ADHD Teens: The Risks of Learning to Drive
Matt McMillen, Washington Post- 12/10/2002

When Brian Cox got his driver's license at 16, his parents wouldn't allow him to have passengers in the car until he had clocked 5,000 safe miles behind the wheel. Kevin Snyder's parents made him drive with them for 21 consecutive days without the slightest infraction before they allowed him to apply for his license. Any time he looked away from the road to change a radio station, for example, his parents pushed him back to Day One. It took him two years to graduate from learner's permit to full license. Both teens' parents had worries beyond those that most parents have when their children start to drive: Brian and Kevin have attention-deficit hyperactivity disorder (ADHD).
   Studies indicate that young people with the disorder, who often find it difficult to concentrate and are more prone than others to impulsive behavior, have abnormally high rates of traffic violations, accidents and instances of driving without a license. One study, funded by the National Institute of Child Health and Human Development and published in July, reported that of 105 people with ADHD who were studied, about 20 percent had had their license suspended or revoked -- the same number who had received 12 or more traffic citations or had caused more than $6,000 in damage in their first crash. Those figures are two to four times the norm for young adults. In addition, about 25 percent of them had been involved in three or more crashes -- a rate seven times higher than normal.
   For those familiar with the disorder -- an estimated 3 to 7 percent of school-age children have it, with perhaps half of them continuing to be affected into adulthood -- those statistics likely are not terribly surprising. Larry B. Silver, a clinical professor of psychiatry at Georgetown University Medical Center who specializes in treating ADHD, puts it plainly: "Those who are distractible may be paying attention to things other than driving." This suggests that many parents of teens with ADHD should pay particularly close attention to their child's driving.
   "We did a lot of road riding with Brian," says his father, Daniel Cox. "We were vigilant about his inattention. Still, the first time I took Brian out, he pressed the accelerator instead of the brake at a stop sign. On the highway, I caught him with his whole head down when changing the radio station." Those early mistakes were hardly unexpected. Cox had started to prepare Brian for driving long before he got his learner's permit. "We knew it was coming," Cox says. "We talked about it, we set up steps."
   Marlene Snyder, Kevin Snyder's mother, has a similar story: "We started talking to Kevin in second grade about consequences involved in driving." She also talked with him about his ADHD. She wanted to be certain that he understood it and its implications for driving -- and to prepare him for the possibility that he might not start to drive when his friends did. For many children with ADHD, says John Pleasant, a Washington-based clinical social worker, the disorder brings with it "a sense of shame and embarrassment . . . of feeling different and angry. . . . For kids old enough to drive, there has been a long-term wrestling with that." Snyder agrees. "Kids don't want to be different from other kids," she acknowledges sympathetically. For her, though, it's a safety issue. "It's a horrible experience, going to a teenager's funeral," says Snyder, who believes ADHD was a factor in several accidents that have left acquaintances dead or seriously injured. It falls to parents to help their child to understand and accept the disorder -- "not like it," says Pleasant, "accept it" -- and to take charge of it. Cox took a novel approach to doing that with his son: He not only talked with Brian about the disorder and safe driving; he also encouraged him to study the subject. When Brian was 14, he built a rudimentary driving simulator and entered it in a statewide science fair in Virginia. He won a first-place award.
   If the attention that Daniel Cox and Marlene Snyder paid to driving and ADHD seems unusual, it may be because they are drawing on professional experience. Snyder, an education consultant specializing in ADHD-related issues, has written a book called "ADHD and Driving: A Guide for Parents of Teens with ADHD." Cox, a professor of psychiatric medicine and the director of the Behavioral Medicine Center at the University of Virginia, has researched the relationship between driving and such diseases and disorders as alcoholism, Alzheimer's and diabetes. Now, his focus is on driving and ADHD. Both of his sons -- Brian and younger brother Cory -- have the disorder. "Seeing them grow up got me focused on that," he says. For both Cox and Snyder, one rule was paramount for their teens once they started to drive: Take your medicine or you can't take the car. Recent drug studies, some conducted by Cox, are giving new strength to that advice.

First Line of Treatment
Stimulant medications such as Ritalin are the most frequent first line of treatment for ADHD. They have been prescribed for more than 50 years and are overwhelmingly regarded as safe for adults and children aged 6 and older who have properly diagnosed ADHD. "Ritalin is a specific drug for a specific disorder," says Cox, whose own research on Ritalin, conducted in 2000, showed evidence that Ritalin improved the driving of college students with ADHD. Comparing seven students with ADHD to six without, his study found that "there was no difference between ADHD and non-ADHD subjects while on Ritalin."
   More recently, Cox compared the driving behavior of young adults on Ritalin to those taking a newer drug, Concerta. Both are methylphenidate-based stimulants; however, Concerta is a long-acting drug that requires a single daily dose, while Ritalin must be taken two to three times a day. The results of that second study, which was funded by McNeil Consumer and Specialty Pharmaceuticals, the maker of Concerta, suggest that those taking the longer-acting stimulant will drive consistently more safely during a given day than those on shorter-acting drugs.
   As Cox pointed out in the first study, "A major limitation with Ritalin is its short half-life. If a driver takes the medication twice a day, at breakfast and lunch, there would be no medication in the bloodstream at one of the high accident times, the 5 to 6 p.m. rush hour." There is also a significant lag period between doses, during which symptoms can return in force. Drivers on Concerta, Cox found, did not have this problem: "One of the unanticipated events was the consistency of the Concerta subjects over time," he says. "Their driving behavior at 11 p.m. was the same as at 2 p.m." Both studies conducted by Cox were small, a limitation that he acknowledges. Still, they are significant -- not only for what they suggest but also for the fact that they are being done at all. Until 10 years ago, the relationship between ADHD and driving risks had gone largely unnoticed.

Studying the Problem
In the early 1990s, on a visit to a rehabilitation center in Milwaukee, Russell Barkley walked past a lab in which the driving skills of elderly people were being measured. Using baby-toy steering wheels connected to a computer, researchers gathered data on critical abilities such as reaction time and problem-solving. Barkley had recently read a Canadian study suggesting a rate of traffic violations and accidents among ADHD drivers that was four times the norm. That study piqued his curiosity. Those flimsy steering wheels gave him an idea. "I looked around at the lab," Barkley recalls, "and said someone should do this for ADHD." Not everyone agreed. On his return to the University of Massachusetts, he found little interest among his colleagues in psychiatry and psychology. To him, though, the idea was new and exciting: "No one had done this."
   Now at the Medical University of South Carolina in Charleston, Barkley was until recently the director of psychology and a professor of psychiatry and neuropsychology at the University of Massachusetts; he also founded the university's clinics for children and adults with ADHD. Barkley began his driving research by attempting to confirm the Canadian findings in a study he conducted in Milwaukee. Surveys submitted by parents of teens with ADHD, as well as by parents of teens who did not have the disorder, revealed a tremendous number of accidents and traffic violations among the former group. During the three- to five-year period covered by the surveys, nearly a quarter of the 44 teens with ADHD had had their licenses suspended or revoked, and the ADHD drivers were involved in 54 crashes. In a control group of 37, only 16 cashes were reported a crash during the same period. "We replicated the Canadian study," Barkley says of his research, the results of which were published in 1993, "but we also saw that it was worse than we had imagined. Their knowledge of the rules of the road was normal -- they just didn't know how to apply them. "At that point we realized it was a scary problem."
   According to Barkley, that first study was crudely done. He wanted to use sophisticated driving simulators and he wanted to evaluate driving behavior on the road. So he hired driving instructors to ride with both ADHD teens and a control group of other young drivers. The teens with the disorder became easily frustrated, and their emotions were closer to the surface as they drove, the study found. The data, as it accumulated, began to paint a frightening picture. "Our driving instructors found that ADHD teens wouldn't wait at stop lights, they cut people off, they drove on the shoulder and ran lights." Two of the instructors quit the study -- they didn't feel safe. Barkley recalls: "If it had not been a study, they said they would have sought revocation of the ADHD teens' driver's licenses." Barkley now realizes he shouldn't have been shocked by what his studies revealed: "In hindsight, it doesn't surprise me, but no one was interested then" in the impact of ADHD on driving performance, he says. "At the time nobody cared, nobody looked, nobody knew."

Parents in Control
Now, as a result of studies like those conducted by Barkley and Daniel Cox, that has begun to change, at least among researchers. And Marlene Snyder hopes to bring the research findings to parents, along with her guidelines for reducing risks on the road. In the 20 steps she offers in her book, the stress repeatedly falls on parental involvement. That involvement, she emphasizes, has to begin before the teen starts to drive: "Parents have to talk really early. The best time to think about responsibilities is before your teen gets behind the wheel." More than just talk, though, parents must model safe driving behavior -- using the side view mirror and signaling before changing lanes, coming to a complete stop at stop signs, observing speed limits. School-based driver's education programs, she writes, "should be treated as an excellent supplement to your own driver education efforts." "Kids with ADHD are often behind other kids in age maturation," she points out. "Parents have to honestly observe their kids -- do I feel safe when I am riding with them?" And if they don't? "They have no business allowing them to drive." Of course, the same could be said of the parents of any teen. As Daniel Cox stresses, "There are all sorts of conditions out there that affect driving: sleep apnea, diabetes requiring insulin. . . . What I want to point out is ADHD is not unique in making driving dangerous."
   Brian Cox, 19, and Kevin Snyder, 25, have been driving for a few years. With supportive parents and the right medication ("No medication, my son doesn't drive," says Daniel Cox, who notes that Brian keeps some Ritalin in his car in case his dosing routine is interrupted), each has learned to drive safely. Cox laughs when asked about his 14-year-old, Cory, but his trepidation is plain. Cory really wants to drive. "He gets to get in and start Brian's '66 Mustang every night," Cox says. But father and son have already started talking about the day, and the conditions, when Cory will start driving. He'll be prepared.

ADHD and Driving
"There are all sorts of conditions out there that affect driving," says Daniel Cox, who has studied attention deficit hyperactivity disorder (ADHD). "What I want to point out is that ADHD is not unique in making driving dangerous." Nor are the ways to improve safety unique for teens with the disorder. Aside from the section on medication in her book "ADHD and Driving," says Marlene Snyder, "the steps are useful for any parent." The steps she and Cox emphasize:
1. Talk with your teen before he or she starts to drive, about both the disorder and its possible consequences on the road.
2. Model good driving practices.
3. Set up firm rules and enforce them strictly -- "Parents love my book, but kids hate it," Snyder jokes.
4. Determine your teen's readiness to drive-- if you don't think it's time, don't let them on the road.
5. Know your state's licensing laws and restrictions, and don't hesitate to set your own. 6. Do not let your teen drive without being properly medicated-- "It's okay for parents to require medications," Snyder says. "It's a safety issue."
   For more information on ADHD or to obtain a copy of Snyder's book, contact Children and Adults with Attention Deficit Disorder (CHADD), a nonprofit organization, at 8181 Professional Place, Suite 201, Landover, MD 20705; 301-306-7070; www.chadd.org.

Portraying Depression As Natural and Treatable
John Langone, New York Times- 12/10/2002

"The Secret Strength of Depression," third edition, by Dr. Frederic Flach, Hatherleigh Press, $15.95.
"When Your Body Gets the Blues," by Dr. Marie-Annette Brown and Jo Robinson, Rodale, $22.95.
Mild, situational or full-blown, melancholy or the blues, depression by any name wounds the soul, to paraphrase Voltaire. It brings sorrow and sadness and sleeplessness and a host of other reactions that can drain life of its color and meaning. Dr. Flach, an attending psychiatrist at two New York hospitals, focuses his book on the depression denoted by "episodes of emotional pain" and offers advice on making it a positive force. Dr. Brown, a registered nurse and a professor of nursing at the University of Washington, looks at a common complaint among women that she calls the "body blues" and textbooks refer to as "vegetative depressive symptoms." It may not be outright depression, but it can have mild depression as a symptom, along with low energy, overeating, difficulty. concentrating, decreased interest in sex and heightened sensitivity to criticism. But however you look at it, blues or depression, each diminishes the enjoyment of life.
   With respect to clinical depression, 10 percent to 25 percent of women and 5 to 12 percent of men will meet the criteria for a diagnosis at some point, according to Dr. Flach. Visits to physicians for depression have increased to more than 20 million in the late 90's from 11 million in the mid-1980's in the United States, he says. His book details the essentials of depression, its nature, how to recognize it and what to expect from various treatments. More than that, it is about how depression forces people to look inward and makes the point that it is an inevitable part of any healthy life. "Becoming depressed," he writes, "is a common psychobiological response to stress." When it involves grief, he says, depression becomes an outlet for the intense feelings of loss associated with the end of a relationship. "When it's a signal that something's wrong, in a marriage or work situation, it fuels us to do something about what's wrong."
   Dr. Brown's book is more in the magazine self-help genre, with charts, checklists, quizzes and vitamin recommendations. With respect to those blues, tens of millions of women are troubled by them, the author says. (Men can have them, too, she adds, especially those over 40). It is Dr. Brown's contention that a woman's biology plays a significant role in her developing the syndrome and that when certain hormones are at a low ebb, trouble starts. One common complaint, she says, is feeling tired and sluggish much of the time, accompanied by overeating and weight gain.
   One can have the "body blues" all by itself, Dr. Brown writes, or it can be part of other disorders. "For example," she says, "PMS could be viewed as the body blues plus bloating, cramps or breast tenderness." Dr. Brown's solution is a simple drug-free one she calls the Levity program, a "tortured acronym "for light, exercise and vitamin intervention therapy. The program involves creating a more natural lighting environment ("Try to work as closely as possible to a window"), going for 20-minute brisk outdoor walks at least five times a week and taking six common and inexpensive vitamins and minerals.

Drug Ads Blur the Line Between Tension & Illness
Linda Marsa, Los Angeles Times- 12/10/2002

The ads seem to be everywhere, on TV, in magazines, doctors' offices, the Internet: Are you feeling tense? Having difficulty sleeping? Scared of criticism? If so, they suggest, the answer could be a pill -- an antidepressant, to be exact. The drugs that revolutionized the treatment of depression a decade ago now are increasingly used to treat anxiety disorders, mental illnesses that can cause paralyzing worry or intense fear of social situations. Caused by a deficiency in brain chemistry, the disorders can indeed be remedied by potent mood-altering medications such as Paxil and Efexor. Drug companies commonly seek new uses for their drugs; it's a way of expanding their market and getting a greater return on the money spent doing research. But now it appears they could be capturing a new segment of patients --those with less serious disorders, such as occasional anxiety. Since the federal government approved the drugs for generalized anxiety disorder and social phobia, prescriptions for the medications have soared. Doctors and other health experts, meanwhile, report a marked increase in the number of patients claiming anxiety disorders and seeking relief.
   Just about everyone has experienced situational anxieties -- when personal or professional stress keeps us keyed up and disturbs our sleep -- and it can be difficult to pinpoint exactly when life's mundane worries escalate into a full-blown psychiatric disorder "There are few conditions where there's a black and white cutoff" says Dr. Franklin Schneier, a psychiatrist at Columbia University in New York. Consequently, some mental health experts say, people with normal angst may get medications they don't need, sometimes suffering from side effects such as agitation, insomnia, loss of libido and, when they try to quit the drugs, withdrawal. At a time when managed care companies are cutting expenses, this marketing of the drugs also ratchets up consumer demand for costly name brands when generics, or even counseling, may do the job just as well.
   Doctors and psychologists say the broad push to prescribe medications for anxiety is further indication we're medicalizing normal variations in temperament. The advertising is "a double-edged sword," says Dr. Michael Brase, medical director for behavioral services for WellPoint Health Networks Inc., the parent of Blue Cross of California. "It's helped some people realize they need to be on medication, but others may be just going though a bad patch in their lives. And that's what muddies the waters."
   GlaxoSmithKline, the maker of Paxil, says the advertising campaigns de-stigmatize anxiety disorders in the same way that publicity surrounding the introduction of Prozac brought depression out of the closet 15 years ago, "Our intention is to educate the public about the symptoms of these disorders" so that people with serious mental illnesses will seek treatment, says Dr. Philip Perera, a psychiatrist and group director for clinical psychiatric research at GlaxoSmithKline in Philadelphia.
   But it's the publicity that has caused many mental health experts to suspect that many people are getting medications for mental disorders that were once believed to be relatively rare. For example, after Paxil was approved to treat social anxiety in 1999, the company nearly tripled its advertising spending, from $33.5 million in 1999 to $91.7 million in 2000. In April 2001, the FDA approved the drug for generalized anxiety disorder as well. In the first six months of 2002, advertising for the drug topped the $60 million mark, according to figures compiled by CMR, a market research company.
   Prescriptions are rising accordingly. Last year, 26 million prescriptions for Paxil were dispensed. This year, more than 16.9 million prescriptions were filled in the first half of the year, a projected spike of more than 25 percent. Similarly, in 1999, when Effexor was approved to treat generalized anxiety, 5.5 million prescriptions were written for the drug; the following year, that figure rose to 8.7 million, according to IMS Health, a health care information company in Fairfield, Conn. "Advertising definitely induces demand for these products," says Steven Findlay, director of research for the National Institute for Health Care Management, a Washington nonprofit. "But we don't know what percentage of these prescriptions are being written inappropriately."
   Dan Kabic is one Paxil user who believes he shouldn't have been given the drug. The 31-year-old marketing manager from San Jose, Calif., says he started taking Paxil two years ago when he was suffering from insomnia. His sleeping pills were no longer working and, he says, "my doctor thought anxiety was causing sleeping problems." But the medication made Kabic feel worse, he says. His weight plummeted, he lost interest in sex, he felt like a zombie and he still couldn't sleep. "It really interfered with my life," says Kabic, who's been weaning himself off of Paxil.
   One out of every five people will suffer from an anxiety disorder at some time, according to Ronald Kessler, a researcher at Harvard Medical School in Boston. Such disorders include obsessive-compulsive disorder, panic attacks, post-traumatic stress syndrome and the two most common -- social phobia and generalized anxiety. Generalized anxiety disorder afflicts about 4 percent of the population, the 10 million people who are paralyzed by irrational fears. Unlike people who are socially phobic, they don't fear human contact; they fret constantly about everything. "They're like `worry machines,"' says Jerilyn Ross, president of the Anxiety Disorders Association of America in Silver Spring, Md. "They can't eat, they can't sleep, they're irritable and jumpy, and you can't calm them down with facts."
   Similarly, anywhere from 3 percent to 13 percent of the population is crippled by social phobia, or social anxiety disorder, in which people are filled with intense dread and avoid everyday social situations. Social phobics fear public humiliation or being judged by others, and may turn down a promotion, quit their jobs or avoid leaving the house rather than deal with people. But the line between generalized anxiety disorder and normal fears is not as clear as it may seem. Almost half of all Americans -- 40 percent to 45 percent, according to recent polls -- consider themselves shy, which is not a psychological disorder. Here again, it's tricky determining when shyness is debilitating enough to require pharmaceutical interventions.
   "It's to the advantage of the drug companies to blur that line," says Bernardo J. Carducci, a professor of psychology and director of the Shyness Research Institute at Indiana University in New Albany. "All of a sudden, that gives them a tremendous market."
   Family physicians dispense about 60 percent of the prescriptions for antidepressants, but they spend an average of only seven minutes with a patient, so there often isn't enough time to do an adequate psychological assessment, Brase says. Consequently, when patients insist they want a particular drug, doctors often cave in, rather than reviewing other therapeutic options.
   "Patients come in with a perception that this medication is going to work for them, and if physicians take the time to challenge that assumption, there's often a credibility issue -- almost like the patients don't believe them," says Martin Fornataro, the West Coast director of pharmacy for Cigna HealthCare in Glendale, Calif. "So physicians end up capitulating to their demands." On the other hand, some doctors must spend so much time clarifying whether a drug is warranted that the discussions can "crowd out more important things that need to be discussed," says Dr. Les Zendle, associate medical director for Kaiser Permanente Southern California in Pasadena.

Hurried Woman Syndrome?
ABC News, 12/11/2002

On a typical afternoon, the Lumberton, Texas, woman was preparing food and managing her children's schedules, but the craziness of coping with soccer practice and math homework was starting to take its toll. "There were times that I felt like I'd get really stressed out," Lee said. "And I went to my doctor and told him 'I have a really low energy level, I don't want to work out, I get kind of grumpy.' And he said, 'Hey, I've got a name for it.'" Her diagnosis? "Hurried woman syndrome," a newly identified condition. The doctor who coined the phrase says the condition affects an estimated 60 million women, or one out of four in the United States, between the ages of 25 and 55.
   Lee's physician, Dr. Brent Bost, a private obstetrician-gynecologist in Beaumont, Texas, and the author of The Hurried Woman Syndrome, recently presented data at a medical conference showing that many doctors are finding this new syndrome in patients leading today's frenetic lifestyles. In his own 15 years as a physician, he had seen the condition many times, and that it is a form of minor depression. "The hurried woman syndrome is the term we coin because it seems to underlie the cause of the problem, which is stress and hurry, and busy lifestyle choices that a lot of people have assumed are normal," said Bost, who trained at the Baylor University Medical Center in Dallas. The syndrome often affects women juggling working outside the home and family, but single women with tough careers and stay-at-home moms can be susceptible, too, he said.

Symptoms Mimic Depression
The four major symptoms associated with the syndrome are weight gain, low sex drive, moodiness and fatigue. Over the course of time, experts believe, these symptoms can trigger changes in brain chemistry that are very similar to depression, although not as severe. "No one goes to bed one night with their brain chemistry perfectly balanced, feeling fine, and then wakes up the next day with five symptoms of depression in a major depression," Bost said. "They go through phases of that. So when you have two or three symptoms, you're not really normal but you're not really in a major depression either." Women suffering from the symptoms should consult their doctor, as there are medical conditions that can cause them, too. For example, anemia, low thyroid, some infections and other metabolic problems can cause fatigue and weight gain.
   Bost says that stress is probably the single most important contributing factor to hurried woman syndrome. Some people might say that stress is a normal part of life, but constant stress isn't a good thing, he said. It takes a toll on families, marriages and health. Sex therapist Laura Berman says many patients haven't heard of hurried woman syndrome before simply because the tolls exacted by constant stress - the main reason for the condition - are underacknowledged by both women and their doctors. Women tend to dismiss the idea that they are doing too much, Berman says. "We're pushed to excel and we don't make the allowances we should to take care of ourselves," she said. "It is expected that we will take our health for granted."

Women React Differently to Stress
It's both a societal issue and a medical one, said Berman's sister, urologist Dr. Jennifer Berman. "We often don't realize the damage to the body that's caused by chronic stress," she said. "If you don't slow down, and you don't find ways to resolve it, your body will pay the price."
   Men and women react differently to stress, both emotionally and physically, she said. A man goes into "fight mode" and produces testosterone. Often he will often become more sexually active. "A woman will produce oxytoxin," the urologist said. "Her sex drive will lessen. She will have a higher risk of heart disease, obesity and other eating disorders."
   Some types of stress can't be avoided, such as a having a sick child or a high-powered career, Bost said. However, for the majority of women, much of the stress is avoidable or at least could be managed better. For some, the solution to hurried woman syndrome lies with antidepressants, he said.

Taking It Easy
Others rely on three pieces of advice: simplify, prioritize, and organize your life. Numerous household responsibilities can aggravate the symptoms. Cheri Cook, of Beaumont, Texas, believes her job as a stay-at-home mom is a perfect example. "I would wake up in the middle of the night thinking all of this stuff, 'I've got to do this, I've got to do that, what should I do first?' And I look over at my husband and he's sleeping, and I think, 'He's not thinking of these things.' "I have tried to cut back, I have tried to simplify," Cook said. "I've learned how to say no, and I can even say no to my children."
   Laura Berman says that if you're experiencing heart pains, sleeplessness, loss of libido, a change in diet, a change in sexual response, or depression, you should take a look at the stress in your life and ask yourself some questions: "What are my expectations?" and "What is my list of priorities?" "Women have a habit of putting themselves last on their list of priorities," she said. "They make promises to themselves, 'I'll do something for myself when I have time.'' Lee also said she has made an effort to simplify and prioritize her life, and it has worked. "I'm such a changed person, so much happier," she said. "Not that I was depressed before, but just crazy. I was tired of everything being so crazy."

Addicts Have Alternative to Methadone
Associated Press, 12/12/2002

WASHINGTON -- Federal health officials have launched an education campaign to let physicians and heroin users know there is a new medication that can curb addicts' cravings and, for the first time, can be prescribed in doctor's offices instead of drug-treatment clinics. The Food and Drug Administration approved buprenorphine in October, an alternative to methadone in helping people kick addiction to heroin and similar opioids, drugs that also are found in prescription painkillers. The Substance Abuse and Mental Health Services Administration is trying to spread the word.
   Methadone is the most common treatment for opioid addiction, but it can be dispensed only in a few special drug-treatment clinics. Only about 20 percent of heroin addicts receive it. Buprenorphine, in contrast, can be prescribed in doctor's offices--if the physician qualifies. The key: Doctors must seek a government waiver allowing them to prescribe buprenorphine after completing eight hours of mandatory training. So far, more than 2,000 physicians have been trained to use buprenorphine and about 300 have received waivers to begin prescribing, according to SAMHSA.
   To increase those numbers--and let addicts know about the new option--the drug abuse agency plans to hold public meetings in Baltimore, Boston, Chicago, Dallas, Detroit, Miami, New Orleans, New York/Newark (N.J.), Portland (Ore.), Salt Lake City, San Francisco, Seattle, Philadelphia-Wilmington (Del.) and San Juan, Puerto Rico.
   Buprenorphine, a tablet dissolved under the tongue, works by blocking the same brain receptors that heroin targets, but without heroin's high and with weaker narcotic effects than methadone.

Computers a Tool to Aid Mentally Ill
Richard Wronski, Chicago Tribune- 12/12/2002

Along with medication and counseling, a northwest suburban hospital believes it has found another effective tool to help people who are mentally ill work their way back into society: the computer. Alexian Brothers Northwest Mental Health Center is teaching computer skills to patients, both for the vocational benefits and for subtler effects it has on their re-entry into society. The computer training isn't technically considered therapy, but it builds self-esteem and enables the mentally ill to better cope with anxiety and workplace stress while providing a skill, according to Denis Ferguson, administrator at the center.
   So far about 34 people, from teenagers to 60-year-olds, have participated in the training program at the Learning Center in Arlington Heights, a project operated by the mental health center. "Generally, the participants are people who have had careers and were stable, but for some reason ran into problems," said program coordinator Maxine Goldstein. "It might be a person who has been in and out of the hospital. They might have had problems with stress." The Learning Center's clients have experienced a wide range of illnesses, including depression, bipolar disorder and schizophrenia. Some have learning disabilities.
   Goldstein said many who benefited from the five-week class at the Learning Center were unable to keep up with the pace of classes at conventional schools because of their disabilities. "Most want to learn but can't in a traditional sense," she said. "Here they can take the class over, they can repeat things--things they can't do in a regular class."
   One woman, Goldstein said, had a good career but had an anxiety disorder. When her parents became ill, she left her job to take care of them, but that just exacerbated her anxiety. Afterward, finding a new job became even more difficult. "It's like getting into a whole cycle where things just get worse," Goldstein said.
   The Learning Center's specialty is desktop publishing. Clients have produced cards, journals and calendars with original artwork that they are selling to raise funds for the center. Ferguson said he was unaware of any other program like the center. It was funded by a $49,000 grant from SBC Communications in March. But more money is needed, Goldstein said, and a search is on for another grant or other funding to keep the Learning Center in business.
   So far, the computer training has helped several people move into the workforce, said Frank Pepich, a vocational counselor. One works for Britannica.com and others have landed positions with libraries. But simply being part of the center's calendar project has shown to be therapeutic. "It's given me a cause," said a client who has a background in marketing and media. "It's good to be involved in a real project and to learn about computers at the same time."
   Judith Cook, a professor of psychiatry at the University of Illinois at Chicago, said vocational education is considered the "best practice" for people with mental illness. She said there are many models, such as the Learning Center program, which show the effectiveness of training people with psychiatric disorders to enter the workforce. "The evidence shows they are just as productive as their non-disabled co-workers," Cook said. "And they are more appreciative of their jobs and more loyal to their employers because they have to worker harder to get these jobs." Cook said the public still needs to be convinced that mental illness can be just as treatable as physical illness. "People are recovering from mental illness now, the same way you recover from a heart attack, or after having a baby," she said. "That's what treatment is all about now. We have the technology."

Report: New York to Evaluate Mentally Ill in Residences
Associated Press, 12/13/2002

NEW YORK -- Over the next few months mental health workers will begin canvassing New York State's adult homes to determine the needs of some 15,000 mentally ill residents, a published report said. The project expected to take more than a year and cost several million dollars marks the start of a proposed overhaul of the adult homes system, which critics say has proved inadequate for psychiatric patients discharged from state hospitals.
   ''It is our expectation that the assessments will reveal that most of the residents of adult homes can, and should, be served in non-institutional settings,'' Jeanette Zelhof, managing attorney for MFY Legal Services, a nonprofit group that represents adult home residents, told The New York Times in Friday's editions.
   The Pataki administration proposed reforms last spring, after The New York Times reported on dangerous adult home conditions. The newspaper found unhealthy and even deadly conditions in mostly New York City-area facilities from unnecessary surgery to dangerously hot bedrooms. The administration has not disclosed how it will cover the cost of building new housing for the mentally disabled estimated at hundreds of millions of dollars over the next 10 years.

Team Treatment for Depression Urged
Associated Press, 12/13/2002

CHICAGO -- Elderly patients suffering from depression fared better when there was a team approach to their care, a study suggests. Researchers found patients had fewer symptoms and greater quality of life when specially trained case managers worked with primary care doctors to help develop treatment plans. "Just the extra attention, that's what made the big difference," said researcher Dr. Jurgen Unutzer of the Neuropsychiatric Institute at the University of California, Los Angeles, which coordinated the study.
   The study in today's Journal of the American Medical Association followed 1,801 depressed older adults from 18 primary care clinics in Texas, California, Indiana, North Carolina and Washington for one year. About half of the patients, age 60 and older, got typical care -- usually a prescription for an anti-depressant. The other half were assigned to a program called Impact, for Improving Mood-Promoting Access to Collaborative Treatment. The program used specially trained nurses or psychologists as case managers to work with patients. Psychiatrists also consulted on patient care. After one year, 45 percent of the patients in the Impact program saw a 50 percent or more reduction in depression symptoms, compared with just 19 percent in the other group.
   The study is important because it shows that many patients with mild to moderate depression can be treated in a primary-care setting, though specialists still are needed in more severe cases, said Dr. Kenneth Sakauye, chairman of the American Psychiatric Association's Council on Aging. Sakauye was not involved in the research. He said the team model might work best at an HMO or medical practice that has the resources for a multidisciplinary approach. Unutzer, however, said the model has worked in smaller practices that shared a case manager to follow up on patients.

Treatment for Childhood Sleep Disorders
Joanne Kenen, Washington Post- 12/13/2002

At age 3, Amaya Jenkins had slept in her crib so seldom that her parents decided to give it away. "It was brand-new," said her mother, La-Shawn Jenkins, who lives near Baltimore. "We had to blow the dust off it." After her exhausted parents repeatedly left her to cry herself to sleep, 6-month-old Catherine Lake of Ellicott City became hysterical when anyone tried to get her near her room, even in broad daylight. Her mother, Tisha, said the child would sleep only in her -- the mother's -- bed.
   My husband, Ken, and I understood these parents' frustration. Approaching his second birthday, our own son, Ilan, was a sunny, smiling easy baby, except at 12, 2, 4 and 6 a.m., when he awoke screaming, no matter what we tried. Clearly, this couldn't go on. That it didn't, we owe to Kimble-Leigh West, the "Sleep Lady" of Severna Park.
   A clinical social worker with a practice near Annapolis, the 38-year-old West has developed an unusual specialty, giving several hundred sleepy parents and sleepless babies a gentler alternative to the "cry it out" approach popularized by Richard Ferber, the Boston Children's Hospital sleep expert. She doesn't promise a tear-free transition to good sleep. But for parents emotionally or philosophically opposed to "Ferberizing" their babies, as well as for parents who have tried Ferber's technique and failed, West's "fewer tears" attitude is a relief. "I am not going to suggest that you just close the door and let your child scream," she reassures new clients, who pay several hundred dollars each for her individualized plans. "I would never suggest anything that would make you feel like a horrible parent."
   Instead West, who has two children of her own, coaches clients on how to help their babies and toddlers become more adept at self-soothing and putting themselves to sleep and how to give the tykes confidence that their parents are still nearby, attentive and responsive, even when they are out of sight. And while some skeptics might wonder how parents too tenderhearted to hear their kids cry are going to weather the next 18 years or so of child-rearing crises, West enthusiasts would likely answer: On a full night's sleep.

Hard Lessons
Sleep researchers estimate about 20 to 25 percent of children under age 5 have sleep difficulties. In some cases, there are physical causes, such as apnea (a breathing disorder) or digestive problems. Sometimes, too, there are emotional issues -- anxiety or separation problems that go deeper than run-of-the-mill nightmares or monster-under-the-bed fears. But often, according to Ferber and other experts in the field, the children just never learned to put themselves to sleep alone in their cribs.
   "The need for sleep is biological, but the ability to sleep is learned," says Rafael Pelayo, director of pediatric sleep services at the Lucile Packard Children's Hospital at Stanford University and a member of a National Institutes of Health sleep research advisory board. "With babies, it's a learning issue, not a discipline issue."
   Since the mid-'80s, pediatricians have recommended "Ferberizing," in which a baby is left alone to cry while the parent briefly reassures the infant at regular, but less and less frequent, intervals. The theory is that if a child learns to fall asleep on his own, without being rocked, nursed, stroked or serenaded, he will be able to go back to sleep on his own during the brief awakenings that almost everyone experiences every night and scarcely remembers the next morning.
   Sleep researchers have shown that "Ferberizing" usually works, according to Jodi Mindell, associate director of the sleep clinic at Children's Hospital of Philadelphia. What may work still better, according to some studies, is a tactic known as "extinction" -- basically, letting the child cry and making no parental checks. But many parents, say researchers, can't turn off their ears and heartstrings long enough to tolerate it.
   Whatever the reason, neither method works all the time. "It's not one-size-fits-all," Mindell says. That leaves room, she says, for alternative approaches such as West's. Pelayo agrees that gradual techniques like West's are often effective. "The question is," he says, "what are the parents comfortable with?"

Life Line
West accepts only four or five families at a time as clients. She works with each intensively, starting with a detailed sleep history and a 90-minute office consultation. Where separation issues are pronounced, West says, some clients may get partial insurance reimbursement. Follow-up involves 10- to 15-minute telephone calls almost every morning for the first week, several days a week for another two or three weeks and an occasional e-mail for three months.
   Many clients say those morning phone calls -- part pep talk, part fine-tuning -- are what helped them stick with the program, especially in the first, draining days. "Having Kim call every morning was invaluable," said Cara O'Connor of Washington, who consulted West about her daughter Caitlin Shirvinski when the child was 11 months old. "You could rehash the night before, talk about what adjustments you need to make, whether it was great or whether you caved and did something you probably shouldn't have."
   West's plans generally involve having the parent start out sitting next to the bed or crib and stroking or soothing the child, without picking the baby up. The parent can make calming "night-night" sounds, but does not converse. Every three days, the mother or father moves a little farther away, until the parent is sitting right outside the bedroom door, dimly lit and still in the child's view. Then the parent moves out of sight but still in earshot. Finally the parent is ready to leave the child for five-minute intervals, after telling the baby where she will be and what she will be doing. "I wasn't just leaving my child in a dark room by herself to cry," said Pam Brooker, a Towson-area resident who consulted West last spring about her then 7-month-old daughter, Anna. "It helped me to be able to be in there and soothe her."
   Nighttime awakenings taper off once the child learns to go to bed independently. Nighttime nursing schedules are adjusted or eliminated depending on the infant's size, age and nutritional needs. Each case is a little different, though. Tisha Lake, for instance, spent two weeks just reintroducing Catherine to her dreaded room, putting in new toys and books before she tackled the sleep problem. She slept in Catherine's room for a few days to ease the transition. Amaya Jenkins has cystic fibrosis, and the choking and gagging characteristic of the disease affected her parents' willingness to leave her unattended. But West developed a routine that addressed the parents' anxiety about Amaya's health and still got the child happily sleeping in her "big girl" bed on her own and through the night in about two weeks.

Firetrucks and Night-Night
Ken and I first saw West in late August. Ilan was almost 2 and we were going through bedtime contortions involving tapes, books, big beds, small beds, rocking chairs, back-rubbing, head-stroking and hand-holding. It was hard to get him to sleep in the crib once he awoke, and he awoke almost every night, repeatedly. We usually surrendered and brought him into our bed, and while there is nothing sweeter than a little head of soft blond curls tucked next to my own cheek, he was not a peaceful sleeper, not even with us. While Ilan retained his cheerfulness, my husband and I were losing ours. I was always grateful that somehow, as a seriously sleep-deprived working mother of two, I had managed to stumble through another day without falling asleep at the wheel, setting my house on fire or nodding off too conspicuously at a Capitol Hill press conference.
   Even for someone whose livelihood involves tracking down information, finding help wasn't easy. I surfed the Web, scoured Montgomery County libraries, ordered books off Amazon, quizzed pediatricians and therapists, phoned all the sleep clinics in Washington and surrounding counties in Virginia and Maryland, only to be told that they did not treat very young children or they only treated children with sleep difficulties arising from breathing disorders. One day, Angela Gadsby, a Maryland pediatrician I know socially, mentioned Kim West. "I send about five families a year to see her," she told me. "They all sleep."
   I suspected, and West agreed, that Ilan's sleep problems were an outgrowth of his reflux, a digestive disorder common in infants. He had outgrown the reflux but hadn't broken his poor sleep patterns. Although he was young to switch from a crib to a bed, we knew he hated anything with bars. So we put a gate on the door, threw a mattress on the floor, found some glorious red firetruck sheets and made a huge deal about his new firetruck bed. Thrilled, he accepted the change and brought along several stuffed animal friends who he thought would like the firetruck bed, too.
   With West's help, we tweaked his evening rituals. We began putting him to bed earlier after West helped us recognize his "sleep window" -- the natural wind-down before that lethal second wind of toddler energy kicks in. If my son rubs his eyes and asks for his special songs, I now know to get the bedtime routine moving quickly. If he starts leaping up and down shouting, "I jump on bed like monkey, Mommy!" I know I miscalculated. I adapted a song he liked by tagging on a verse about firetruck beds, love and night-night, and sang it each night. He protested each time I moved the rocking chair farther away, but it was nothing either of us couldn't handle. By the time I left the room the first few nights, he was asleep. Then we had a few nights of tears until I realized that, while he resented my leaving him for work or household tasks, he was perfectly ready to share me with his big brother. "Go Zachy homework," he now says as I prepare to leave his room. "Ilan night-night." We've had delaying tactics, but within normal 2-year-old realms. One week he came up with a series of pressing errands: "I fly kite." "I get e-mails." "I make coffee." But mostly he'll just lie down when told. We still have some bad nights and too-early mornings, but his sleep has improved significantly.
   West reports some failures, but not many. She estimates that fewer than one in 20 cases show no progress, usually because of such complicating factors as marital problems, a physical disorder that had not been detected or an otherwise competent parent or caretaker who can't or won't get with the sleep program. But for the most part, patients speak about West with awe. "I absolutely have my life back," said La-Shawn Jenkins, who was convinced that Amaya's illness would stymie West. "Our life does not revolve around getting our baby to sleep. We can talk about things other than what an awful night it was."

Schizophrenia Gene Verified in Scottish Study
Nicholas Wade, New York Times- 12/14/2002

The long search for a gene that helps cause schizophrenia may at last be bearing fruit after many false starts and disappointments, scientists are reporting. An errant gene first implicated among schizophrenic patients in Iceland has now turned up in a survey of Scottish patients too, giving a confirmation of the earlier result. The gene may be involved in remodeling the connections that brain cells make with one another, called synapses.
   Many of the Icelandic and Scottish patients have the same variant pattern in the gene, supporting the idea that when the gene does not work as designed, wrongly formed nerve-to-nerve wirings accumulate in the brain, giving rise to the schizophrenia. Not all schizophrenics carry the variant, and many people carry the variant but are normal, an expected pattern in diseases caused by several genes. But in both populations, inheriting the variant form of the gene appears to double the risk of schizophrenia.
   The finding, if correct, would bolster the strategy followed by Decode Genetics, a Reykjavik-based company that is using the Icelandic population as a test bed to search for the genetic roots of common diseases such as cancer, diabetes and Parkinson's disease. The schizophrenia gene is one of the first it has found, and the company expects to make many other such discoveries.
   Dr. Kari Stefansson, a former Harvard neuropathologist who is the company's chief executive, said Decode and its partner, the drug company Hoffmann-La Roche, were developing new drugs to counteract the aberrant gene's effects but could not say when any would be ready for clinical testing.
   The variant form of the gene in Icelanders was reported in July by Decode Genetics. But many scientists have grown skeptical of claims about a schizophrenia gene because some have not been confirmed by later studies. The gene at issue is called neuregulin-1. It makes a signaling protein that influences the receptivity of brain cells to several types of neurotransmitters, the chemicals that convey messages between nerve cells. Stefansson said neuregulin-1 may govern the process by which the synapses, or wiring, between nerve cells is made and unmade in response to the brain's experiences. A defect in neuregulin-1 might lead to an accumulation of wrongly formed synapses, accounting for the progressive nature of the disease.

Drug Firms and Doctors: The Offers Pour Iin
Liz Kowalczyk, Boston Globe- 12/15/2002

During the past six months, Dr. Eugene Fierman and his two colleagues were showered with offers worth thousands of dollars. At least once a week, the nation's pharmaceutical firms invited them for ''educational evenings'' at some of the city's priciest restaurants, including cocktails and dinner at Radius paid for by Pfizer, an insomnia discussion at Locke-Ober, and a depression talk at Maison Robert -- both on Wyeth's tab. Drug firms through intermediary companies paid for at least 50 hours of free continuing medical education courses, which the psychiatrists could complete by phone, mail, on the Internet, or at hotels - required courses for doctors that traditionally were the province of medical schools but now are increasingly funded by the industry. Some pharmaceutical companies wanted to hire them as temporary advisers, including Forest Pharmaceuticals, which promised the doctors $500 each for listening to a Saturday morning talk about the firm's new antidepressant, Lexapro, at a Cambridge hotel and then providing ''advice and feedback.'' And occasionally, drug company employees dropped off at the doctors' rented office at Faulkner Hospital small gifts: a box of cookies from the Wyeth salesman, four classical CDs from the Pfizer representative.
   With investigations into the industry's sales tactics growing, and a new voluntary code of conduct in place that stresses educating rather than entertaining doctors, Fierman, Dr. Ann Potter, and Dr. Gregory Harris -- like many of their colleagues throughout the medical profession -- said sales representatives now rarely offer the most lavish gifts that were routine in past years: theater tickets, golf trips, and resort weekends. Instead, drug makers are paying for or offering more consulting opportunities, even for one evening, continuing medical education courses, and dinners billed as educational events with specialist speakers. At the Globe's request, the three doctors kept track of pharmaceutical-related invitations and offers they received over a five-month period. The material was enough to overflow a 1-foot-square, 2-foot-high box. ''It's hard to resist all this money and free stuff floating around,'' said Harris. ''But it's a slippery slope, and I don't want to be in the position of doing something that crosses the line.''
   The shift in the tactics drug companies are using to establish close relationships with doctors was occurring even before the industry adopted the new guidelines in July. The amount of money pharmaceutical firms spent on meetings and events, including continuing medical education, teleconferences, dinners, symposia, and get-togethers with physician advisers, more than doubled over four years to $2.1 billion in 2001, according to Verispan, a company that tracks promotional spending. Drug industry funding of continuing medical education courses alone last year totaled $540 million, and the national organization that accredits continuing medical education providers has become so concerned about potential bias that it plans to issue stricter rules as early as January.
   Drug makers say these classes and gatherings provide physicians with crucial information about medicines that could help their patients -- and allow doctors to speak to each other about their experiences. But Dr. Marcia Angell, former editor of the New England Journal of Medicine, said the danger is that companies simply disguise marketing as education, while slanting presentations toward their own products and helping to increase health-care costs. ''These companies are in the business of selling drugs, period,'' Angell said. ''It's ludicrous to think you'd look to a company for education about a product they're trying to sell.''
   Physician leaders also are concerned about what they see as a rise in consulting and question whether doctors are providing meaningful advice to the companies -- something required by the new guidelines -- or are merely being paid large sums to listen to a sales pitch. And federal law prohibits companies from offering doctors cash inducements to prescribe their drugs. Dr. Sidney Wolfe, director of Public Citizen Health Research Group in Washington, D.C., said some consulting fees have gotten so high that he believes they border on illegal inducements. He has referred several cases to the US inspector general.
   With the focus on drug industry marketing intensifying, doctors are increasingly concerned about their interactions with sales reps, and some are taking steps to limit their visits -- or keep them out of their offices entirely. But that -- Fierman, Harris, and Potter discovered -- is not so easy. The doctors decline consulting offers, and they no longer attend dinners. The cookies go to Bill Johnston, the practice's part-time receptionist, who brings them to his fellow band members. Their one concession: They accept drug samples for uninsured patients, a marketing tool on which the drug industry spent $10.5 billion last year.
   In early summer, Potter felt the practice was overrun with Eli Lilly salespeople. One day, she found a 22-year-old sales representative in the waiting room talking to a patient. Potter called his manager and requested only one Eli Lilly sales visit a month. The manager said no. The reason: The doctors get too many samples, he said. They gave in to two visits a month -- as long as they got to choose the sales rep -- even though they know samples probably increase their prescribing of those particular drugs. ''You can't totally drop out of this crazy system,'' Fierman said.

`Dinners are exploding'
At least once a week between August and November, sales representatives invited Fierman, Harris, and Potter for cocktails and dinner. The most modest restaurants: Figs and the Newton Marriott. The most posh were Radius, the Ritz-Carlton, and the Four Seasons -- all dinners they didn't attend. Dr. Ronald Katz, an internist in a large, busy practice on Beacon Street in Brookline, said ''dinners have exploded in the past couple of months,'' which he believes are ''in lieu of trips and the most expensive things they used to do.''
   The industry's new code of sales conduct requires dinners be ''modest as judged by local standards'' -- a guideline some companies are complying with and others are not. ''This should not include the city's most expensive restaurants,'' said Jeff Trewitt, a spokesman for the industry trade group, the Pharmaceutical Research and Manufacturers of America. ''We want there to be no distractions. We want the focus to be on a meaningful conversation about a new medicine and its potential value and characteristics.''
   Dr. Susan Black, a family practice doctor in Tewksbury, drove into the city one night this fall for a dinner and discussion at the Four Seasons on urinary incontinence in women, sponsored by Pharmacia, which makes a drug for overactive bladder called Detrol LA. She earned one hour of continuing medical education credit; Massachusetts doctors must earn 40 hours of medical education credits with an approved provider every two years to remain licensed. ''They were discussing their own research, the company's research. And they were trying to show the drug was better than their competitor's,'' Black said. ''I thought I should go because this is a big issue for my older patients. There are some really good new physical therapy approaches and surgical approaches, but they didn't discuss those.''
   Executives at Pfizer, which has paid for dinners at pricey restaurants in Boston since July, said the choice of restaurant is a ''judgment call'' made by local sales reps. ''The price of the meal is so inconsequential, given what we're grappling with around the guidelines and what's educational or not,'' said Dr. Mark Horn, Pfizer director of medical alliances. ''I would focus on the speaker, the content, and the quality of the presentation. As long as it's balanced and fair, I'm less concerned with the selection of the eateries.''

Many education courses
Last Thursday at 1 p.m., Fierman called a toll-free number to earn one hour of continuing medical education credit listening to a teleconference called ''Stabilizing the Dopamine-Seratonin System: A New Era in the Treatment of Psychosis'' -- one of dozens of free, pharmaceutical-company-funded continuing medical education courses offered to the practice during the past six months. This course, which Fierman enrolled in at the Globe's request, was organized by a private California company called Continuing Medical Education Inc. and paid for with an unrestricted grant from Bristol-Myers Squibb and Otsuka America Pharmaceutical. The companies in November received approval from the Food and Drug Administration for a new antipsychotic medication called Abilify.
   As Fierman listened from his small office overlooking Arnold Arboretum of Harvard University, Dr. Peter Weiden, director of the Schizophrenia Research Program at SUNY Downstate Health Science Center in Brooklyn, began with a history of antipsychotics and a description of why newer drugs like Zyprexa and Risperdal are superior to older medications like Haldol. (Fewer side effects like tremors.) But he devoted more than half the hour to the benefits of Abilify, often referring to it as ''the new kid on the block.'' Although companies are not allowed to promote unapproved drugs, Continuing Medical Education Inc. began offering the course before Abilify was approved, something allowed under continuing medical education rules. Fierman said the science in the class was sound, and that Abilify might very well be the next blockbuster for the mentally ill. But he said advertising the course as an objective class on brain receptors was misleading. ''If this were a lecture saying we're introducing our new drug, that would be fine,'' he said.
   Drug companies usually aren't accredited continuing medical education providers themselves. They pay for the classes offered by medical schools and accredited third-party companies like Continuing Medical Education Inc. In this case, Continuing Medical Education Inc. suggested the class topic to the drug firms and they had no input into the content, said Steve Mandell, the company's vice president of sales and business development. But Dr. Murray Kopelow, chief executive of the Accreditation Council for Continuing Medical Education, which oversees the continuing medical education system for doctors, said third-party companies and medical schools may have grown so dependent on drug companies for their livelihood that they're no longer independent providers and have lost control of the agenda - and sometimes the content. ''These relationships have complicated the situation,'' said Kopelow, whose organization will consider sending physician volunteers to monitor the courses for commercial slant. ''There's probably more bias than we know.''

Consulting offers grow
Pharmaceutical companies, physicians said, also are pushing to increase their consulting relationships with them. Drug firms for years have hired respected physicians, often referred to as ''thought leaders,'' to speak about their drugs at conferences and serve on advisory boards. Some doctors earn thousands of dollars from these extracurricular activities. But some doctors said drug firms are offering more small, one-time consulting opportunities. And Fierman, Potter, and Harris received dozens of requests from drug marketing research firms -- whose clients are pharmaceutical companies -- to provide their opinions for a fee on the effectiveness of proposed direct-to-consumer ads and even report on how often competitors' sales reps visited their offices.
   Other physicians reported similar offers: Novartis promised Dr. Richard Parker $300 to give ''feedback about hypertension'' and Dr. Martin Solomon $500 to provide advice on hormone replacement therapy. Eli Lilly promised Dr. Jonathan Moray $750 to attend a dinner meeting on therapy for attention deficit hyperactivity disorder and ''provide his perspective on ... potential new treatment options.''
   Novartis spokeswoman Christine Landy said the company ''needs this feedback to guide future marketing and research'' and draw up written contracts -- as required by the sales code -- to clearly outline the doctor's role. But most of these dinners include a presentation about a drug the company makes or is developing. ''The companies used to call it coming to dinner,'' Solomon said. ''Now it's called consulting.'' Potter attended a consultants dinner meeting in the spring for which she was paid $400. The company, which she did not want to name, asked physicians how to catch their attention so they would prescribe the firm's antidepressant. ''I thought, `What am I doing here?' It was advice,'' she said, ''but it was advice on marketing.''

Kids Overdosing on Cold Medicine to Get High
ABC News, 12/16/2002

Parents concerned about whether their children are abusing drugs might also want to keep their medicine cabinets under lock and key. Across the country, children and teens are intentionally overdosing on cold medicine or "robotripping" in order to get a hallucinogenic high. Robotripping,is the slang term for intentionally overdosing on over-the-counter cold medication such as the cough medicine Robitussin. Although cough syrup abuse is nothing new — it dates to more than 30 years ago — it seems to be undergoing a revival lately, with cases of teens overdosing on the medicine popping up across the country.
    Robitussin, NyQuil, Benadryl and Coricidin are among the favorites. Tom, a 16-year-old boy whose last name is being withheld, told Good Morning America that some school friends told him about robotripping and he got high off a bottle of Robitussin. He then began experimenting with other over-the-counter medicines, taking eight to 16 Coricidin tablets at a time, he said. "I started out with Robitussin, I drank an eight-ounce bottle," Tom said. "The Robitussin was more like a high off of marijuana, and with Coricidin you can't sit still, you keep talking," he said. Ian, 17, said he used Coricidin, Nyquil and Benadryl to get high. "It kind of got all concentrated into your head, and you really got kind of hyper and are all over the place and acting real stupid," Ian said.

DXM Is Trouble Ingredient
The culprit ingredient is dextromethorphan, a common additive in cough suppressants that can cause hallucinations when used in large amounts, according to Dr. Drew Pinsky, an addiction expert. "There's Web sites out there that tell these kids how to do this, how to get the pills, how to take enough pills," Pinsky said. Users can suffer psychosis, brain damage, and seizures. Overdoses can be fatal. Fourteen people died last year from intentional overdoses of cold medicines, and several hundred were hospitalized, Pinsky said. "These are legal drugs, so only the worst cases of overdose make it into the records," Pinsky said. More than 80 over-the-counter cold medicines contain DXM, or dextromethorphan, a chemical that serves as a powerful cough suppressant when taken properly, but produces psychedelic effects when taken in large doses. DXM abuse is hard to track because it is legal and most abusers are under 18.
    Ian and Tom say they're off Coricidin and Robitussin now, after getting help. "I never got caught with it, but I got caught in school for being drunk and high, and they sent me to a drug counseling program and that covered everything," Ian said. "I've been clean off of that stuff for about two months now," he said. Tom, who says he used Coricidin and Robitussin from late last year until October of this year, said he had managed to keep up a normal appearance in front of his teachers and parents, even when he was hallucinating, but away from home or school, he sometimes became uncontrollable. He would sleepwalk, talk in his sleep and have blackouts. Tom says he's clean today and in an outpatient rehabilitation program while attending narcotic anonymous meetings.

Pee Wee Drug Dealers
There is also concern about the age at which children are abusing drugs, which seems to be getting younger. In Port St. Lucie, Fla. last week, two 9-year-old children were found with 15 small bags of marijuana, reportedly while riding the school bus to their elementary school. One boy was passing the baggies to the other. The two boys are both in the third grade. Police are investigating whether the boys intended to sell the drugs.

Blue Cross to Give Doctors Care-, Cost-Based Bonuses
Liz Kowalczyk, Boston Globe- 12/17/2002

Blue Cross and Blue Shield of Massachusetts, the state's largest health insurer, in January will begin awarding doctors cash bonuses if they do an above-average job of caring for patients while simultaneously providing that care for less money. Blue Cross's new initiative will allow more than 8,000 doctors -- about half the physicians in HMO Blue, the insurer's managed care plan -- to compete for the extra money, starting Jan. 1. The bonuses are part of a national movement by employers and health plans to shift the way managed care rewards physicians and to pay the best-performing doctors more than their average peers.
    Many of these new incentive programs reward doctors only for meeting certain quality-of-care standards, such as providing diabetics with regular eye exams. But Blue Cross decided to take a slightly different approach. With medical costs soaring and overnight hospital visits rising again, Blue Cross also will award bonuses to physicians who control the cost of care more successfully than their colleagues, or who ''beat the trend,'' as doctors describe the program.
    Blue Cross's bonus plan differs in other ways, too: It provides potentially larger bonuses to doctors, and it rewards the doctors' group rather than individuals. Once the program is fully implemented, a group can earn up to 15 percent on top of the total regular fees it receives from Blue Cross in a given year. The group would then divide the windfall among its doctors.
    ''We think this is the responsible thing to do,'' said Deborah Devaux, vice president of provider contracting. ''Right now we're not paying the high-performing doctors enough, while we're paying too much to everyone else.'' Blue Cross's goal, Devaux said, is eventually to enroll every physician in its network in a pay-for-performance plan. The new incentives are a far-reaching expansion of an existing program and will be part of the insurer's contracts with physicians that take effect Jan. 1. During the first year, it will apply to 15 large groups, including those affiliated with Partners HealthCare and Beth Israel Deaconess Medical Center in Boston, and Baystate Medical Center in Springfield. These doctors care for 350,000 to 400,000 HMO Blue members.
    Some doctors are extremely worried about the implications of these programs, which encourage physicians to compete for a limited pot of money, but others believe doctors should be rewarded like people in most other professions -- based on how well they do their jobs. ''Most doctors aren't aware this is coming down the pike, but I don't think they should be concerned,'' said Dr. Richard Parker, medical director of the Beth Israel Deaconess Physicians Organization. ''It encourages doctors to be doing what they should be doing and already are doing, but help us do it even better.''
    Blue Cross will measure physicians in three categories:
*Quality - The insurer will review claims from primary-care physicians for eight types of care, including whether the doctors gave HMO Blue female patients mammograms and pap smears, and whether they saw children with asthma to adjust their medications and asked teenagers about their drug and alcohol use.
*Patient satisfaction and access - Blue Cross will survey 200 patients who see specialists in each group, asking 10 questions, such as whether their doctors explained their treatment options and discussed the side effects of medications.
*Cost - The plan will tally the money it spent to treat HMO Blue patients in each physician group, including dollars that went to prescription drugs, surgery, overnight hospital stays, lab tests, and imaging tests. Blue Cross will calculate how much costs increased for all the groups, on average, during the year.
    Groups whose costs increased less than the average will receive a bonus. Groups that perform better than average on the quality and satisfaction and access measures will earn an even larger bonus - up to the 15 percent. The plan will pay the bonuses for 2003 during the middle of 2004.
    ''Frazzled, busy doctors are not always taking time to tell patients they don't need an MRI every time they have back pain,'' said Dr. James Fanale, senior vice president for provider partnerships. ''This rewards them for taking the time. Otherwise, it's too easy to give patients the MRI. Doctors might think, `Why should I bust myself doing this, when all it's going to do is save the insurance company money?'''
    Blue Cross will reward doctors more for limiting costs than for excelling on the quality and satisfaction measures. But plan executives said doctors' groups must adopt special quality initiatives as part of their cost-control programs, such as cutting down on unnecessary use of antibiotics for viruses that don't respond to them - a measure that saves money and improves care.
    These bonus programs are expanding rapidly across the country. General Electric, Verizon Communications, and other employers and health plans will launch programs in Massachusetts, Ohio, and Kentucky next year to pay physicians quality bonuses. And in California, six health plans are starting a similar initiative Jan. 1.
    As the number of programs has grown, so have doctors' concerns about whether plans are measuring quality accurately, and about whether the bonuses are large enough to motivate doctors. Dr. Charles Welch, president of the Massachusetts Medical Society, said a bonus of at least 10 percent is required to persuade physicians to do the extra work. Internists in the Northeast earn an average of $150,000 annually, according to the American Medical Group Association. Welch also worries that plans simply are holding back money they would have otherwise put into regular fees and requiring doctors to earn the dollars back through bonuses. This outcome is entirely possible, plan executives acknowledge.
    During the 1990s, managed-care plans paid doctors incentives to keep patients out of the hospital and otherwise limit care, but they also docked physicians' pay when they failed to do so. Many of the new incentive programs, including Blue Cross's, don't take money away from doctors who fail to meet the goals. But Fanale said it's possible the plan won't increase regular fees as much next September, so they can save money for the bonuses. Blue Cross is not putting up new money for the bonus programs, but is counting on the savings produced by doctors to pay for it. Blue Cross raised physician fees 3 percent in September.

New York Lawsuit Over Adult Homes For Mentally Ill
Clifford J. Levy, New York Times- 12/17/2002

The New York attorney general, Eliot Spitzer, sued the former operators of one of the state's largest and most troubled adult homes for the mentally ill yesterday, seeking $12 million in damages to compensate hundreds of residents who had been subjected to what state lawyers described as years of scandalous care and deplorable conditions.
    The former operators were accused of repeatedly engaging in "illegal, fraudulent and deceptive" conduct that endangered the psychiatric patients entrusted by the state to the home, Seaport Manor, in Canarsie, Brooklyn. The lawsuit charges that the home routinely neglected residents who were in crisis, distributed psychotropic medication haphazardly or not at all, allowed rooms to become infested with vermin, and misappropriated money. All the while, the former operators siphoned off hundreds of thousands of dollars a year from Seaport, and paid its administrator, who is also a defendant in the lawsuit, as much as $180,000 a year in salary, and $250,000 in retirement benefits, according to court papers.
    The lawsuit, filed in State Supreme Court in Brooklyn, is a milestone in the oversight of New York's adult homes, which have long been so loosely regulated that they have often faced only modest penalties even after state inspectors cited them for grievous violations. The homes were once considered promising alternatives to the grim psychiatric wards that the state began closing in the 1960's, but have instead come to be seen by mental health experts as little more than sprawling flophouses that keep the mentally ill isolated from society.
    The new threat of serious financial penalties for operators of the homes, , which now shelter 15,000 mentally ill people in New York, is intended to send a message that dangerous problems will no longer be tolerated, officials said. The $12 million in damages demanded by the attorney general is roughly the amount that Seaport residents paid the home between December 1998 and June 2002, money that was drawn mostly from their disability checks. If the operators lose the lawsuit, it would most likely be up to a judge to determine the size of the restitution fund, and how much should be returned to the residents. "This was a failure of government that it took this long to respond, and we are now going to step into this void," Mr. Spitzer said in an interview. He added that his office would aggressively pursue similar cases: against other adult homes.
    Mr. Spitzer's office began investigating Seaport after the home was the focus of an article in The New York Times last spring that appeared as part of a series detailing widespread failings in the adult homes system. The article described: how from 1995 through 2001, at least 79 Seaport residents died, or roughly: one every month, including at least three who committed suicide and two others whose bodies were discovered decomposing. The average age of death was 58, and in almost every case the state never investigated the circumstances of the deaths.
    After having done little to punish Seaport's operators, the Pataki administration responded to the investigation by The Times by moving to revoke their license, and the home, which once had 346 beds, is now nearly closed. Only a few residents remain, and they will soon be transferred elsewhere. The administration also subsequently put together a reform panel, which issued a plan last month to largely do away with the adult homes system over the next decade.
    In addition to the lawsuit brought yesterday, the United States attorney's office in Manhattan is conducting a criminal investigation into Seaport. Seaport's operators -- Baruch Mappa, Martin Rosenberg and Emil Klein -- did not respond to three messages left with their lawyers yesterday. Nor did the former administrator, Esther Elizabeth Rosenberg, who is Mr. Rosenberg's daughter, and her son-in-law, Seth Fried, who was assistant administrator and was also named in the lawsuit.
    While Seaport immediately assumed an important role in the mental health network after it opened in 1975, it became notorious for mismanagement and poor conditions. For years it was plagued by drug dealing, prostitution and violence. In a 1997 study, the State Office of Mental Health even referred to the home as "The New Warehouse for the Insane." Still, the Pataki administration, like its predecessors, allowed it to stay open.
    While it generally does not discuss deaths of Seaport residents, the attorney general's lawsuit uses state inspection reports and interviews with officials, residents and others to paint a dispiriting portrait of life inside the home. One inspection report referred to "layers of mouse droppings, cockroaches, flies and fleas in some resident bedrooms and/or bathrooms," says the lawsuit, filed in conjunction with the State Department of Health, which regulates the adult homes. And the court papers also detail how Seaport would promote itself to potential new residents as having "No. 1 Status" among the state's adult homes.
    Advocates for adult home residents, who have long criticized Albany for failing to punish adult homes like Seaport, were heartened by the lawsuit. But George Gitlitz of the Coalition of Institutionalized Aged and Disabled added that state officials who he said had looked the other way for too long should also be held accountable.
    Seaport residents, many of whom were transferred to other homes with records that are nearly as bad, said they hoped the lawsuit might pressure other operators to make improvements. "For the first time, they are doing something besides giving them a slap on their wrist." said Karen Burkoff, 52, who was a resident of the home for six years.

Heroin Deaths Rise Dramatically in Massachusetts
Stephen Smith, Boston Globe- 12/18/2002

Deaths from heroin and related narcotics in Massachusetts soared close to fourfold during the 1990s, an increase the state's public health commissioner described yesterday as an emerging health care crisis. A report issued by the state Department of Public Health also found that heroin now ranks as the illegal drug of choice for patients checking into rehab clinics, with 42 percent of patients who received substance abuse treatment this year reporting that they had used the drug recently. That compares with just 19 percent a decade earlier.
    The heroin surge, specialists say, is a classic case of market-driven economics: The drug is both purer and cheaper today, with a hit of heroin selling in some neighborhoods for less than a six-pack of beer. And, unlike a decade ago, when heroin was rejected by middle-class users as the province of street junkies, today the drug is snorted and smoked, burnishing its appeal in the suburbs. ''Heroin is suffocating our society,'' said Dr. Howard K. Koh, the Massachusetts commissioner of public health. ''It has invaded every corner of our Commonwealth.''
    The effects of heroin addiction are evident across New England. All six New England states have seen heroin use rise in the past decade; Portland, Maine, alone recorded 27 overdose deaths during the first 10 months of this year. Health officials also report increasing rates of AIDS and hepatitis C related to injection-drug use. For addicts seeking help, the outlook is clouded by budget cuts to a range of agencies that help fund drug treatment clinics.
    The new study, compiled by reviewing government, hospital, and drug assistance records, found that in 2000, the most recent year for which numbers are available, there were 363 overdose deaths from heroin or another narcotic, such as OxyContin, in Massachusetts. In 1990, there were just 94. Although the study does not break down that figure into heroin and other drugs, the counselors who provide treatment to substance abusers believe that the overwhelming majority of those narcotic-related deaths can be attributed to heroin.
    ''There's no question that it's an ever-growing problem that is getting to parts of the population that would have never considered doing heroin before,'' said Tom Magaraci, CEO of Habit Management, the largest provider of narcotic treatment in the state. ''There's a lot of heroin on the street - on streets everywhere. ''We're talking to suburban kids who tell us they go to parties, and there are drugs all around, including heroin, and it's just an accepted thing.'' The report on heroin was issued two months after another state study showed that cocaine use tripled among Massachusetts middle school students and doubled among high school students in the past three years.
    Across New England, heroin in the past five years has begun claiming more lives than homicides. For example, there were twice as many overdose deaths (40) in New Hampshire in 1999 as homicides (21), according to the New England High Intensity Drug Trafficking Area, a consortium of representatives from law enforcement and health agencies.
    At $5 to $20 for a small bag, heroin represents a cheap and potent high. In fact, an analysis performed by a Massachusetts state lab concluded that in 2002, the purity of heroin samples ranged as high as 66.9 percent, far higher than a decade earlier. That increase in purity means two things: Users can buy less heroin and get the same high, and the risk of overdosing rises substantially.
    In just one city, Lynn, heroin has claimed more than 50 lives in the past six years, police chief John Suslak said. It has also spawned crime -- armed robberies, for instance -- by users trying to support their habits. Increasingly, those users no longer fit the profile of a heroin junkie. A decade ago, drug counselors said, the typical addict was a middle-aged man. Today, the junkie is increasingly likely to be young and, more than ever, female.
    The Department of Public Health report found that from 1996 to 2001, there was a 230 percent increase in 15- to 24-year-olds who received hospital treatment because of their addiction to heroin and other narcotics. ''If people picture an addict in the alley injecting themselves, they'd better get that picture out of their head,'' said George C. Festa, executive director of the New England consortium.
    For heroin abusers, gaining access to treatment programs could prove more difficult in the coming year. Bay Cove Human Services, which provides drug treatment services in Boston, has 286 patients in its long-term methadone program, but 50 more are waiting to get in, said Stan Connors, the agency's president. Because of federal and state budget cuts, agencies such as Bay Cove expect that dozens of patients will lose benefits that help provide methadone to wean them off heroin. Bay Cove executives estimate that 35 of the patients in the methadone program will stop receiving care when they lose government benefits next year. ''Just recently, we had two 19-year-olds come in who both had five-year histories of using heroin,'' Connors said. ''Where are they going to go if we have even more cuts?''

Virginia Mental Health Change Proposed
William Branigin, Washington Post- 12/18/2002

Gov. Mark R. Warner yesterday proposed a major shift in Virginia's mental health policy that would divert patients from state institutions to community programs through what he called a "reinvestment" of as much as $22 million a year. The proposal would move money from five state institutions -- including the Northern Virginia Mental Health Institute -- to the state's 40 Community Services Boards, beginning in fiscal 2004. But it would neither add funding nor reverse the 15 percent funding cuts already imposed on the boards.
    "I am committed to making sure that Virginians with disabilities not only have the same rights as everyone else, but the same opportunities," Warner said. "By redirecting resources . . . to care in the community, we will be able to serve more people and offer them community-based treatment." Warner (D) said that the move would result in 450 fewer beds at the five institutions but that no funds would be diverted from mental health care overall. He said the redirected funds could be used, for example, to establish a community program in a vacant building at Central State Hospital in Petersburg and to create regional jail service teams to provide assessments and counseling.
    Warner called the proposal "the first stage of a multi-year vision to fundamentally change how mental health, mental retardation and substance abuse services in Virginia are delivered and managed." He pledged to continue efforts to build "a community care infrastructure" and said he was "committed to mental health reform."
    Advocates for the mentally disabled welcomed the initiative but questioned whether it would provide enough money to care for the mentally ill adequately while reforming the system. "I think it is a remarkable and progressive move . . . because Virginia's mental health system is long overdue for system reform," said Valerie Marsh, executive director of the Virginia chapter of the National Alliance for the Mentally Ill. "But I'm worried about there being enough money to do it right." Reform efforts in other states, she said, have required additional funding, not "just a shifting of the same pot of money."
    According to Marsh, 12,000 Virginians have been denied mental health services in the last year because of budget cuts, and alliance offices have been flooded with calls from family members whose mentally ill loved ones have attempted suicide, landed in jails or been turned away from hospitals. Marsh said that although she applauds Warner's proposal, she would urge him to restore the money cut from the budget. "Repair the damage you've already done," she said. "People are hurting right now."
    Warner said his budget, to be presented Friday, would redirect as much as $21.7 million a year to community care from state mental hospitals in Staunton, Falls Church, Marion, Petersburg and Williamsburg by eliminating units and beds. He said the initiative was generated by the Community Services Boards and has received "virtually unanimous support" from advocacy groups. James Reinhard, commissioner of the Department of Mental Health, Mental Retardation and Substance Abuse Services, said the funding shifts would be phased in, starting with $12.6 million in fiscal 2004 and reaching $21.7 million a year in fiscal 2005 and beyond.
    Because there is more demand for beds at the Northern Virginia Mental Health Institute in Falls Church than at other state hospitals, the institute would not be included in Warner's Community Reinvestment Project until 2005, Reinhard said. Then it would have to trim $3.3 million from its budget and lose about 30 of its 134 beds. He said this could be done in part by shifting patients to appropriate group homes. James A. Thur, director of the Fairfax-Falls Church Community Services Board, said local officials would have to be "extremely creative" in reducing usage of the facility, which often turns people away for lack of space. "We're going to look at how we can work collaboratively with private psychiatric hospitals," he said.