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Daily Archives: January 9, 2018

An Imperfect Vaccine, A ‘Bad Strain’, And Cold Weather Combining To Trigger Rough Flu Season

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Foster Care Services Struggling Because Of Gaps In States’ Data On Opioid Crisis

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First Edition: January 9, 2018

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Defending Against This Season’s Deadly Flu: 5 Things To Know Now

The nation is having a Terrible, Horrible, No Good, Very Bad flu season.

Flu is widespread in 46 states, according to reports to the U.S. Centers for Disease Control and Prevention (CDC).

Nationally, as of mid-December, at least 106 people had died from the infectious disease.

In addition, states across the country are reporting higher-than-average flu-related hospitalizations and emergency room visits. Hospitalization rates are highest among people older than 50 and children younger than 5.

In California, which is among the hardest-hit states, the virus struck surprisingly early this season. The state’s warmer temperatures typically mean people are less confined indoors during the winter months. As a result, flu season usually strikes later than in other regions.

Health experts aren’t sure why this season is different.

“We’re seeing the worst of it right now,” said Dr. Randy Bergen, a pediatrician who is leading Kaiser Permanente-Northern California’s anti-flu effort. “We’re really in historic territory, and I just don’t know when it’s going to stop.” (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Here are five things you should know about this flu season:

1. It’s shaping up to be one of the worst in recent years.

The H3N2 influenza A subtype that appears to be most prevalent this year is particularly nasty, with more severe symptoms including fever and body aches. Australia, which U.S. public health officials follow closely in their flu forecasting â€” in part because their winter is our summer — reported a record-high number of confirmed flu cases in 썡. Another influenza B virus subtype also is circulating, “and that’s no fun, either,” Bergen said.

Flu season in the U.S. typically starts in October and ends in May, peaking between December and February.

2. This season’s flu vaccine is likely to be less effective than in previous years.

U.S. flu experts say they won’t fully know how effective this season’s vaccine is until the it’s over. But Australia’s experience suggests effectiveness was only about 10 percent. In the U.S., it is 40 to 60 percent effective in an average season. Vaccines are less protective if strains are different than predicted and unexpected mutations occur.

3. You should get the flu shot anyway.

Even if it is not a good match to the virus now circulating, the vaccine helps to ease the severity and duration of symptoms if you come down with the flu.

Children are considered highly vulnerable to the disease. Studies show that for children a shot can significantly reduce the risk of dying.

High-dose vaccines are recommended for older people, who also are exceptionally vulnerable to illness, hospitalization and death related to the flu, according to the CDC.

“Some protection is better than no protection,€ Bergen said, “but it’s certainly disappointing to have a vaccine that’s just not as effective as weâd like it to be.

Shots may still be available from your doctor or local health clinic, as well as at some chain drugstores. Check the Vaccine Finder website  for a location near you.

4. Basic precautions may spare you and your family from days in bed.

As much as possible, avoid people who are sick. Wash your hands frequently and avoid touching your mouth, nose and eyes.

Masks aren’t particularly effective in keeping you from catching the flu, although they mayhelp keep sick people who wear them from spreading their germs further.

If you are sick, cover your cough and stay home from work if you can, Bergen said. Remaining hydrated, eating nutritious foods and exercising can also help strengthen your immune system.

Because elderly people are so vulnerable to the flu, some nursing homes and assisted living facilities may limit visitors and resident activities, depending on the level of illness.

5. Don’t mistake flu symptoms for those of a common cold.

The hallmarks of flu are fever and body aches that accompany cough and congestion, Bergen said.

If you feel as if you’re having trouble breathing, or if your fever can’t be controlled with medication like Tylenol, check with your doctor. Itâs even more important for patients to see a doctor if they have a chronic medical condition like diabetes or heart disease, or if they are young or elderly.

Kaiser Permanente doctors now are being advised to prescribe antiviral drugs like Tamiflu — given as a pill or, for kids, an oral suspension — even without a lab test for influenza, Bergen said. According to a report in the Los Angeles Times, however, Tamiflu supplies are running low.

And Bergen cautioned that these medications are only partly effective, reducing the time of illness by just a day or two.

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VA Clears The Air On Talking To Patients About Marijuana Use

“Don’t ask, don’t tell” is how many veterans have approached health care conversations about marijuana use with the doctors they see from the Department of Veterans Affairs.

Worried that owning up to using the drug could jeopardize their VA benefits — even if they’re participating in a medical marijuana program approved by their state — veterans have often kept mum. That may be changing under a new directive from the Veterans Health Administration urging vets and their physicians to open up on the subject.

The new guidance directs VA clinical staff and pharmacists to discuss with veterans how their use of medical marijuana could interact with other medications or aspects of their care, including treatment for pain management or post-traumatic stress disorder.

The directive leaves in place a key prohibition: VA providers are still not permitted to refer veterans to state-approved medical marijuana programs, since the drug is illegal under federal law, with no accepted medical use.

That disconnect makes veterans wary, said Michael Krawitz, a disabled Air Force veteran in Ironto, Va., who takes oxycodone and marijuana to treat extensive injuries he suffered in a non-combat-related motorcycle accident while stationed in Guam in 1984.

“Vets are happy that there’s a policy, but they’re unnerved by that prohibition,” he said.

Krawitz, 55, is the executive director of Veterans for Medical Cannabis Access, an advocacy group. He has always been open with his VA doctors about his medical marijuana use and hasn’t suffered any negative consequences. But Krawitz said he has worked with veterans who have been kicked out of their VA pain management program after a positive drug test and told they couldn’t continue until they stopped using cannabis.

Such actions are usually misunderstandings that can be corrected, he said, but he suggests that the Veterans Health Administration should provide clear guidance to its staff about the new directive so veterans aren’t harmed if they admit to using marijuana.

Although the new guidance encourages communication about veterans’ use of marijuana, the agency’s position on the drug hasnât changed, said Curtis Cashour, a VA spokesman.

Cashour referred to a quote from Veterans Affairs Secretary David Shulkin at a White House briefing last May, who said he thought that among “some of the states that have put in appropriate controls [on the use of medical marijuana], there may be some evidence that this is beginning to be helpful. And we’re interested in looking at that and learning from that.” But until federal law changes, the VA is not “able to prescribe medical marijuana.”

Cashour declined to provide further information about the new directive.

Under federal law, marijuana is classified as a Schedule 1 drug, meaning it has no accepted medical use and a high potential for abuse. Heroin and LSD are other Schedule 1 drugs. Doctors aren’t permitted to prescribe marijuana. Instead, in states that have legalized the use of medical marijuana, doctors may refer patients to state-approved programs that allow marijuana use in certain circumstances. (Doctors can, however, prescribe three drugs approved by the Food and Drug Administration that are made of or similar to a synthetic form of THC, a chemical in marijuana.) 

Twenty-nine states and the District of Columbia have laws that allow people to use marijuana legally for medical purposes. Patients who have a disease or condition that’s approved for treatment with marijuana under the law are generally registered with the state and receive marijuana through state-regulated dispensaries or other facilities.

Moves by states to legalize marijuana for medical or recreational use have created a confusing landscape for patients to navigate. Attorney General Jeff Sessions announced last week he would rescind an Obama-era policy that discouraged federal prosecution for marijuana use in states where it is legal. That action has further clouded the issue.

Some consider caution a good thing. The accelerating trend of states approving marijuana for medical and recreational purposes may be getting ahead of the science to support it, they say.

A report released last January by the National Academies of Sciences, Engineering and Medicine examined more than 10,000 scientific abstracts about the health effects of marijuana and its chemical compounds on conditions ranging from epilepsy to glaucoma. The experts found conclusive evidence for a relatively limited number of conditions, including relief of chronic pain, nausea and vomiting associated with chemotherapy and muscle spasms associated with multiple sclerosis.

“I believe that there are chemicals in marijuana that have medicinal properties,” said Dr. Otis Brawley, chief medical officer at the American Cancer Society. “I would love to know what those are, what their medicinal properties are and what the dose should be.” But, he said, studies are extremely challenging to do because of restrictions in the United States on conducting research on Schedule 1 drugs.

No matter where the research stands, getting a complete medication or drug history should be standard procedure at any medical appointment, say medical providers.

In that respect, the guidance from the VA is a positive development.

“It’s absolutely critical that you know what your patients are taking, if only to be better able to assess what is going on,” said Dr J. Michael Bostwick, a psychiatrist at Mayo Clinic in Rochester, Minn., who has written on medical marijuana use.

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Her Sister’s Keeper: Caring For A Sibling With Mental Illness

When sisters Jean and Ruby were growing up in Harlem, they invented a game of make-believe called “Eartha.” The little girls would put on their prettiest dresses and shiniest shoes and sit down to tea as grown-up ladies. They discussed details of their hoped-for husbands and children, and all the exciting things they would do together.

But 45 years later, the sisters’ lives are nothing like they imagined. Ruby Wilson, 54, has paranoid schizophrenia and lives in an assisted living facility in North Carolina. Her sister Jean Moore, 57, is her legal guardian.

“You have all these thoughts about how things should be, could be, how you’d like them to be. And they’re just not going to be,” says Jean, a nonprofit consultant who lives in Maryland.

Few bonds are as tight as those between sisters, and despite everything, Jean and Ruby remain close. “Our bond is inseparable. It feels like more than just two separate things bonded together. It feels like you’re really in there — you know, when you put sugar in tea and it dissolves? Yeah, it’s like that,” Jean explained.

Jean Moore (left) visits her sister Ruby Wilson in Clinton, N.C. “Our bond is inseparable. … You know, when you put sugar in tea and it dissolves? Yeah, it’s like that,” Jean says. (Andrew Craft for Kaiser Health News)

But their relationship, marred by mental illness, has not been simple. Being Ruby’s guardian and caretaker is an enormous responsibility, and even all these years later, Jean still mourns the loss of the life her sister might have had.

Tight-Knit And €˜Always On Time’

On a sunny day this winter, Jean made the five-hour drive from Maryland to see her sister in the small town of Clinton, N.C., just east of Fayetteville.

Ruby sat in her room alone, wearing a denim dress with her hair piled high on her head and her nails painted red. She gave her sister a wide, gummy grin. After 30 years cycling in and out of hospitals, group homes, assisted living facilities and sometimes the street, Ruby has lost most of her front teeth. Jean smiled back, squeezing Ruby’s shoulders. These days, Ruby has few other visitors.

“Jean is splendid,” said Ruby. “She’s always on time. She™s very considerate. She’s very caring. She’s very nurturing. She’s really like a mother figure to me.â

Jean was surprised by Ruby’s words of praise. â€There are times when Ruby will say I’m not her sister. So this is a good day,” she said and gave a half-hearted laugh.

You have all these thoughts about how things should be, could be, how youd like them to be. And they’re just not going to be.

Jean Moore

Things Come Undone

On the back patio of the facility, surrounded by a chain-link fence, Ruby said that she and her sister, just two years apart, were raised “almost like twins.”

“They used to say our name as JeannieandRuby. It was like one person,” added Jean. They dressed in identical outfits and went together to piano lessons and ballet classes.

But when the girls became teenagers, their lives began to diverge. Jean was focused on school, while Ruby was more of a social butterfly. In high school, Ruby started spending time with kids their mother worried were a bad influence and started experimenting with drugs.

Ruby had her first baby at age 17 and quickly fell into a depression. As sadness descended into psychosis, she was diagnosed with paranoid schizophrenia. Whenever she had a psychotic episode, Ruby would be hospitalized. But her treatment was scattered and inconsistent over the next 35 years, and she continued to spiral downward.

Ruby Wilson (left) and her sister Jean Moore sip drinks as they talk about family. Ruby has paranoid schizophrenia and Jean is her legal guardian. (Andrew Craft for Kaiser Health News)

Schizophrenia affects about 1 percent of Americans and is believed to be caused by a combination of genetic and environmental factors. Patients often suffer from hallucinations, delusions and difficulty focusing; usually, symptoms begin between 16 and 30 years old.

Ruby moved with the baby from New York to the small city of Washington, N.C., where the sisters’ grandmother lived. Two years later, Ruby lost custody of her son, and he was sent back to Harlem to live with her mother. Ruby stayed in North Carolina, and ended up homeless. She was self-medicating with illicit drugs, eating at food kitchens and staying in shelters.

But for Jean, one thing is certain: “Ruby’s a survivor.” On average, women with schizophrenia die 12 years earlier than the general population.

Meanwhile, Jean went to college, got married and spent a decade in the military overseas, where, inspired by her sister, she asked to work in behavioral health for military personnel and their families. She went to law school, got divorced and spent a few years doing development work in Africa. By the time Jean returned to the United States and met her second husband, Ruby had become estranged from the family and was living on her own in North Carolina.

“I just couldn’t stand knowing she was in that condition and not getting the help she needed,” said Jean. So she drove down to North Carolina to find her sister. It’s a small town, and after asking around, she found Ruby walking the streets.

Jean Moore (left) fixes her sister’s collar while taking a break from shopping on Oct. 12, 2017, in Clinton, N.C. (Andrew Craft for Kaiser Health News)

Jean Moore, a nonprofit consultant who lives in Maryland, regularly makes the five-hour drive down to Clinton, N.C., to be with her sister Ruby. (Andrew Craft for Kaiser Health News)

‘Like Staying On A Wild Horse’

An estimated 8.4 million Americans are caregivers to adult loved ones with a mental illness, most often a son or daughter, parent, spouse or sibling.

“Caregiving situations for siblings pack an extra emotional punch for the caregiver,” said John Schall, who runs the Caregiver Action Network, a nonprofit organization that supports people providing care to loved ones. “Its not unusual for us to think at some point of being the caregiver for our elderly parents, but it’s a whole different thing to be a caregiver for a sibling who we always thought of as equals.”

When it comes to caring for Ruby, “Jeannie has always been the lead,” said Ardella Wilson, Jean and Ruby’s older sister. Jean visited North Carolina as often as possible to “scout Ruby out” and make sure she was surviving. “Jeannie knows how to talk to her,” added Ardella. Ruby would sometimes make biting comments to both her sisters, but Jean always seemed to come up with the right response that allowed them all to move on.

At first, Jean’s role caring for her sister and trying to manage her medical treatment was unofficial. But in 2010, Jean got a call from a case manager: Ruby would become a ward of the state unless Jean wanted to become her legal guardian. So, Jean stepped up, formalizing the role she’d been serving for years.

One in 3 caregivers of people with mental illness have some type of legal responsibility for a loved one, such as guardianship or power of attorney.

The new role gave Jean more power to get access to Ruby’s health information and to help keep her safe, but finding the appropriate care for Ruby remained an challenge. You have to be so proactive as a guardian. It’s a full-time job,” said Jean.



In addition to her responsibilities for Ruby, Jean was trying to get her own career off the ground in Maryland. She wanted to pass the bar exam so she could become a practicing lawyer, but there was always something else to handle. It wasn’t just her sister. Although Jean never had children of her own, she stepped in to help take care of Ruby’s now three children, supporting them emotionally and financially. The youngest came to live with her in high school, and over the years, Jean had become an important figure in the lives of Ruby’s grandchildren as well.

In the past, hundreds of thousands of patients like Ruby were housed in state mental hospitals. Most of those hospitals were closed beginning in the 1960s, as part of the “deinstitutionalization” movement to get people with mental illnesses back into the community. Today, alternative housing arrangements can be scarce and imperfect, leaving many people with serious mental illnesses homeless or in jails or shelters. Jean didn’t want that for her sister.

But each time she tried to get help for Ruby, something seemed to go wrong. Ruby would refuse to take medication and then disappear for long periods, only resurfacing when she was arrested or sent to a psychiatric hospital. “For a while, it was like a revolving door in and out of the hospital,” Jean recalled.

Every time Ruby was discharged, it was an enormous struggle to find somewhere for her to live. Part of Ruby’s mental illness is that she doesn’t recognize she is sick, which made her a difficult patient; she refused to take her medications and tried to run away several times.

Some facilities refused to accept her because she was considered a flight risk. Others said they were full or did not accept her insurance. Others were unaffordable; the money Ruby gets each month from Social Security often wasn’t enough to pay for the cost of the private facilities where space was available.

The hospital staff would call dozens of group homes and assisted living facilities before landing on one that would agree to accept Ruby. Those placements never lasted long. The facilities claimed to be secure, but Ruby would inevitably run away and end up back at another psychiatric hospital, only to repeat the process. “It’s like staying on a wild horse,” said Jean. She started to worry that the right place for Ruby might not exist.

“The options [for mental health services] now are almost nonexistent in many ways,” said Jane Hamilton, a psychiatric nurse who runs Partners on the Path, an organization that provides support to caregivers. “People in rural settings have a harder time than people in an urban setting,” because there are fewer facilities. “But the funding for mental health care is not adequate anywhere to meet the needs of the people who need support. So people fall through the cracks.”

A Place For Ruby

During a recent hospitalization, Ruby received an additional diagnosis of memory loss and was accepted into the locked memory unit of the assisted living facility in Clinton, which is usually reserved for dementia patients. It’s the most secure facility she’s been in so far, and Jean is pleased with her progress over the past year. Ruby has become more stable, even-tempered, personable and pleasant. Her old sense of good humor has started to return.

Still, the situation at Ruby’s assisted living facility is not ideal. The other residents are elderly and many are nonverbal, ravaged by years of Alzheimer’s disease and dementia. Ruby is lonely.

The sisters talk every week, but Jean has time to visit only every month or so, and then she can stay only a day. She worries it isn’t enough.

What just kind of rises to the top for me is this enormous amount of love that I have for my sister.

Jean Moore

Ruby has few other visitors. It’s hard for their 92-year-old mother to make the trek from the apartment in Harlem where she still lives. Ruby has 11 grandchildren and a great grandchild who live in North Carolina and Maryland, but she hasn’t seen them in years.

That means Jean is Ruby’s last real link to the outside world, and her visits are the only time Ruby gets to leave the facility.

The sisters tease each other, reminisce about playing dress-up as little girls and giggle conspiratorially about the oversized undergarments their mother sometimes sends.  When Ruby drifts onto a tangent that can be hard to follow, Jean quickly brings her back. She seems to understand and follow Ruby’s logic, even when it seems convoluted.

The Challenges Of Caregiving

Later, after dropping Ruby back at the facility, Jean explained that while she’d like to be closer to Ruby, she worries about finding the right facility in Maryland and fears that the state might not want to pay for a costly patient from another region.

Resources For Caregivers

More than half of caregivers are dissatisfied with the availability of mental health community services where their loved one lives, and three-quarters feel high emotional stress.

Here are a few resources to try if you need help:

  • National Alliance on Mental Illness
  • Caregiver Action Network
  • Partners on the Path
  • AARP

She has thought about moving to North Carolina herself and possibly starting her own group home where Ruby could live, but she has her own husband, job and life to consider.

Psychiatric nurse Jane Hamilton said people often underestimate the emotional and physical cost of caregiving. Caregivers are twice as likely to be diagnosed with a chronic health condition, and Hamilton stresses that it’s crucial for caregivers to take care of their own physical, spiritual and emotional needs. “It’s not a guilty pleasure. It’s not a nicety. It’s not selfish,” Hamilton said.

Over the years, Jean has tried to embrace her many complex feelings by becoming active with the National Alliance on Mental Illness, a support and advocacy group for families of people with mental illness. “I think of it as a way to fight. Becoming an advocate offers an avenue to vent.” she said.

Trying to plan for Ruby’s future remains a painful struggle, even after all these years. The sisters have a history of mental illness in their family, and sometimes Jean wonders why this illness befell Ruby and not her?

“Ruby was always so full of life. She was the more attractive one, more stylish, she knew all the people on our block, she was social. And she was the one who had the children,” said Jean. More than anything, Jean said, she wishes she could have protected her little sister from the devastating effects of her illness.

She pulled out an old family photo of the sisters playing Eartha: two skinny-legged little girls in tights and skirts, carefree and smiling as they clutch their cups of tea. JeannieandRuby, so close they could be twins. In Ruby, Jean sees the person she might have been had their fortunes been reversed.

“What just kind of rises to the top for me is this enormous amount of love that I have for my sister,” said Jean. As painful as her visits to North Carolina can be, she said, she wishes she could stay longer. “One day is not enough time to spend with my sister.”

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