweight or obese. For African-Americans, that number is 76.7%. For Caucasians, 66.7% are obese. Clearly, our population is heading for a health crisis because of obesity and this is largely preventable.
Arthritic conditions are the most common cause of disability in the United States. Fifty-four million people are diagnosed with arthritis. Just under half of those report having to limit their usual daily activities because of pain or limitation of movement. The risky behaviors associated with arthritis are those that lead to obesity and limited physical activity.
Diabetes is another major problem since a large percentage of adults are obese, which can lead to diabetes. It is the leading cause of kidney failure, leading to dependence on dialysis machines or a kidney transplant. All of these interventions are costly. Diabetes is also one of the leading causes of amputations of the lower limbs because it is primarily a disease of blood vessels, causing injury to the vascular system, which include the kidneys, legs and eyes. It’s is the leading cause of blindness in adults. The risky behaviors associated with the diabetes have to do with those that lead to the development of obesity, which are, as mentioned already, largely due to physical inactivity and a poor diet.
Smoking has a huge negative impact on health. It is associated with cancers located wherever the bloodstream carries the tobacco carcinogens (cancer causing chemicals in tobacco). Lung, blood, kidney and urinary bladder cancers are caused by smoking. Cancer of the cervix in women, one of the most common, is related to tobacco use. If the smoker is able to avoid these cancers, the chances are good that chronic obstructive pulmonary disease (COPD for short) will develop. It develops because the tobacco smoke slowly destroys the air sacs in the lung. The air sacs are responsible for getting oxygen from the air and transporting it via the red blood cells to the body. A person with COPD slowly suffocates as his lungs cannot get oxygen to the red blood cells. Smoking is a risk to your health that you should avoid, obviously.
Unhealthy (Risky) behavior is behavior YOU CAN CHANGE. You can change the course of your life to one dominated by good quality living and avoidance of a sickly future. These risky behaviors, to summarize, are not getting proper exercise, not eating a good diet, tobacco use and drinking alcohol excessively. These behaviors cause chronic disease and much of the unnecessary suffering, sickness, and premature death in our country.
Almost 90% of the United States’ $3 trillion annual health care costs go to caring for individuals with chronic health conditions, both mental and physical. As we have discussed so far, these conditions can be traced back to risky behavior and, therefore, most of this suffering and cost is not necessary.
Some of these costs break down like this:
Total cost for care of cardiovascular disease is $316 billion in 2012-2013.
Total cost for cancer care was $157 billion in 2012.
Total cost for diabetic care in 2012 was $245 billion.
Total costs for the care of arthritic diseases were $128 billion.
The total costs for the care of obesity related health problems were 4147 billion from 2006 data.
The total cost for smoking and tobacco related diseases from 2009-2012 was $300 billion.
Alcohol health care costs in 2010 were $249 billion. Most of the cost was from binge drinking.
These costs include lost earnings and loss of productivity.
A healthier lifestyle, one that limits risky behavior, can cut out a lot of premature death and suffering. In 2015, 40 percent of adolescents and adults said they ate fruit less than once a day. A recommended fruit and vegetable diet is important in preventing many cancers as well as preventing obesity, diabetes and heart disease, and stroke.
Cigarette smoking causes almost half a billion deaths each year in the United States. This is a huge burden on our families and our nation as costs add up in the care of the smokers’ different chronic diseases, including lung and heart disease, stroke, and a number of cancers. Don’t start smoking. Drinking alcohol excessively causes 88,000 deaths each year. Half of these deaths are due to binge drinking.
*Risky behavior can lead to chronic disease, pain, suffering and it can lead to premature death. Most of these heath care issues and their huge costs could be eliminated by eliminating risky behavior.
*Risky behavior involves choices. Do I drive fast or follow recommended speed limits? Do I use seat belts or ignore their proven safety? Do I try to eat right and exercise or do I think my body is different from everyone else’s and can withstand the daily impact of poor dieting and restricted physical activity?
Here are some recommendations from Cancerprogressreport.org to change your risky behavior lifestyle:
*Be as lean as you can be without being underweight.
*14 types of cancers are linked to being obese.
*For 30 minutes every day, be physically active.
*Physical activity can not only decrease you chance for getting cancer, but also decrease stroke, heart attack, and vessel disease.
*Stop eating foods that are energy dense like fatty foods, foods high in sugar, foods low in fiber, and sugary drinks because these will lead to obesity.
* A diet that will lead to healthy weight is one of a variety of vegetables, fruit, whole grains, and beans as these foods are low in energy density.
* Limit red meat and stay away from processed meat and foods (hot dogs, bacon, and salami) as these foods are a known risk factor for colon cancer.
* Limit alcohol. Alcohol is a risk for 7 cancers: breast, colorectal, esophageal, liver, stomach, mouth, and throat cancers.
*Do not smoke.
By Robert W. Vera, MD, FACOG LCSW/LCDC and Mona Baeza, MSN, APRN, FNP-C.
THERE IS NO PREVENTION FOR BREAST CANCER, ONLY EARLY DETECTION
October is breast cancer awareness month. As you see your medical provider this month for your yearly examination, pap smear and breast exam, here are some pointers to make your visit more useful and beneficial.
There is an organized way your medical provider approaches your visit and your examination.
A “HISTORY” is taken:
The HISTORY OF THE PRESENT ILLNESS is asked first: Do you have any current problems or is this a yearly checkup?
FAMILY HISTORY comes next: Is there any disease that seems to run in the family? Is there anyone currently sick in the family? The family history is very important and will be discussed further below. Take some time to think about your family history as far back as can be remembered.
MEDICAL HISTORY: What medicines are you taking and for what reason? Sometimes there are medical problems that do not require medicines, but these conditions are important to mention.
SURGICAL HISTORY follows: Have you had any surgeries that are important to mention? Prior surgeries can be used as a guide to look for other problems during the examination.
SOCIAL HISTORY: This is important. Questions such as tobacco use, alcohol consumption, drug usage, sexual history should be mentioned.
All of this “history” given to your medical provider will allow for evaluation of any future problems you may encounter as well as to check for any risky behavior. Risky behavior may cause future problems and should be eliminated (smoking, using drugs, not wearing seat belts, too much alcohol, eating poorly and being overweight are some examples of risky behavior). These can be straight forward to understand. For example, having had gallbladder surgery, which is common in El Paso, may point to a risky dietary habit which can lead a medical provider to evaluate for heart or blood vessel disease as they can be related. A history of chronic tiredness may point to sleep apnea which can be associated with the development of diabetes, high blood pressure and cardiovascular disease.
Breast Cancer Awareness Month, let us discuss family history and breast cancer. A family history of breast cancer, ovarian cancer, endometrial cancer (cancer of the uterus), colon cancer and other glandular cancers (pancreas and prostate cancers) is concerning because these cancers may have a hereditary cause. In other words, cancers that run in the family, such as the ones mentioned, have a good chance of being caused by abnormalities in the family’s DNA. DNA is the molecule that passes traits from one generation to the next. Breast cancer, as already mentioned, can be one of those cancers that is passed genetically. It is usually a disease of the postmenopausal woman, that is, it usually starts during menopause (age 55 and up). Breast cancers that run in the family (hereditary cancers) tend to start earlier in a woman’s life (age 30 or 40 years) and tend to have a more aggressive growth than the postmenopausal cancer. These breast cancer genes (in the DNA) can be tested using proven DNA analysis techniques in the laboratory. These genes repair DNA or help control the cells in our body when they divide, so that the DNA has a chance to be repaired. What this means is that certain family histories can be a signal for your medical provider to offer certain genetic testing to evaluate your risk of getting a cancer. This information is not only important for you, but also, for your mother, father, daughters and sons. So, if you have a mother, sister, aunt and/or grandmother with breast cancer, uterine cancer, ovarian cancer, pancreatic cancer, or colon cancer then it is important to mention it to your medical provider and let him/her decide with you if this is indeed important history to have genetic testing. It would also be worthwhile to mention any cancers that the males in the family seem to get. These genes are autosomal dominant, meaning that one out of every two family members may be affected and this includes the women and men in the family. It is important to remember that about 3,000 men in the United States get breast cancer every year, while 250,000 women will get it yearly. Certainly, family history and possible need for genetic testing is even more important if you have had breast cancer before menopause yourself. Genetic testing will allow your family to be PROACTIVE about cancer, rather than reactive.
The breast exam will allow your medical provider to assess for lumps or thickening in the breast that you have noticed. Nipple discharge, skin changes, or any lumps under your axilla (the armpit) should also be brought to attention. It is necessary to report any changes you may have noticed in your breasts. Pain in the breast is usually not associated with breast cancer unless it is advanced disease.
Now, I am going to give you some information on why early detection of breast disease is so important to you. The smallest lump in the breast that can be felt by you or your medical provider is about one centimeter in size. That is about the diameter of a dime or penny. We know how a tumor grows and we know that by the time it is a centimeter in size, it has already been present in the breast for ten years. Yes, ten years! That is very concerning. The best technology we have for early detection of breast cancer is the mammogram. Mammography uses low dose x-rays to find abnormalities in the breast. To understand how mammography detects a small tumor, once again you must understand how long it takes a tumor to grow to the size that it can be detected by a mammogram. A tumor has to grow to a certain size to be able to be detected by a mammogram. Cancer in the breast has to grow about 7 years before it can be “seen” by our technology, the mammogram. This, nonetheless, is “early detection” of a breast tumor.
If a mammogram discovers an early cancer, however, it is most likely still confined to that breast and if it is still confined to that breast, then the patient has very close to a 100% survival chance. Saying it another way, if detected early while still confined or limited to only the breast, the chance for cure is almost 100%. This is why early detection is so important and why it is valuable to mass screen the population, that is, to screen women with or without symptoms, with mammography. It is because the “early cancer” that a mammogram can find cannot be felt and usually have no symptoms. It is valuable because “early detection” can lead to close to 100% survival. When breast cancer leaves the breast and spreads to the lymph nodes or to more distant organs (the lung or the bone, for example), the ability for cure is less certain; the chances for cure decrease. The treatments for metastatic breast cancer, cancer that is NOT confined to the breast, have improved significantly. Research on the cancer cell has led to cancer fighting medication and agents that are much more targeted now, instead of being generalized where everyone used to receive the same treatment just a few years ago. Survival rates for metastatic breast cancer have improved over the last decade. We continue to learn more about the disease, how to treat it, and how better to manage the complications.
In summary, the take home message is in the title. There Is No Prevention for Breast Cancer. There Is Only Early Detection and early detection can lead to cure. Go to your appointment with open eyes and knowledge of your family history. Genetic testing is available. Know that you are doing all you can do for yourself and your family by understanding your family history, available genetic testing, and getting early detection with mammography.
Dr. Vera has been on staff at San Vicente Clinic since July 2017. El Paso, Texas, National Super Doc from 2006-2016. Recipient of several national teaching awards at Texas Tech El Paso. Teaching Staff at Texas Tech University Health Sciences Center in El Paso from 1989 to 2016. Chief of Gynecologic Surgery at Texas Tech-El Paso for 15 years. Medical Director of the Brownsville Community Health Center 1988-89. Obstetrician/Gynecologist at the Brownsville Community Health Center 1985-89. National Health Service Corp 1981-1985. Texas Tech Health Sciences Center-El Paso 1981-1985. Residency in Ob/Gyn. Texas Tech Health Sciences Center-El Paso 1981-1985. Residency in Ob/Gyn. University of Texas Southwestern Medical School. 1981. Medical Doctor UTEP 1977. BS in biology. Minor chemistry. Who’s Who among American Colleges and Universities 1977. Irvin HS 1971. Member of the Downtown Lions Club.