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2/16/2019

Long-term treatment for a chronic condition

Though it seems Americans don’t agree on much, screening for cancer is an exception. Who wouldn’t support preventing or identifying cancer at an early, more treatable stage, when the alternative is pain, toxic therapies, and a shortened life? That may be why people get confused when news headlines don’t reinforce a “just do it” message. A recent example of the disconnect between public perception and medical evidence is screening for prostate cancer using the prostate-specific antigen (PSA) test. The United States Preventive Services Task Force (USPSTF), a non-governmental expert panel that produces guidelines for primary care providers, proposed new recommendations saying doctors should only order the PSA test for older men after discussing its pros and cons and eliciting preferences for screening.
Screening for prostate cancer with the PSA test: The backstory

To understand the new draft recommendation requires a brief history of this test. Introduced in the 1980s as a way to follow patients already diagnosed with prostate cancer, it began to be used to screen for new cancers. Given that the PSA is an easy blood test to perform, it was quickly adopted — without waiting for evidence that it actually worked. For many years, the USPSTF said there wasn’t enough information to recommend for or against the PSA test.

That changed in 2012 when the USPSTF released a controversial recommendation against screening. It was based in part on a large US study showing no decrease in prostate cancer deaths among men screened using the PSA test. The recommendation also reflected concern about the test causing a surge in prostate cancer diagnoses, many of which were small, low-risk cancers being treated with surgery or radiation — treatments with common side effects.

I was uncomfortable with this “don’t screen” recommendation and am happy about the proposed change. Here’s why: while the US screening trial was negative, another large study in European men showed a small decrease in prostate cancer deaths after more than 10 years of follow-up. Moreover, specialists had devised new strategies to avoid overtreating low-risk cancers.
Having a conversation about screening with the PSA test

I discuss the pros and cons of the PSA test with my patients and ask about their personal preferences for screening. I tell them that while screening can reduce death due to prostate cancer by 20%, the “bang for the buck” is small. It takes screening of over 1,000 men to prevent one death. I also highlight that the benefit of screening is years off, but the risks of treatment — impotence, incontinence, and bowel problems — occur right away.

I also emphasize the PSA test isn’t very accurate. There can be anxiety due to false positive results, meaning further testing shows no cancer. I mention the potential for diagnosing a low-risk cancer where the treatment may be worse than the disease, and that following them closely without treatment may be preferable. How much a man wants to know something like this can differ — some view it as useful information, others see it as an endless source of worry.

Finally, I share my own perspective. As a medical student in the late 1980s learning about the PSA test, my grandfather was dying from prostate cancer. He was an otherwise healthy man who had many good years left, and I wondered if the PSA test could have helped him. Because of this family history, I have decided to have the PSA test. But I’m also unsure what I would do if I didn’t have that history. The small potential for benefit must be weighed versus the risk of false positives or of finding a low-risk tumor that may never cause harm. I can see how two men without risk factors for prostate cancer could make different decisions.

So, I think the USPSTF got it right. This is a decision best made by a well-informed patient in collaboration with his doctor. The challenge in implementing this is practical: the short time I have with each patient. I could save time by simply ordering the test without a discussion. But in my role as health advisor, I need to be able to not only say when I think we should or should not do something, but also when there is a choice. And when there isn’t one right decision for everyone, my patient is the best person to make the choice that’s right for him. I can state my personal preference, but need to highlight why that may not be the right answer for him.
Screens have become so embedded in daily life that it’s hard to imagine turning them off for a whole week. Besides the fact that many, if not most, children use them for homework, they are also how we get work done, get questions answered, communicate, shop, and relax. For many families, they are also how they calm children down and keep them occupied. How do you go a day without all that — let alone a week?

I agree, that sounds hard. But as a pediatrician I’m worried about the way screens have insidiously worked their way into our lives.

According to the Campaign for a Commercial-Free Childhood (CCFC), 8 to 18-year-olds spend an average of seven hours a day on screen media. Some of that is homework, but clearly it’s not all homework. Preschoolers spend two to four hours, toddlers two hours, and a third of babies under a year are spending more than an hour watching videos every day.

It’s not all awful, of course. There is certainly high-quality educational content out there. However, children aren’t always watching that high-quality educational content. And even if they were, when you are watching a screen you are generally sedentary, not interacting with others, and relying on the screen to entertain or guide you rather than entertaining or guiding yourself.

This has implications for the health and development of children. Excessive screen time is associated with a higher risk of obesity. It can lead to poorer problem-solving and social skills, and poorer grades. It’s been linked to attention-deficit hyperactivity disorder and other behavioral problems.

That’s why I think families need to be mindful — and build some safeguards into their daily lives and family culture. Here are some suggestions:

1. Rearrange the living room so that the television isn’t the center of attention. This is a tip from the CCFC that I really like. Sure, watching TV together is fun; my family really enjoys our family movie nights. But if all the furniture faces the TV, not only is the natural tendency to turn it on when you sit down, but the message is that it’s what the living room is for — rather than talking to each other, playing a game, or doing anything else but watching TV.

2. Keep TVs out of bedrooms. They just don’t need to be there. Once it’s bedtime, laptops and phones should be out of there too; increasingly, screens are interfering with sleep, especially for teens.

3. Don’t turn on the TV during meals — and put the cell phones aside. Talk to each other instead. Family dinners have all sorts of benefits for children, from increasing their vocabulary to improving their nutrition to building better bonds between children and parents to helping keep teens out of trouble. While you’re at it…

4. Don’t have automatic screen times. So many families have the habit of turning on screens in the morning, or after school, or during dinner prep. Now, it’s not always terrible to do this; having a child watch one age-appropriate program while you do a few chores or just relax yourself can be helpful to many families. But be thoughtful about it. Does this really help? (I found that when our mornings became screen-free, things worked more smoothly, as my children paid better attention.) Is there an alternative, like engaging the child in cooking, or having them get homework done? Make sure it’s the best choice for the moment.

5. Make sure you’ve got supplies for creativity. Like paper, crayons, markers, and paints. Head to a craft store; bring your kids along and invest in some supplies for making things. Buy toys that encourage creativity and imagination, like building blocks, cars, or dollhouses. There should be lots to reach for when you are tempted to reach for a screen. Speaking of times when you are tempted to reach for a screen…

6. Pack books, small toys, playing cards, or paper and crayons whenever you head to anywhere you may get stuck waiting with your child. In my office, it seems like the only thing parents ever have on hand is their phones. There are so very many alternatives; help your child learn that.

7. Head outside. In general, children spend much more time indoors than they used to (we all do). Whether it’s heading to the park, going for a bike ride, walking around the block, or kicking a soccer ball in the back yard, make a concerted effort to make some outdoor time at least every week (every day is even better). It naturally disengages you from screens and literally engages your children with the world.Ever wonder what it would be like to be able to look at people’s entire adult lives? Not asking older people to remember, but starting with them as teenagers and tracking their health and well-being until they die? We’ve been lucky enough to do this for the past 78 years, starting in the late 1930s and early ‘40s with a group of men who agreed to be part of one of the longest studies of adult life ever done.

The Harvard Study of Adult Development has tracked the lives of 724 men from the time they were teenagers into old age — 268 Harvard College sophomores, and 456 boys from Boston’s inner city. Using questionnaires, interviews, medical records, and scans of blood and brains, we’ve monitored their physical and mental health, work lives, friendships, and romances.

Here are five of the big lessons we’ve learned about what contributes to a good life.
Lesson 1: Happy childhoods matter

Having warm relationships with parents in childhood predicts that you will have warmer and more secure relationships with those closest to you in adulthood. We found that warm childhoods reached across decades to predict more secure relationships with spouses at age 80. A close relationship with at least one sibling in childhood predicts that people are less likely to become depressed by age 50. And warmer childhood relationships predict better physical health in adulthood all the way into old age.
Lesson 2: Fostering the welfare of the next generation can ease the sting of difficult childhoods

People who grow up in difficult childhood environments (chaotic families, economic uncertainty) grow old less happily than those who have more fortunate childhoods. But by the time these people reach middle age (ages 50 to 65), those who mentor the next generation — guiding younger adults at home or at work — are happier and better adjusted than those who do not. The kind of maturation needed to nurture younger people also seems to reduce some of the sting of growing up disadvantaged.
Lesson 3: Coping effectively with stress has lifelong benefits

We all have habitual ways of managing stress and relieving anxiety. Some people tend to ignore uncomfortable facts, while others tend to face difficult issues and deal with what is unpleasant. For example, someone who is angry at his boss might “forget about it” but start missing important work deadlines. Alternatively, he might find a way to take up his concerns directly with that boss. We found that the people who cope with stress by engaging more directly with reality rather than pushing it away have better relationships with others. This coping style makes it easier for others to deal with them, which in turn makes people want to help them. They end up having better relationships and more social support, and this predicts healthier aging in your 60s and 70s. People who use these more adaptive coping mechanisms in middle age also end up with brains that stay sharper longer.
Lesson 4: Breaking bad habits earlier in life makes a difference

Watching people’s smoking habits across adulthood, those who quit earlier are less likely to develop lung disease as they grow old. They are also more likely to live longer than people who do not quit smoking or who quit later in life. Our findings differ from some studies that find no change in risk of disease and death once you’re tobacco-free for 15 years or more. Getting off the couch and starting to exercise earlier in life predicts that you’ll stay healthy longer in life, that your brain will stay sharper, and even that your immune system will be stronger.
Lesson 5: Time with others makes us happier

Looking back on their lives, people most often report their time with others as the most meaningful part of life, and what they’re proudest of. Time with other people makes us happier on a day-to-day basis, and time with a close partner buffers us against the mood dips that come with increased physical pain.

You can learn more about the study and our research at www.robertwaldinger.com and www.adultdevelopmentstudy.org. We are now studying the children of these men. Almost 1,300 of these second-generation baby boomers are participating in our study, and we hope to know more about what helps people thrive across generations. In 2015, motor vehicle accidents claimed the lives of more than 35,000 Americans. Sadly, the toll exacted by motor vehicle accidents has now been eclipsed. Data from the American Society of Addiction Medicine show that more than 52,000 of we Americans lost our lives to opioid overdose in 2015. Here in the Commonwealth, the story is even more grim; even accounting for differences in average age from community to community — younger people are still more likely to be affected than older people — the opioid overdose death rate has climbed to 23 per 100,000 residents as compared to 9 per 100,000 for the nation as a whole. The causes are numerous and a subject for another day. Similarly, approaches to solve the crisis are numerous and no one solution works for everyone who decides he or she has developed an opioid problem.
Medication Assisted Treatment (MAT)

One approach to treat people who are addicted to opioids is Medication Assisted Treatment (MAT) that combines medications to treat addiction with more traditional counseling approaches. One medication often used in MAT programs is buprenorphine-naloxone (trade name Suboxone, among others). This preparation — hereafter BN — combines buprenorphine, an opioid medication with partial activity that blunts cravings, and naloxone, an opioid overdose reversal medication that discourages abuse of the medication. When we compare groups of people addicted to opioids who are treated with and without BN, we see that those who receive the medication have a significantly higher rate of remaining free of other opioids. But how long should one continue the medication? A month? A year? A lifetime? And is it safe to continue the medication? We do not have the full answers yet, but early signals from the research indicate that not only is it safe but that longer treatment is better than shorter treatment.
Long-term treatment for a chronic condition

Many in the medical community have come to view addiction as a chronic disease. And, like many chronic diseases, it is one that can be managed but not yet cured. The thinking goes that just as those of us with high blood pressure take high blood pressure fighting medication each day for years, those of us with addiction would take addiction-fighting medication every day over years. The evidence shows that long-term proper treatment for high blood pressure lowers the risk for heart attack; evidence is now beginning to grow that long-term MAT can similarly decrease risk for relapse in those with addiction. As reported in a 2008 study in the American Journal on Addictions, patients who were successfully stabilized with a short course of BN could then be switched to long-term treatment with the medication. Forty percent of patients remained in treatment at two years and 20% at five years. When we remember that nearly half of people prescribed medication for blood pressure do not take their pills, we see that people on BN are not more likely to skip their medication than are people with better-studied chronic diseases. More importantly, though, greater than 90% of urine samples from those in the study remained free of opioids other than BN.

Long-term treatment with BN works.
How do people do without longer-term buprenorphine-naloxone treatment?

It is one thing to say that someone on a medication has a good outcome, but it is something else to prove that without the medication the person would not do well. Many advocate short-term treatment with BN. Help a person become stable and then taper off the medication. We now have evidence that this approach, however well intentioned, may be misguided. A 2014 study reported in the Journal of the American Medical Association demonstrates that over half of people who continued on BN maintenance remained free of opioids compared to just a third of those who were stabilized on BN and then tapered off. Further, far more of those treated with maintenance BN remained in the study compared to those who were tapered, suggesting that people remain committed to treatment while receiving BN.
Is long-term MAT safe?

Even if many people can be helped by extended BN treatment, it is important to consider possible side effects. Though we do not know the effects of being on BN for many decades, the 2008 American Journal on Addictions study looked for but did not find any serious adverse effects on the people treated. Earlier concerns that BN could cause liver damage also appeared to be unfounded as blood tests did not show signs of liver problems in any of the patients in the study.

More research is needed, of course, but the early evidence suggests that BN can safely help people remain off unwanted opioids over the long term just as blood pressure medication can protect people from the effects of high blood pressure. That is good news because each day off unwanted opioids is a day a person can focus on improving his or her life. Of course, buprenorphine-naloxone maintenance is not for everyone, but when it works it can work well and can give people room to breathe and rebuild their lives.

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