California law has tried for almost 50 years to protect people with mental illness from forced treatment, and for just as long, critics have said that the state is leaving mentally ill people without treatment, abandoning them to die on the streets. Last week, the critics’ arguments won out, as the Legislature unanimously passed SB 43, which would allow the state to force more people into mental health care or substance use treatment. Gov. Gavin Newsom appears likely to sign the bill.

Legislators are right that California needs a new approach. But for the bill to help the many Californians who desperately need care, the state needs to enact the law carefully and consistently — drawing on available research and the expertise of people who work in, or have been through, the system. As a sociologist who has conducted hundreds of interviews and shadowed professionals throughout the state, I’ve seen firsthand how people who need the most help from multiple systems often fall through the cracks of all of them. The new law seeks to address these gaps by expanding the legal standard for a conservatorship, a legal tool that allows a third party, usually a county public guardian, to place someone in a psychiatric facility and obligate them to take medication.

The standard is “grave disability,” which now is limited to an inability to meet one’s need for food, clothing and shelter because of a mental illness. Under the new law, individuals who are unable to ensure their own medical care and personal safety could also be taken into state custody. It also would allow conservatorships on the basis of a severe substance use disorder.

Advocates for reform envision that these changes will provide legal leverage to push providers to finally care for some of the most vulnerable people in the state — including those who present with expensive needs and no way to pay. It is also seen as a tool to address a small part of the homelessness crisis in California, if it can connect severely mentally ill unhoused people with care. Yet the dangers in this bill are evident. Even aside from civil liberties concerns, studies on the effectiveness of involuntary treatment in improving symptoms are inconclusive.

Hospitalization can even be counterproductive: Significant numbers of people leave psychiatric units traumatized, suicidal and uninterested in further treatment. Clinicians, family members and some patients can point to situations in which conservatorship was a life-saving intervention, but hard data that it can address substance abuse or homelessness are virtually nonexistent. And yet the individuals targeted by SB 43 have often turned down, or been unsuccessful in, voluntary services or supportive housing. In short: Expanding conservatorships isn’t an evidence-based policy.

It’s a risky experiment taken in a desperate moment. Getting it right will require strategy, leadership and oversight from state government. First, the state needs to provide clear guidance to carefully circumscribe the situations in which conservatorships are, and are not, appropriate. Proponents of reform have often emphasized seemingly clear-cut cases, but deciding whether someone with mental illness should be conserved for failing to manage their diabetes or turning down chemotherapy is more complicated. The state needs to convene a broad range of stakeholders to flesh out the new definition of “grave disability” and provide continuous training on best practices for the key actors in the conservatorship system, including clinicians, judges and law enforcement.

Second, California should couple expanding the number of people under conservatorship with more narrowly tailoring the restrictions people experience within this type of care. Grave disability, one clinician told me, isn’t a “light switch.” Even if someone loses the right to decide where they live or whether to take medication, they should be empowered to make decisions across as many other domains of life as possible. Even involuntary treatment requires buy-in from patients to be effective over the long term. Yet in interviews, I constantly heard patient complaints about psychiatric facilities that denied even the smallest dignities, like choosing what movie to watch or eating a bag of chips.

The state could help promote choice and reduce coercion by ensuring that all conservatees have a chance to fill out a psychiatric advance directive, making their preferences clear to all the professionals serving them. Minimizing coercion also means moving people into less restrictive levels of care as fast as possible. Although many insist California doesn’t have enough locked beds for the seriously ill patients who need them, studies have consistently shown that many of the beds that do exist are occupied inappropriately by people who no longer need acute care but have nowhere else to go.

Most sub-acute facilities in California are private and for profit; clinicians have to engage in what one psychiatrist described as a “beauty contest” to persuade these facilities to admit their clients. Regulators could ensure that when it comes to being admitted to lower levels of care, patients are prioritized by need, not profitability. Finally, the state must set clear metrics for evaluating SB 43 and be prepared to reconsider the approach if they are not met.

One factor to address: the shocking racial inequities in who is subject to involuntary treatment. (In San Francisco, half of individuals with eight or more involuntary treatment episodes in the past year are Black. Only 6% of the city is Black.) Ideally, conservatorship breaks people out of a cycle of ineffectual and traumatic coercion and gets them onto a path to more enduring recovery. If the law works as its advocates intend, it ultimately ought to reduce California’s high rates of short-term involuntary hospitalizations.

If it goes awry, it could turn the clock back to the dark days of mass institutionalization. The outcome hinges entirely on how SB 43 is put into action.

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OLYMPIA, Wash. (AP) — Washington lawmakers approved and Gov. Jay Inslee quickly signed a major new drug policy Tuesday that keeps controlled substances illegal while boosting resources to help those struggling with addiction.

A compromise reached a day earlier by Democratic and Republican leaders sought to bridge a gap between liberals who believe drugs should be decriminalized and conservatives who insist the threat of jail is necessary to force people into treatment.

The law retains criminal penalties for drug possession, making it a gross misdemeanor punishable by up to six months in jail for the first two offenses and up to a year after that. But police and prosecutors would be encouraged to divert cases for treatment or other services, and the measure provides $44 million for investments that include methadone mobile units, crisis centers and short-term housing for people with substance-use disorders.

“It is our deep hope that this will help people away from the scourge of addiction, that it will reduce crime overall in our communities and will help our children be safe from the scourge of drug addiction,” Inslee said before signing the bill.

The Senate voted 43-6 in favor; the House 83-13 in favor.

Lawmakers said the bill struck a balance between public order and compassion for those struggling with substance abuse.

Legislators were under pressure to pass a bill not just because of the soaring addiction crisis, but because of a self-imposed deadline: A temporary, 2-year-old law that makes intentional drug possession illegal is due to expire July 1.

Unless the compromise became law, drug possession — even of fentanyl and other dangerous opiates — would have become decriminalized under state law. The only other state that has tried decriminalizing drug possession is neighboring Oregon, where the experiment is off to a rocky start.

Several lawmakers made emotional statements about losing close relatives to addiction. Sen. Ron Muzzall, an Oak Harbor Republican, broke up as he described how his niece, Rachel Marshall – the creator of the popular Seattle company Rachel’s Ginger Beer – died last month.

“If we cannot offer hope for these people that are in the throes of addiction, what good are we?” he said. “I failed. My niece, whom I loved and had a great relationship. She hid that addiction from me.”

Another Republican, Sen. John Braun, of Centralia, lost a nephew two years ago and said in recent weeks he has often thought of him and what the state could do differently to help others.

“If we want to save people’s lives, if we want to help people -– and I think everyone in this chamber does -– we have to try something different,” he said.

Sen. Yasmin Trudeau, a Tacoma Democrat, said she supported the bill as a first step. But she urged her colleagues to be ready to do more to shore up housing and behavioral health resources.

“We’ve got so much work to do beyond this bill to actually achieve anything that’s in it,” Trudeau said. “We’re not going to achieve it with one bill. … And we are not going to achieve it by simply criminalizing those that are deep in their addiction, deep in poverty, and deep in pain and trauma.”

Under the law, the sale of drug paraphernalia, such as glass tubes for smoking fentanyl, is a civil infraction. But possession is not banned, and public health programs are allowed to distribute such materials as well as test strips that can detect the presence of fentanyl or other substances in drugs.

The law allows cities and counties to ban drug paraphernalia and allows them to regulate recovery residences and harm-reduction programs such as those that provide methadone or other medication to treat addiction, just as they regulate other essential public services.

In 2021, the Washington Supreme Court struck down the state law making drug possession a felony as unconstitutional because it did not require prosecutors to prove someone knowingly had the drugs. Washington was the only state in the country without that requirement.

In response, lawmakers made intentional drug possession a misdemeanor and required police to refer offenders to evaluation or treatment for their first two offenses. But there was no obvious way for officers to track how many times someone had been referred, and the availability of treatment remained inadequate. Lawmakers made the measure temporary and gave themselves until this July 1 to come up with a long-term policy.

Inslee called lawmakers back to the Washington Statehouse for the special session after they failed to pass a new drug law last month.

“This has been a longer period than many bills to get to my desk,” Inslee said. “But I do believe this process produced a better bill.”

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Researchers have found long-term evidence that actively monitoring localized prostate cancer is a safe alternative to immediate surgery or radiation.

The results, released Saturday, are encouraging for men who want to avoid treatment-related sexual and incontinence problems, said Dr. Stacy Loeb, a prostate cancer specialist at NYU Langone Health who was not involved in the research.

The study directly compared the three approaches — surgery to remove tumors, radiation treatment and monitoring. Most prostate cancer grows slowly, so it takes many years to look at the disease’s outcomes.

“There was no difference in prostate cancer mortality at 15 years between the groups,” Loeb said. And prostate cancer survival for all three groups was high — 97% regardless of treatment approach. “That’s also very good news.”

The results were published Saturday in the New England Journal of Medicine and presented at a European Association of Urology conference in Milan, Italy. Britain’s National Institute for Health and Care Research paid for the research.

Men diagnosed with localized prostate cancer shouldn’t panic or rush treatment decisions, said lead author Dr. Freddie Hamdy of the University of Oxford. Instead, they should “consider carefully the possible benefits and harms caused by the treatment options.”

A small number of men with high-risk or more advanced disease do need urgent treatments, he added.

Researchers followed more than 1,600 U.K. men who agreed to be randomly assigned to get surgery, radiation or active monitoring. The patients’ cancer was confined to the prostate, a walnut-sized gland that’s part of the reproductive system. Men in the monitoring group had regular blood tests and some went on to have surgery or radiation.

Death from prostate cancer occurred in 3.1% of the active-monitoring group, 2.2% in the surgery group, and 2.9% in the radiation group, differences considered statistically insignificant.

At 15 years, cancer had spread in 9.4% of the active-monitoring group, 4.7% of the surgery group and 5% of the radiation group. The study was started in 1999, and experts said today’s monitoring practices are better, with MRI imaging and gene tests guiding decisions.

“We have more ways now to help catch that the disease is progressing before it spreads,” Loeb said. In the U.S., about 60% of low-risk patients choose monitoring, now called active surveillance.

Hamdy said the researchers had seen the difference in cancer spread at 10 years and expected it to make a difference in survival at 15 years, “but it did not.” He said spread alone doesn’t predict prostate cancer death.

“This is a new and interesting finding, useful for men when they make decisions about treatments,” he said.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

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MEDICATION FOR OPIOID USE DISORDER WAS LOWEST AMONG ADOLESCENTS AND ADULTS AGES 50 AND OLDER

Despite strong evidence that medication is the most effective treatment for opioid use disorder (OUD), adolescents and most adults with a need for OUD treatment reported a lack of medication for OUD in the past year, according to a study by researchers at Columbia University Mailman School of Public Health. Among those who may have needed opioid use treatment, only 28 percent received medication for OUD. Until now, national studies on medication for OUD were lacking. The findings are published in JAMA Network Open.

“Our nationally representative research revealed critical gaps in treatment engagement and use of medication for opioid use disorder. Increased efforts to address barriers to care are critically needed,” said Pia Mauro, PhD, assistant professor of epidemiology at Columbia Mailman School and the study’s lead author. “Evidence supporting the effectiveness of medication for opioid use disorder such as methadone, buprenorphine, or naltrexone is unequivocal, but most people who needed OUD treatment in the U.S did not receive this gold standard treatment.“

The findings were based on data from the 2019 National Survey on Drug Use and Health. Participants were community-based, and data excluded people who were institutionalized or homeless not in shelters. The researchers identified adolescents and adult respondents who may benefit from medication for OUD defined as meeting criteria for a past-year opioid use disorder, reporting past-year medication for OUD, or receiving past-year specialty treatment for opioid use.

The data showed that 57 percent received no treatment for the disorder, and 15 percent received only services without medication. Notably, adolescents (aged 12-17 years) did not receive (medication for opioid use disorder) MOUD in the past year and only 13 percent of adults 50 years and older received medication for the disorder. “Our findings support calls for additional MOUD engagement and retention strategies tailored for both adolescents,” noted Mauro.

Among adults, the likelihood of past-year MOUD receipt compared to no treatment was also lower for people aged 50 years and older, versus for those 18 to 25 years of age. “Our finding that a minority of adults and no adolescents received MOUD indicates substantial gaps in access,” observed Mauro. “These results provide critical evidence to inform national efforts needed to increase equitable access to MOUD.”

Nearly one-third of non-Hispanic white people in need of OUD treatment received medication, compared with approximately 20 percent of people identifying as non-Hispanic Black or multiracial groups and 15 percent of Hispanic people. In contrast, roughly similar proportions of each racial and ethnic group received non-medication services, revealing significant disparities specifically for access to medication treatment among people of color.

MOUD was lower among women, more likely among adults with at least some college, and less likely in small metropolitan areas versus large metropolitan areas. While contacts with the health care system (85 percent) and criminal legal system (61 percent) were common, most people encountering these systems did not report receiving MOUD (30 percent and 39 percent, respectively). 

Starting in 2020, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act mandated that Medicaid cover all three U.S. Food and Drug Administration–approved medications for OUD, including methadone in certified opioid treatment programs. 


“Policies that expand Medicaid coverage for these medications is an important population-level strategy to potentially increase access to effective opioid use disorder treatment in the publicly insured population,” said Hillary Samples, PhD, assistant professor at the Rutgers School of Public Health and study senior co-author. “In any case, our findings provide further evidence that investments are needed to increase MOUD prescribing and referrals in ambulatory settings.”

Co-authors are Sarah Gutkind and Erin Annunziato, Columbia Mailman School of Public Health.

The study was supported by the National Institute on Drug Abuse (grant numbers DA045224, DA049950, DA031099).  

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Recent years have seen rapid advances in the development of long-acting effective methods to prevent and treat HIV, notably long-acting injectable antiretroviral therapy (LAI ART) and long-acting injectable preexposure prophylaxis (LAI PrEP). Yet while these formulations have huge potential, their global availability and access is inhibited by factors including lack of funding from international organizations, unequal insurance coverage, patent protections that keep costs high, and social inequities. The article by researchers at Columbia University and the University of Toronto appears in the journal Current Opinion in HIV and AIDS.

As of February 2022, LA ART administered every two months is approved in the United States, Canada, and Europe. The U.S. also approved LAI PrEP in December 2021. Both are as effective as existing daily oral pills but with a convenience that has the potential to significantly improve uptake. The World Health Organization has recommended the monthly vaginal PrEP ring, which may alleviate adherence barriers that exist for oral PrEP—and the frequency of clinic visits for LAI PrEP—but is much less effective than both. Approximately 30 long-acting ART and PrEP formulations are now in clinical trials, including monthly oral pills; vaginal and rectal gels; vaginal rings, films, and inserts; intramuscular and subcutaneous injections; implants; enemas; and micro-array patches.

“The development of long-acting ART and PrEP have provided renewed hope that ending the HIV epidemic is within reach. However, pervasive socio-structural inequities highlight the need for cautious optimism,” says study co-author Morgan Philbin, PhD, assistant professor of sociomedical sciences at Columbia University Mailman School of Public Health.

However, LA ART could exacerbate existing social inequities in care access because it is only available to virologically suppressed individuals; viral suppression is lower among minoritized populations, including by race and ethnicity, sexuality, gender, and socioeconomic status. Additionally, insurance coverage for long-acting ART and long-acting PrEP is lacking in the U.S., with many states’ AIDS Drug Assistance Programs (ADAP) not covering LAI ART; insurance coverage for LAI PrEP remains unknown. In addition, people in the Global South who participated in the research trials that demonstrated their efficacy may not have equitable access once they are approved—LAI ART is only currently approved in the U.S., Canada, and Europe.

“Tackling the social and political dimensions that limit equitable access requires political struggle, social movements, and global accountability. In order for long-acting HIV formulations to truly fulfill their promise of ‘ending the HIV epidemic’, equity in availability, access and uptake must be addressed on a global scale,” says Philbin.

Earlier research by Philbin and colleagues examined attitudes toward long-acting injectable HIV therapy among women with a history in injection, and among women more broadly. She has also uncovered geographic disparities in HIV care.   

The study’s co-author is Amaya Perez-Brumer, PhD ‘19, assistant professor at the Dalla Lana School of Public Health, University of Toronto.

The journal article was supported in part by grants from the U.S. National Institute on Drug Abuse (DA039804A) and National Institute of Mental Health (MH124552); and the Canadian Institute of Health.

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The long-awaited milestone comes as U.S. cases, hospitalizations and deaths are all rising and health officials warn of a tsunami of new infections from the omicron variant that could overwhelm hospitals.

The drug, Paxlovid, is a faster way to treat early COVID-19 infections, though initial supplies will be extremely limited. All of the previously authorized drugs against the disease require an IV or an injection.

An antiviral pill from Merck also is expected to soon win authorization. But Pfizer’s drug is all but certain to be the preferred option because of its mild side effects and superior effectiveness, including a nearly 90% reduction in hospitalizations and deaths among patients most likely to get severe disease.

“The efficacy is high, the side effects are low and it’s oral. It checks all the boxes,” said Dr. Gregory Poland of the Mayo Clinic. “You’re looking at a 90% decreased risk of hospitalization and death in a high-risk group — that’s stunning.”

The Food and Drug Administration authorized Pfizer’s drug for adults and children ages 12 and older with a positive COVID-19 test and early symptoms who face the highest risks of hospitalization. That includes older people and those with conditions like obesity and heart disease, though the drug is not recommended for patients with severe kidney or liver problems. Children eligible for the drug must weigh at least 88 pounds (40 kilograms).

The pills from both Pfizer and Merck are expected to be effective against omicron because they don’t target the spike protein where most of the variant’s worrisome mutations reside.

Pfizer currently has 180,000 treatment courses available worldwide, with roughly 60,000 to 70,000 allocated to the U.S. Federal health officials are expected to ration early shipments to the hardest hit parts of the country. Pfizer said the small supply is due to the manufacturing time — currently about nine months. The company says it can halve production time next year.

The U.S. government has agreed to purchase enough Paxlovid to treat 10 million people, and it will be provided free to patients. Pfizer says it’s on track to produce 80 million courses globally next year, under contracts with the U.K., Australia and other nations.

President Joe Biden said the pill marks a “significant step forward in our path out of the pandemic” and said his administration will work with states to ensure equitable distribution.

Health experts agree that vaccination remains the best way to protect against COVID-19. But with roughly 40 million American adults still unvaccinated, effective drugs will be critical to blunting the current and future waves of infection.

The U.S. is now reporting more than 140,000 new infections daily and federal officials warn that the omicron variant could send case counts soaring. Omicron has already whipped across the country to become the dominant strain, federal officials confirmed earlier this week.

Against that backdrop, experts warn that Paxlovid’s initial impact could be limited.

For more than a year, biotech-engineered antibody drugs have been the go-to treatments for COVID-19. But they are expensive, hard to produce and require an injection or infusion, typically given at a hospital or clinic. Also, laboratory testing suggests the two leading antibody drugs used in the U.S. aren’t effective against omicron.

Pfizer’s pill comes with its own challenges.

Patients will need a positive COVID-19 test to get a prescription. And Paxlovid has only proven effective if given within five days of symptoms appearing. With testing supplies stretched, experts worry it may be unrealistic for patients to self-diagnose, get tested, see a physician and pick up a prescription within that narrow window.

“If you go outside that window of time I fully expect the effectiveness of this drug is going to fall,” said Andrew Pekosz, a Johns Hopkins University virologist.

The FDA based its decision on company results from a 2,250-patient trial that showed the pill cut hospitalizations and deaths by 89% when given to people with mild-to-moderate COVID-19 within three days of symptoms. Less than 1% of patients taking the drug were hospitalized and none died at the end of the 30-day study period, compared with 6.5% of patients hospitalized in the group getting a dummy pill, which included nine deaths.

Pfizer’s drug is part of a decades-old family of antiviral drugs known as protease inhibitors, which revolutionized the treatment of HIV and hepatitis C. The drugs block a key enzyme which viruses need to multiply in the human body.

The U.S. will pay about $500 for each course of Pfizer’s treatment, which consists of three pills taken twice a day for five days. Two of the pills are Paxlovid and the third is a different antiviral that helps boost levels of the main drug in the body.

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Associated Press writer Tom Murphy contributed to this report.

MATTHEW PERRONE | AP News

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