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State senators at THRIVE press conference. Photo by Maureen Rossi

Advocates say new budget has wins for people in recovery

By Maureen Rossi

With the opioid epidemic still endemic throughout Suffolk County and beyond, New York State senators are hoping the new state budget will mean more help for those in the throes of addiction.

Measures woven into and passed in the state budget include increasing access for those suffering with substance use disorder to access 28-day inpatient and outpatient programs without prior insurance authorization.  They also include money for a recovery high school start -up and no prior authorization for medication- assisted treatment.  

“These are critical reform measures,” said New York State Sen. Monica Martinez (D-Brentwood). In addition, she touted another reform, which will require emergency rooms to enact screening, brief intervention and referral to treatment for all overdose patients before they are released. For the first time, emergency room doctors will also initiate medically-assisted treatment to overdose patients prior to their release, utilizing drugs like buprenorphine that alleviate the craving for opioids including heroin. 

Long Island advocates rally in Albany for the state to do more about the opioid crisis on LI Lobby Day in March. Photo from Friends of Recovery NY

Martinez was joined by her Democratic colleagues at a press conference in Islandia April 12.  Senators Anna Kaplan (D-Great Neck), James Gaughran (D-Northport), Kevin Thomas (D-Levittown) and Todd Kaminsky (D-Long Beach) gathered at THRIVE Long Island, a community center for people in addiction recovery whose funding was a legislative win three years back.

The Island’s Democrats were joined by stakeholders to celebrate critical initiatives passed in this year’s state budget to combat Long Island’s pernicious opioid epidemic. Those stakeholders include parents of those lost to the epidemic, those in recovery and those in the prevention and addiction field, including the CEO of Family & Children’s Association Jeffrey Reynolds, of Smithtown.

 “There is still much work to be done to combat the opioid epidemic we are seeing here on Long Island,” Martinez added.  She looked to Reynolds to the right of the podium and shared that he was tenacious in getting the Long Island’s senators’ attention as the hours dwindled in budget meetings. “He used social media and tagged every single one of us and let us know what funding was missing in the budget.”

Kaplan said the crisis affects every community, every school and every community.   

“Too many innocent souls have been lost to this disease, they have been failed time and again,” Kaplan said.  “We are done with half-measures — we will do everything we can to help people get into long-term recovery.”  

One such measure included and passed in the budget was the funding of another THRIVE center for Nassau in Hempstead. The doors are scheduled to open next month.

Kaminsky met with some Long Island parents who lost loved ones to the epidemic prior to the budget process. Figures released by the addiction experts on Long Island put that figure at 3,400 since 2010.

“When a parent tells you the story of how they found their child (dead), you want to make sure another parent doesn’t experience that,” said Kaminsky.   

When it came to budget negotiations that lasted around the clock, the state senator said they would not take no for an answer.  

Suffolk County has long been a powerhouse when it comes to shining a light on the opioid epidemic and taking legislative measures to address it. Packages of historic bills have been pushed through statewide by Suffolk County advocates. The county is one of the state’s hardest hit counties and they were the first county in the country to file a lawsuit against Purdue Pharma, the makers of the drug OxyContin.  

Reynolds addressed the senators on behalf of the sixty-plus advocates present.  “ ‘Thank you’ seems insufficient. You promised on campaign trails you would do good for Long Island. Thank you so much for your efforts,” he stated.

However, Reynolds promised that he and the Long Island advocacy movement will always ask the senators to do more. 

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Blood pressure is typically highest during the day and lowest at night. Stock photo

By David Dunaief, M.D.

Dr. David Dunaief

There are currently about 75 million people with high blood pressure in the U.S. Put another way, one in three adults have this disorder. If that isn’t scary enough, the Centers for Disease Control and Prevention reports that the number of people dying from complications of hypertension increased by 23 percent from 2000 to 2013 (1).

Speaking of scary, during nighttime sleeping hours, the probability of complications, such as cardiovascular events and mortality, may have their highest incidence.

Unfortunately, as adults, it does not matter what age or what sex you are; we are all at increased risk of complications from high blood pressure, even isolated systolic (top number) blood pressure, which means without having the diastolic (bottom number) elevated as well. Fortunately, hypertension is highly modifiable in terms of reducing the risk of cardiovascular disease and mortality (2). At least some of the risk factors are probably familiar to you. These include being significantly overweight and obese (BMI >27.5 kg/m²), smoking, poor diet, lack of exercise, family history, age, increased sodium, depression, low vitamin D, diabetes and too much alcohol (3).

Of course, antihypertensive (blood pressure) medications treat this disorder. In addition, some nonpharmacological approaches have benefits. These include lifestyle modifications with diet, exercise and potentially supplements.

Risk factors matter, but not equally

In a study, results showed that those with poor diets had 2.19 times increased risk of developing high blood pressure. This was the greatest contributor to developing this disorder (4). Another risk factor with a significant impact was being at least modestly overweight (BMI >27.5 kg/m²) at 1.87 times increased risk. This surprisingly, albeit slightly, trumped cigarette smoking at 1.83 times increased risk. This study was observational and involved 2,763 participants. The moral is that a freewheeling lifestyle can have a detrimental impact on blood pressure and cause at least stage 1 hypertension.

High blood pressure doesn’t discriminate

One of the most feared complications of hypertension is cardiovascular disease. In a study, isolated systolic hypertension was shown to increase the risk of cardiovascular disease and death in both young and middle-aged men and women between 18 and 49 years old, compared to those who had optimal blood pressure (5). The effect was greatest in women, with a 55 percent increased risk in cardiovascular disease and 112 percent increased risk in heart disease death. High blood pressure has complications associated with it, regardless of onset age. Though this study was observational, it was very large and had a 31-year duration.

Nightmares that may be real

Measuring blood pressure in the clinic can be useful. However, in a meta-analysis (involving nine studies from Europe, South America and Asia), results showed that high blood pressure measured at nighttime was potentially a better predictor of myocardial infarctions (heart attacks) and strokes, compared to daytime and clinic readings (6).

For every 10 mmHg rise in nighttime systolic blood pressure, there was a corresponding 25 percent increase in cardiovascular events. This was a large meta-analysis that utilized studies that were at least one year in duration. Does this mean that nighttime readings are superior in predicting risk? Not necessarily, but the results are interesting. The nighttime readings were made using 24-hour ambulatory blood pressure measurements (ABPM).

There is something referred to as masked uncontrolled hypertension (MUCH) that may increase the risk of cardiovascular events in the nighttime. MUCH occurs in those who are well-controlled during clinic readings for blood pressure; however, their nocturnal blood pressure is uncontrolled. In the Spanish Society of Hypertension ABPM Registry, MUCH was most commonly seen during nocturnal hours (7). Thus, the authors suggest that ABPM may be a better way to monitor those who have higher risk factors for MUCH, such as those whose pressure is borderline in the clinic and those who are smokers, obese or have diabetes.

Previously, a study suggested that taking at least one antihypertensive medication at night may be more effective than taking them all in the morning (8). Those who took one or more blood pressure medications at night saw a two-thirds reduction in cardiovascular event risk. Now we can potentially see why. These were patients who had chronic kidney disease (CKD). Generally, 85 to 95 percent of those with CKD have hypertension.

Eat your berries

Diet plays a role in controlling high blood pressure. In a study, blueberry powder (22 grams) in a daily equivalent to one cup of fresh blueberries reduced systolic blood pressure by a respectable 7 mmHg and diastolic blood pressure by 5 mmHg over 2 months (9).

This is a modest amount of fruit with a significant impact, demonstrating exciting results in a small, preliminary, double-blind, placebo-controlled randomized trial. Blueberries increase a substance called nitric oxide, which helps blood vessels relax, reducing blood pressure.

In conclusion, nighttime can be scary for high blood pressure and its cardiovascular complications, but lifestyle modifications, such as taking antihypertensive medications at night and making dietary changes, can have a big impact in altering these serious risks.

References:

(1) CDC.gov. (2) Diabetes Care 2011;34 Suppl 2:S308-312. (3) uptodate.com. (4) BMC Fam Pract 2015;16(26). (5) J Am Coll Cardiol 2015;65(4):327-335. (6) J Am Coll Cardiol 2015;65(4):327-335. (7) Eur Heart J 2015;35(46):3304-3312. (8) J Am Soc Nephrol 2011 Dec;22(12):2313-2321. (9) J Acad Nutr Diet 2015;115(3):369-377. (10) JAMA Pediatr online April 27, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.    

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Maurizio Del Poeta. File photo from SBU

Maurizio Del Poeta, a professor in the Department of Molecular Genetics & Microbiology at Renaissance School of Medicine at Stony Brook University, works to combat potentially deadly fungal infections. Recently, several press reports have highlighted the prevalence in New York and New Jersey of Candida auris, which is resistant to drugs and can cause death. Through an email exchange, Del Poeta shared his perspective on this fungal infection and his efforts to develop a treatment.

Are there multiple drug-resistant strains of numerous types of Candida?

Yes, there are several species of Candida that are resistant to some antifungals. For instance, Candida lusitaniae is normally resistant to amphotericin B. Candida glabrata is normally resistant to fluconazole. There are over 20 species of Candida that can cause infection in humans. Most are sensitive to antifungals. C. auris is normally resistant to all antifungals. They are resistant for mainly two reasons: (1) the target/enzyme is genetically different and, thus, the drug does not recognize the target; thus it does not bind to the target; and thus it does not inhibit it; (2) the drug is pumped out by membrane transporters. C. auris is notorious for having multiple membrane transporters.

I understand the damage from Candida is primarily among people who are immunocompromised. Is there a risk for those people who are also healthy?

Healthy people should be fine. But who is really “healthy?” Because C. auris is spreading in hospitals and nursing homes, all patients in hospitals and nursing homes are at risk: some more (e.g., cancer patients, patients with an organ transplant, patients in ICU, patients taking corticosteroids) and some patients have less risk because they are more immunocompetent, but certainly those patients could get contaminated.

What makes it so hard to eliminate Candida?

Because (1) we are not used to and (2) because we still do not know which type of disinfectant is efficacious against C. auris … Unlike other Candida infections, which are generally thought to result from autoinfection from host flora, C. auris can be transmitted between patients … C. auris requires implementation of specific infection control measures, such as those used for control of [other infections] (e.g., private room and on contact precautions). Because C. auris can survive in plastic surfaces, floors, and door knobs for weeks, it is essential that infection control measurements be implemented in the health care settings.

Does the work you’re doing offer hope, albeit in the earlier stages, for ways to treat and reduce the virulence of Candida?

Yes, our new compounds are sensitive to C. auris in vitro against the C. auris clinical isolates that are resistant to current antifungals. We are currently testing their efficacy in vivo (animals). We are doing this in collaboration with the National Institutes of Health and the Health Science Center in San Antonio, Texas. Our compounds have different mechanism of action from the current antifungals,

Given that the symptoms of a Candida infection -— fever, weakness and aches — are so prevalent in other types of infections, are there ways to make a clinically differentiated diagnosis of Candida without taking a blood sample or conducting extensive analysis?

Unfortunately, there are not. Diagnosis of C. auris can only be made using sophisticated tests. Normal phenotypic tests are not able to identify C. auris for certain. If we want to stop (or at least control) the epidemic, anyone with a Candida infection in a hospital setting should be treated as C. auris. Hospital trafficking of nurses, doctors, visitors from and to patients with C. auris should be highly restricted. Nurses and doctors should not be allowed in cafeteria without changing gowns, particularly if they are taking care of a patient infected with C. auris and other common sense practices should be implemented; but, unfortunately, they are normally out of the window in the hospital settings … In the case of C. auris “isolating rooms” and “contact precautions” should be implemented.

How does your treatment for Candida work?

The class of compounds are “acylhydrazones.” They target the synthesis of fungal sphingolipids.

Given what you know about the prevalence of Candida, particularly in New York, and the minimal information about the specific locations where hospitals have found Candida, what would you advise anyone who might be “at risk” for Candida to do if they had elective surgery scheduled?

Elderly and immunocompromised people going to the hospital should be treated with “contact precautions.” No need for isolation unless positive for C. auris.

Is C. auris the most virulent or problematic species of Candida confronting public health professionals today?

Not really. C. glabrata is also a nasty Candida strain. What makes C. auris difficult is the resistance to drugs.

Do other species suffer through Candida infections as well?

Although humans are the most known carriers and hosts for Candida infection, other animals can also get infected such as dogs, horses and cattle. Certain Candida species are used in food production. Candida utilis extracts are used in Asia as a “salt” instead of salt because these extracts are salty and do not cause hypertension. We actually have a collaboration with the Japanese company that makes these extracts. Candida krusei is used to ferment cacao during chocolate production. Whereas C. utilis is not a human pathogen, C. krusei actually is.

How do you protect yourself, your office and your staff from the spread of the infection?

We use biosafety label 2. My lab is certified to handle BSL2 organisms, such as C. auris. We use all sorts of protective gears and standard protective procedures to make sure lab personnel are protected and to make sure we keep the microbes inside the lab. Entrance to my lab is strictly prohibited to anyone that did not receive appropriate training.

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From left, Joe Martinez; St. Catherine of Siena’s Chief Operating Officer John Pohlman; St. Catherine of Siena’s President James O’Connor; and St. Catherine of Siena’s Director of Colon and Rectal Surgery Tara Martinez. Photo from St. Catherine of Siena

Habberstad BMW in Huntington hosted St. Catherine of Siena’s Cocktails for a Colorectal Cause event on March 27. Dr. Tara Martinez, director of Colon and Rectal Surgery, took the opportunity to use the unique space to raise awareness about the importance of screenings during Colorectal Cancer Awareness month, celebrated nationally during March. 

The special fundraising event was attended by St. Catherine’s senior and departmental leadership, medical staff and community members, many of whom were dressed in blue for the cause.

The two-hour cocktail party had a two-prong objective. The first was to raise awareness about the new American Cancer Society screening guidelines for colorectal cancer, which was moved from age 50 to 45 for both men and women in 2018. The second goal was to raise funds to support the hospital’s community service initiative to provide free colonoscopy screenings to underserved populations on Long Island.

“Colorectal screenings save lives and the earlier you are screened, the better your outcomes,” said Martinez. “Colorectal cancer affects men and women alike, so please be diligent about your health, and encourage your loved ones to get screened at the appropriate age.”

Martinez also took the opportunity to thank Habberstad BMW General Manager Jim McCarthy for supporting the medical center and joining such important dialogue

In addition to co-hosting the event in its showroom, the dealership sponsored the hors d’oeuvres and  donated raffle prizes, including a BMW Genuine Cruise M-Bike. The event’s raffle sales yielded $2,120, and Habberstad BMW also donated a percentage of all sales during the month of March to support free colonoscopy screenings to be provided by St. Catherine of Siena throughout the year. 

“The event was certainly fun, well attended and most importantly, it offered the unique opportunity for me to educate the community about updates in colorectal screenings. We look forward to doing it again next year,” said Martinez. For more information about colorectal screenings, please call 631-870-3444.

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Comparing Paleo and Mediterranean diets

By David Dunaief, M.D.

We have made great strides in the fight against heart disease, yet it remains the number one cause of death in the United States. Why is this? Many of us have the propensity toward heart disease. Can we alter this course, or is it our destiny?

A 2013 study involving the Paleo-type diet and other ancient diets suggests that there is a significant genetic component to cardiovascular disease, while another study looking at the Mediterranean-type diet implies that we may be able to reduce risk factors greatly. Most of the risk factors for heart disease, such as high blood pressure, high cholesterol, sedentary lifestyle, diabetes, smoking and obesity are modifiable (1). Let’s look at the evidence.

Genetic components

Researchers used computed tomography scans to look at 137 mummies from ancient times across the world, including Egypt, Peru, the Aleutian Islands and Southwestern America (2). The cultures were diverse, including hunter-gatherers (consumers of a Paleo-type diet), farmer-gatherers and solely farmers. Their diets were not vegetarian; they involved significant amounts of animal protein, such as fish and cattle.

Researchers found that one-third of these mummies had atherosclerosis (plaques in the arteries), which is a precursor to heart disease. The ratio should sound familiar. It seems to coordinate with modern times.

The authors concluded that atherosclerosis could be part of the aging process in humans. In other words, it may be a result of our genes. Being human, we all have a genetic propensity toward atherosclerosis and heart disease, some more than others, but many of us can reduce our risk factors significantly.

I am not saying that the Paleo-type diet specifically is not beneficial compared to the standard American diet. Rather, that this study does not support that, although validating the Paleo-type diet was not its intention. However, other studies demonstrate that we can reduce our chances of getting heart disease with lifestyle changes, potentially by following a Mediterranean-type diet with an emphasis on a plant-rich approach.

Mediterranean-type diet

A study about the Mediterranean-type diet and its potential impact on cardiovascular disease risk was published in the New England Journal of Medicine (3). Here, two variations on the Mediterranean-type diet were compared to a low-fat diet. People were randomly assigned to three different groups. The two Mediterranean-type diet groups both showed about a 30 percent reduction in the risk of cardiovascular disease, with end points including heart attacks, strokes and mortality, compared to the low-fat diet. This improvement in risk profile occurred even though there was no significant weight loss.

The Mediterranean-type diets both consisted of significant amounts of fruits, vegetables, nuts, beans, fish, olive oil and potentially wine. I call them “the Mediterranean diet with opulence,” because both groups consuming this diet had either significant amount of nuts or olive oil and/or wine. If the participants in the Mediterranean diet groups drank wine, they were encouraged to drink at least one glass a day.

The study included three groups: a Mediterranean diet supplemented with mixed nuts (almonds, hazelnuts or walnuts), a Mediterranean diet supplemented with extra virgin olive oil (at least four tablespoons a day) and a low-fat control diet. The patient population included over 7,000 participants in Spain at high risk for cardiovascular disease.

The strength of this study, beyond its high-risk population and its large size, was that it was a randomized clinical trial, the gold standard of trials. However, there was a significant flaw, and the results need to be tempered. The group assigned to the low-fat diet was not, in fact, able to maintain this diet throughout the study. Therefore, it really became a comparison between variations on the Mediterranean diet and a standard diet.

What do the leaders in the field of cardiovascular disease and integrative medicine think of the Mediterranean diet study? Interestingly there are two diametrically opposed opinions, split by field. You may be surprised by which group liked it and which did not. Cardiologists hailed the study as a great achievement. They included Henry Black, M.D., who specializes in high blood pressure, and Eric Topol, M.D. They emphasized that now there is a large RCT measuring clinical outcomes, such as heart attacks, stroke and death.

On the other hand, the integrative medicine physicians, Caldwell Esselstyn, M.D., and Dean Ornish, M.D., both of whom stress a plant-rich diet that may be significantly more nutrient dense than the Mediterranean diet in the study, expressed disappointment with the results. They feel that heart disease and its risk factors can be reversed, not just reduced. Both clinicians have published small, well-designed studies showing significant benefits from plant-based diets (4, 5). Ornish actually showed a reversal of atherosclerosis in one of his studies (6).

So who is correct about the Mediterranean diet? Each opinion has its merits. The cardiologists’ enthusiasm is warranted, because a Mediterranean diet, even one of “opulence,” will appeal to more participants, who will then realize the benefits. However, those who follow a more strict diet, with greater amounts of nutrient-dense foods, will potentially see a reversal in heart disease, minimizing risk — and not just reducing it.

Thus, even with a genetic proclivity toward cardiovascular disease, we can very much alter our destinies. The degree depends on the willingness of the participants.

References:

(1) www.uptodate.com. (2) BMJ 2013;346:f1591. (3) N Engl J Med 2018; 378:e34. (4) J Fam Pract. 1995;41(6):560-568. (5) Am J Cardiol. 2011;108:498-507. (6) JAMA. 1998 Dec 16;280(23):2001-2007.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.  

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A thyroid nodule is an abnormal growth that forms a lump in the thyroid gland. Stock photo
Most identified incidentally are benign

By David Dunaief, M.D.

Dr. David Dunaief

More than 50 percent of people have thyroid nodules detectable by high-resolution ultrasound (1). Fortunately, most are benign. A small percent, 4 to 6.5 percent, are malignant, with the number varying depending on the study (2). Thyroid nodules are being diagnosed more often incidentally on radiologic exams, such as CT scans of the chest, MRI scans, PET scans and ultrasounds of the carotid arteries in the neck (3).

There is a conundrum of what to do with a thyroid nodule, especially when it is found incidentally. It depends on the size. If it is over one centimeter, usually it is biopsied by fine needle aspiration (FNA) (4). While most are asymptomatic, if there are symptoms, these might include difficulty swallowing, difficulty breathing, hoarseness, pain in the lower portion of the neck and a goiter (5).

FNA biopsy is becoming more common. In a study evaluating several databases, there was a greater than 100 percent increase in thyroid FNAs performed over a five-year period from 2006 to 2011 (6). This resulted in a 31 percent increase in thyroidectomies, surgeries to remove the thyroid partially or completely.

However, the number of thyroid cancers diagnosed with the surgery did not rise in this same period. Though the number of cancers diagnosed has increased, the mortality rate has remained relatively stable over several decades at about 1,500 patients per year (7). Thyroid nodules in this study were least likely to be cancerous when the initial diagnosis was by incidental radiologic exam.

Treating borderline results

As much as 25 percent of FNA biopsies are indeterminate. We are going to look at two modalities to differentiate between benign and malignant thyroid nodules when FNA results are equivocal: a PET scan and a molecular genetics test. A meta-analysis (a group of six studies) of PET scan results showed that it was least effective in resolving an unclear FNA biopsy. The PET scan was able to rule out patients who did not have malignancies, but did not do a good job of identifying those who did have cancer (8).

On the other hand, a molecular-based test was able to potentially determine whether an indeterminate thyroid nodule by FNA was malignant or benign (9).

Unlike in the PET scan study above, the researchers were able to not only rule out the majority of malignancies but also to rule them in. It was not perfect, but the percent of negative predictive value (ruled out) was 94 percent, and the positive predictive value (ruled in) was 74 percent. The combination test improved the predictive results of previous molecular tests by 65 to 69 percent. This is important to help decide whether or not the patient needs surgery to remove at least part of the thyroid.

Significance of calcification on ultrasound

Microcalcifications in the nodule can be detected on ultrasound. The significance of this may be that patients with microcalcifications are more likely to have malignant thyroid nodules than those without them, according to a small prospective study involving 170 patients (10). This does not mean necessarily that a patient has malignancy with calcifications, but there is a higher risk.

Good news

As I mentioned above, most thyroid nodules are benign. The results of one study go even further, showing that most asymptomatic benign nodules do not progress in size significantly after five years (11). The factors that did contribute to growth of about 11 percent of the nodules were age (<45 years old had more growth than >60 years old), multiple nodules, greater nodule volume at baseline and being male.

The authors’ suggestion is that, after the follow-up scan, the next ultrasound scan might be five years later instead of three years. However, they did discover thyroid cancer in 0.3 percent after five years.

Thyroid function may contribute to risk

In considering risk factors, it’s important to note that those who had a normal thyroid stimulating hormone (TSH) were less likely to have a malignant thyroid nodule than those who had a high TSH, implying hypothyroidism. There was an almost 30 percent prevalence of cancer in the nodule if the TSH was greater than >5.5 mU/L (12).

The bottom line is that there is an urgent need for new guidelines regarding thyroid nodules. Fortunately, most nodules are benign and asymptomatic, but the number of cancerous nodules found is growing. Why the death rate remains the same year over year for decades may have to do with the slow rate at which most thyroid cancers progress, especially two of the most common forms, follicular and papillary.

References:

(1) AACE 2013 Abstract 1048. (2) Thyroid. 2005;15(7):708. (3) uptodate.com. (4) AACE 2013 Abstract 1048. (5) thyroid.org. (6) AAES 2013 Annual Meeting. Abstract 36. (7) AACE 2013 Abstract 1048. (8) Cancer. 2011;117(20):4582-4594. (9) J Clin Endocrinol Metab. Online May 12, 2015. (10) Head Neck. 2008 Sep;30(9):1206-1210. (11) JAMA. 2015;313(9):926-935. (12) J Clin Endocrinol Metab. 2006;91(11):4295.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management.    

We invite you to check out our weekly Medical Compass MD Health Videos on Times Beacon Record News Media’s website, www.tbrnewsmedia.com.

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Narcan, a drug that stops opioid overdoses. File photo by Jessica Suarez

By Donna Deedy

New York State Attorney General’s office announced March 28 that it has expanded a lawsuit against opioid manufacturers, distributors and members of the Sackler family, whose company Purdue Pharma made and marketed OxyContin.

The lawsuit, originally filed in Suffolk County, has now become the nation’s most extensive case to date to legally address the opioid crisis.  

Suffolk County Executive Steve Bellone (D)applauded the move.

“It is our hope that our lawsuit, and ones like it, will bear fruit that forever changes the way destructive—but profitable—drugs are marketed and sold across the nation,” he said.

“As the Sackler Family and the other defendants grew richer, New Yorkers’ health grew poorer and our state was left to foot the bill.”

— Letitia James

The lawsuit alleges that six national prescription opioid manufacturers, four prescription drug distributors and members of the Sackler family are largely responsible for creating the opioid epidemic through years of false and deceptive marketing that ignored their obligation to prevent unlawful diversion of the addictive substance. 

The amended lawsuit includes Attorney General Letitia James’  findings from a multi-year, industry-wide investigation of opioid market participants, which alleges that manufacturers implemented a common “playbook” to mislead the public about the safety, efficacy, and risks of their prescription opioids. 

“Manufacturers pushed claims that opioids could improve quality of life and cognitive functioning, promoted false statements about the non-addictive nature of these drugs, masked signs of addiction by referring to them as “pseudoaddiction” and encouraged greater opioid use to treat it, and suggested that alternative pain relief methods were riskier than opioids, among other grossly misleading claims,”  the attorney general’s office stated in its summary of the amended suit. The office claims that manufacturers used a vast network of sales representatives to push dangerous narratives and target susceptible doctors, flood publications with their deceptive advertisements, and offer consumer discount cards and other incentives to them to request treatment with their product. 

The manufacturers named in the amended complaint include Purdue Pharma and its affiliates, members of the Sackler family (owners of Purdue) and trusts they control, Janssen Pharmaceuticals and its affiliates (including parent company Johnson & Johnson), Mallinckrodt LLC and its affiliates, Endo Health Solutions and its affiliates, Teva Pharmaceuticals USA, Inc. and its affiliates and Allergan Finance, LLC.  The distributors named in the complaint are McKesson Corporation, Cardinal Health, Inc., Amerisource Bergen Drug Corporation and Rochester Drug Cooperative, Inc.

“As the Sackler Family and the other defendants grew richer, New Yorkers’ health grew poorer and our state was left to foot the bill,” James stated. “The manufacturers and distributors of opioids are to blame for this crisis and it is past time they take responsibility.” 

“This company and company’s owners knew the addictive quality and used it for financial gain.”

— Kara Hahn

The opioid epidemic has ravaged families and communities nationwide and across New York. Suffolk County has been particularly hard hit statewide. When the county originally filed its lawsuit, legislators reported that the region suffered the highest number of heroin deaths statewide.  Between 2009 and 2013, 418 people died of a heroin overdose. Many people turned to heroin when their prescriptions ran out.  The opioid related death tolls have continued to rise.According to New York State Health Department data for 2017, opioid pain relievers, including illicitly produced fentanyl, caused 429 deaths in Suffolk County. Over six thousand people were admitted for opioid addiction, including heroin, into the counties Office of Alcohol and Substance Abuse Services. 

“I applaud New York State Attorney General James for joining in our efforts to recoup untold amounts of public funds that were spent to assist those afflicted by this epidemic,” Bellone stated. “Suffolk County is taking a page out of Big Tobacco’s playbook to hold the Sackler family and others accountable for their role in connection with the opioid crisis.  

The Suffolk County legislature is proceeding with their lawsuit as it was originally put forward, but officials agreed with the state’s initiative.

“The pharceutical companies opened the flood gates,” said county Legislator Sarah Anker (D-Mt. Sinai). “I agree the Sacklers should be targeted for a lawsuit.”

County Legislators Anker, Kara Hahn (D-Port Jefferson) and William Spencer (D-Centerport) originally co-sponsored the bill.

“It’s an incredibly important that all responsible be held accountable,” Hahn said. “This company and company’s owners knew the addictive quality and used it for financial gain.”

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After Rockland County declared a countywide state of emergency last week banning any person under 18 who is unvaccinated for measles from public spaces, Suffolk County issued a recommendation.

In a press release, Suffolk County Executive Steve Bellone (D) and Suffolk County Health Commissioner Dr. James Tomarken urged county residents to make sure they are immunized against measles. Despite the recent ban in Rockland County due to a reported 157 cases of measles since October 2018, there is no immediate public concern in Suffolk.

“In light of recent reports, residents should make sure to receive their measles shots to protect themselves,” Bellone said in the press release. “While there is no immediate public health concern in Suffolk County, this should serve as a reminder to do what is necessary out of an abundance of caution.”

Stony Brook Children’s Hospital’s Dr. Sharon Nachman, division chief of Pediatric Infectious Diseases and professor of pediatrics, said early symptoms of measles, which is a virus, can be mistaken for the common cold with a patient suffering from a runny nose, fever and red, watery eyes. She said even doctors can miss the signs of measles, that is until the typical rash of flat red spots appears.

The best protection against measles is the measles, mumps, rubella vaccine, the doctor said, and two doses of the MMR vaccine is needed. Measles is highly contagious, and a person could infect others even 60 feet away. She said an unvaccinated person can potentially catch the measles even if they were in the same supermarket or airport as an infected person.

“The reason for the isolation is to keep the kids who are at risk from the kids who are incubating the illness, or they don’t know they have measles,” she said, adding there are those who are unable to be vaccinated due to medical reasons.

The doctor said anyone born before 1957 more than likely had measles. After 1957, three different vaccines for measles, mumps and rubella were given, and now all are combined into one immunization called MMR. She said one should find their immunization records to see if they received two rounds of each when it was split, or two doses of the MMR vaccine. Once a person gets the measles or the proper doses of the MMR vaccine, they are immune to measles.

Nachman said it’s important to get the full doses, and if a person isn’t sure if they got two rounds of MMR, an extra dose will not hurt them.

When she talks with parents who are hesitant about the immunizations, Nachman said she tells them not to be fooled by what’s written on the internet, and to make sure any website they visit has a review process by professionals as anyone can write anything on a blog without checking facts.

The doctor also said it’s important to remember diseases such as measles are still in the environment, and just because we don’t have an outbreak right now, it doesn’t mean it’s not possible. She calls immunization “community protection” instead of using the common term “herd immunity,” which describes when the majority of the population is vaccinated, there is less likelihood of an unvaccinated person being infected.

“You have to do the same thing for your entire community that you expect your community to do for you,” she said. “That’s what community protection is all about. You don’t want your kid getting into a car unless the driver is wearing a seatbelt and your kid is wearing a seatbelt. That’s what a community does. It protects everyone in the community.”

According to the Centers for Disease Control and Prevention website, cases of measles have been confirmed in 15 states and is still common in many parts of the world. Measles has been brought into the United States by unvaccinated American travelers and foreign visitors, according to the website. Worldwide, an estimated 20 million people get measles. Out of those infected, 146,000, mostly children, die from the illness each year.

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Stony Brook University Hospital plans to launch two mobile emergency room units in the spring designed to treat stroke patients.
Lifesaving service for the community

By Ernest J. Baptiste

Ernest Baptiste

According to a study in the American Heart Association’s journal Stroke, when a blood vessel supplying the brain is blocked, nearly two million brain cells are lost for each minute that passes, making stroke one of the most time-sensitive diagnoses in medicine. The faster blood flow can be restored to the brain, the more likely that a person will have a full recovery.

That said, Suffolk County residents now have one more reason to look to Stony Brook Medicine for the highest level of care for both ischemic stroke (when a clot blocks the flow of blood to the brain) and hemorrhagic stroke (bleeding within the brain tissue).   

This month we are launching Long Island’s first mobile stroke unit program — a revolutionary pre-hospital program designed to provide specialized, lifesaving care to people within the critical moments of stroke before they even get to the hospital.

While new to Long Island, mobile stroke units have successfully reduced stroke disability and have improved survival rates in other major metropolitan areas across the country. Stony Brook Medicine is collaborating with over 40 emergency medical service (EMS) agencies throughout Suffolk County to provide this lifesaving, time-sensitive care.

Each mobile stroke unit is a mobile emergency room with a full crew of first responders, brain imaging equipment and medications. The units also have telehealth capability to Stony Brook University Hospital, which allows our physicians at the hospital to communicate in real time with the crew and patient, and immediately check for a blocked vessel or bleeding in the brain. This helps to markedly accelerate the time needed to make an accurate stroke diagnosis.

The first responders onboard the mobile stroke unit can then begin administering time-sensitive, advanced stroke treatments while the person is en route to the nearest hospital that can provide them with the appropriate level of care. 

The units are in operation seven days a week, from 8 a.m. to 8 p.m., which is the window of time when most stroke calls are received in Suffolk County.

One is strategically stationed at a base station located off of the Long Island Expressway at Exit 57. The other, which will be launched soon, will be stationed similarly off of Exit 68. These locations were chosen for easy east-west and north-south access. The team will take calls within a 10-mile radius of each base, which includes about 40 different communities.

Ernest J. Baptiste is chief executive officer of Stony Brook University Hospital.

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Fiber-rich foods, including whole grains, seeds and legumes, as well as some beverages, such as coffee and wine, contain measurable amounts of lignans. Stock photo
Lignans may reduce diabetes risk

By David Dunaief, M.D.

Dr. David Dunaief

Type 2 diabetes is pervasive throughout the population, regardless of age. Yet, even with its prevalence, many myths persist about managing diabetes. Among these are: Fruit should be limited or avoided; soy has detrimental effects with diabetes; plant fiber provides too many carbohydrates; and bariatric surgery is an alternative to lifestyle changes.

All of these statements are false. Let’s look at the evidence.

Fruit

Fruit, whether whole fruit or fruit juice, has been thought of as taboo for those with diabetes. This is only partially true. Yes, fruit juice should be avoided because it does raise or spike glucose (sugar) levels. The same does not hold true for whole fruit. Studies have demonstrated that patients with diabetes don’t experience a spike in sugar levels whether they limit the number of fruits consumed or have an abundance of fruit (1). In another study, whole fruit was shown to reduce the risk of type 2 diabetes (2).

In yet another study, researchers looked at the impacts of different whole fruits on glucose levels. They found that berries reduced glucose levels the most, but even bananas and grapes reduced these levels (3). That’s right, bananas and grapes, two fruits people associate with spiking sugar levels and increasing carbohydrate load. The only fruit that seemed to have a mildly negative impact on sugars was cantaloupe.

Whole fruit is not synonymous with sugar. One of the reasons for the beneficial effect is the flavonoids, or plant micronutrients, but another is the fiber.

Fiber

In the Nurses’ Health Study and NHS II, two very large prospective observational studies, plant fiber was shown to help reduce the risk of type 2 diabetes (4). Researchers looked at lignans, a type of plant fiber, specifically examining the metabolites enterodiol and enterolactone. They found that patients with type 2 diabetes have substantially lower levels of these metabolites in their urine, compared to the control group without diabetes. There was a linear, or direct, relationship between the amount of metabolites and the reduction in risk for diabetes. The authors encourage patients to eat more of a plant-based diet to get this benefit.

Foods with lignans include flaxseed; sesame seeds; cruciferous vegetables, such as broccoli and cauliflower; and an assortment of fruits and grains (5). The researchers believe the effect is from antioxidant activity.

Soy and kidney function

In diabetes patients with nephropathy (kidney damage or disease), soy consumption showed improvements in kidney function (6). There were significant reductions in urinary creatinine levels and reductions of proteinuria (protein in the urine), both signs that the kidneys are beginning to function better.

This was a small, but randomized controlled trial over a four-year period with 41 participants. The control group’s diet consisted of 70 percent animal protein and 30 percent vegetable protein, while the treatment group’s consisted of 35 percent animal protein, 35 percent textured soy protein and 30 percent vegetable protein.

This is very important since diabetes patients are 20 to 40 times more likely to develop nephropathy than those without diabetes (7). It appears that soy protein may put substantially less stress on the kidneys than animal protein. However, those who have hypothyroidism should be cautious or avoid soy since it may suppress thyroid functioning.

Bariatric surgery

In recent years, bariatric surgery has grown in prevalence for treating severely obese (BMI>35 kg/m²) and obese (BMI >30 kg/m²) diabetes patients. In a meta-analysis of bariatric surgery involving 16 RCTs and observational studies, the procedure illustrated better results than conventional medicines over a 17-month follow-up period in treating HbA1C (three-month blood glucose measure), fasting blood glucose and weight loss (8). During this time period, 72 percent of those patients treated with bariatric surgery went into diabetes remission and had significant weight loss.

However, after 10 years without proper management involving lifestyle changes, only 36 percent remained in remission with diabetes, and a significant number regained weight. Thus, whether one chooses bariatric surgery or not, altering diet and exercise are critical to maintain long-term benefits.

There is still a lot to be learned with diabetes, but our understanding of how to manage lifestyle modifications, specifically diet, is becoming clearer. The take-home message is: focus on a plant-based diet focused on fruits, vegetables, beans and legumes. And if you choose a medical approach, bariatric surgery is a viable option, but don’t forget that you need to make significant lifestyle changes to accompany the surgery.

References:

(1) Nutr J. 2013 Mar. 5;12:29. (2) Am J Clin Nutr. 2012 Apr.;95:925-933. (3) BMJ online 2013 Aug. 29. (4) Diabetes Care. online 2014 Feb. 18. (5) Br J Nutr. 2005;93:393–402. (6) Diabetes Care. 2008;31:648-654. (7) N Engl J Med. 1993;328:1676–1685. (8) Obes Surg. 2014;24:437-455.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. 

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