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School of Dental Medicine, CU Anschutz take lead fighting opioid epidemic

Pills
More Coloradans have died from overdoses of opioids such as hydrocodone, oxycodone and fentanyl since 2011 than have been killed in homicides.

Helping patients cope with severe pain is a priority for dentists and physicians, but the opioid epidemic requires health-care practitioners to face a balancing act. Prescription opioids such as Vicodin, Percocet and OxyContin are powerful painkillers that provide real relief. However, they can be addictive, and misuse can have devastating and even deadly consequences. Every year since 2011, more Coloradans have died of opioid overdoses than have died in homicides.

CU Anschutz fights the opioid epidemic

This is the first in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.

Dentists, including oral and maxillofacial surgeons, are on the front lines of the epidemic, writing about 12 percent of all prescriptions for immediate-release opioids. Individually and as a profession, they have to strike the right balance between managing pain and preventing abuse. Now, the University of Colorado School of Dental Medicine (SDM) is coming to their aid.

“We’re taking opioid abuse very seriously and doing whatever we can to address the problem,” said Michael Henry, DDS, PhD. Henry is the school’s associate dean for academic affairs, and he has spent his career training dentists and studying orofacial pain.

Henry and his colleagues at the School of Dental Medicine are just some of the researchers at the CU Anschutz Medical Campus fighting the opioid epidemic. CU Anschutz faculty members and students evaluate public health options, find new ways to track prescriptions and direct Colorado’s major public education campaign. The state relies heavily on CU Anschutz to coordinate the response to the crisis, with the university providing the Colorado Consortium for Prescription Drug Abuse Prevention’s director and the chairs of many of its work groups.

At the SDM, faculty look for alternatives to opioids, develop new prescribing standards and create new curriculums. Their work already has shown results that benefit dentists, physicians and patients.

Searching for and finding new approaches

Dentists want to start by finding effective pain relievers that will not cause addiction or dependence. That effort is paying off and leading to surprising findings, Henry said. One is that a combination of acetaminophen, which is the active ingredient in Tylenol, and ibuprofen, which is in Advil, can be more effective than opioids in the management of post-operative and procedural dental pain. Under the guidance of their dentists, recovering patients can take the combination of over-the-counter medicines longer without having to worry about getting hooked and can avoid common opioid side effects such as nausea and constipation.

Dr. Michael Henry
Michael Henry, DDS, PhD, is associate dean of the School of Dental Medicine.

The SDM wants the dental community and patients to know that kind of new information.

“We’re really trying to get that message out,” Henry said. “The data is pretty strong that that’s a very, very potent combination.”

The school has developed guidelines about the best medications to prescribe depending on the type of pain, along with recommended dosages.

Better guidelines are important because opioids will continue to have a place in pain management, Henry said. While it is still appropriate to prescribe opioids after some dental surgical procedures where severe post-operative pain is expected, researchers are carefully evaluating the specific number of opioid-containing tablets that are prescribed. Improving best practices can help dentists identify when opioids are appropriate and help them do what’s best for patients.

Opioid abuse by the numbers

329 people died in Colorado from misusing prescription opioids in 2015

 

224,000 Coloradans misuse prescription drugs each year

 

Colorado ranks 15th in the nation for opioid abuse—down from second in 2011

“We have to be concerned about opioid addiction, but we have to consider that in light of providing patients with proper pain management,” Henry said.

Through continuing education programs for current dentists, the school will share that protocol, as well as best practices for discussing pain and opioids with patients. The next course is on Feb. 25, and Henry will teach it along with Rachael Rzasa-Lynn, MD, who is director of the Interventional Pain Clinic in the School of Medicine, and Robert Valuck, PhD, RPh, who is the director of the Skaggs School of Pharmacy and Pharmaceutical SciencesCenter for Pharmaceutical Outcomes Research and an opioid abuse expert.

Improving patients’ knowledge about painkillers

Henry said it is not enough for dentists to understand the latest research and best practices. Patients also need to be educated, and that includes helping them overcome misconceptions about painkillers.

Patients often assume that after a procedure they will be prescribed Percocet, Vicodin or a similar medication—after all, they’ve heard those are the most powerful. There also is the perception that if a medication needs a prescription, it must be better than what is available over-the-counter.

That perception is not true, Henry said, but it is difficult for dentists to change patient expectations. Patients could doubt their treatment, which has negative consequences for pain management.

“Patient expectation is our biggest challenge,” Henry said. “So much of pain relief is based on the expectation of the patient. The expectation of pain relief can actually activate brain regions that contribute to analgesia. If they are expecting that medicine to be effective, it has a greater chance of being effective. That’s basic pain science.”

Meanwhile, institutions such as the SDM and organizations such as the American Dental Association continue pain management education and work to combat the epidemic.

“Every week I see new concerns regarding the role that dentists play in opioid abuse,” Henry said. “This is at the forefront of dentistry.”

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Research investigates role of protein in obesity

Obesity in Latin America is increasingly concentrated among women of low socioeconomic status, but surprisingly little is known about what such women eat or how their diets compare to others.

protein sources

Yet in a study published recently in the American Journal of Human Biology, researchers at the CU Anschutz Medical Campus, in collaboration with colleagues at CU Boulder and the University of Costa Rica, tested an explanation for greater obesity among these women: limited access to dietary protein leads them to consume a lower proportion of protein in the diet, driving higher calorie intake and obesity.

The study, “Using the protein leverage hypothesis to understand socioeconomic variation in obesity,” examined elements of the protein leverage hypothesis in a sample of Costa Rican women.

“Studies conducted in a laboratory setting show that when people eat a diet with a lower proportion of protein, they tend to consume more calories,” said lead author Traci Bekelman, a post-doctoral fellow in pediatrics at the CU School of Medicine. “We tested out this relationship between protein and calories in a real world setting in order to provide insight into rising obesity among the poor in Latin America.”

According to the report, the majority of research on the dietary causes of obesity has focused on carbohydrates and fats. This study suggests that explanations for obesity, especially among populations with limited access to food, should not overlook the potential role of protein.

The protein leverage hypothesis predicts that protein intake is more tightly regulated by the body than intake of other macronutrients. If one does not eat enough protein, in grams, to achieve the body’s intake target, an appetite for protein drives individuals to keep eating and could result in excess calorie intake and obesity.

Consistent with expectations, researchers found that obesity was higher and the proportion of protein in the diet was lower among low socioeconomic status women compared to others. They also found an association between the proportion of protein in the diet and total calorie intake. As the proportion of protein in the diet increased, total calorie intake decreased.

Researchers also looked at the relationship between the proportion of protein in the diet and calorie intake within different socioeconomic groups. They expected that the relationship would be strongest for women of low socioeconomic status because the protein leverage hypothesis should be most relevant to populations on low protein diets, but they found this relationship to be strongest for women of middle- and high-socioeconomic status. They found no relationship among women of low socioeconomic status.

“One possible explanation for this unexpected finding is that women of low socioeconomic status cannot afford to continue eating until they reach the body’s protein intake target,” Bekelman said.

According to the report, researchers were surprised to find that over half the women in the full sample did not meet their protein requirements, revealing a potential public health issue, especially because the protein deficit is among women of childbearing age.

The cross-sectional study used a random sample of 135 women from San José whom researchers placed into one of three socioeconomic categories. Researchers interviewed the participants over a nine-month period to collect information on their body mass index and what they ate and drank.

The study should not be interpreted as a causal link between protein intake and obesity and had a number limitations related to study design. The report recommends that further research on the protein leverage hypothesis should include studies that measure energy balance by simultaneously collecting data on energy intake, energy expenditure and body weight.

At CU Anschutz, scientists engage in high-profile academic studies resulting in discoveries that contribute new information about the nature and treatment of disease to the rest of the world.

 

 

 

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Student’s study for state health department links heroin, opioid abuse

Lindsey Kato takes the opioid epidemic personally — the Colorado School of Public Health (ColoradoSPH) alumna has lost eight friends to heroin overdoses. She said most of those friends began abusing prescription opioid painkillers such as Vicodin and OxyContin in high school. Then they graduated to heroin, an even more lethal and addictive opioid.

Kato grew up in Juneau, Alaska, a community hit hard by opioid abuse and a surge in heroin use. “I still continue to lose friends,” said Kato, who in December received her Master of Public Health degree. “I want to understand how did I end up here, and how did my friends end up there.”

CU Anschutz fights the opioid epidemic

This is the second in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.

For Kato, “here” meant the University of Colorado Anschutz Medical Campus, where she studied epidemiology. That led to a job with the Colorado Department of Public Health and Environment (CDPHE). In May 2016 and while still a student, she began working as the department’s heroin strategies coordinator. The job helps bridge the public health and law enforcement communities, which in the past have not always seen eye-to-eye on how to deal with addiction.

Kato’s responsibilities included collecting all the data about arrests for heroin or opioid possession and distribution that Colorado law enforcement agencies could provide. She also studied the progression from prescription medications to street drugs, leading a project that conducted surveys in nine Denver-area methadone clinics. The CDPHE will publish the survey findings next month in a report titled “Heroin in Colorado.”

Lindsey Kato
Colorado School of Public Health graduate Lindsey Kato, MPH

Kato’s work is an example of how CU Anschutz faculty, students and alumni help fight opioid abuse. Epidemiologists in the ColoradoSPH study demographic trends and social impacts in the hopes of helping individuals, families, communities and government officials come to grips with the epidemic. Other researchers at CU Anschutz study alternative pain treatments, develop continuing education programs for rural doctors and integrate databases used by doctors, dentists and pharmacists.

Understanding prescription opioids’ connection to heroin

The State of Colorado considers opioid and prescription drug abuse a public health crisis, and it relies heavily on CU Anschutz to coordinate the response, with the university providing the Colorado Consortium for Prescription Drug Abuse Prevention’s director and the chairs of many of its work groups.

The state has become especially concerned about the link between opioid abuse and heroin, said Robert Valuck, PhD, RPh, a professor at the Skaggs School of Pharmacy and Pharmaceutical Sciences and expert in opioid abuse. Valuck coordinates the consortium.

In 2015, 160 people in Colorado died of heroin overdoses, up from 37 in 2000 and 91 people in 2012, according to the state health department.

The idea that painkillers prescribed by a doctor or dentist could lead to heroin addiction surprises people, Valuck said. Some think it might be harmless to share meds with family members in pain or keep unused pills in the medicine cabinets. But that can lead to disaster — according to national statistics, about 69 percent of opioid abusers started that way.

The connection between the two epidemics seems to make sense. Heroin is in the same family of drugs as prescription opioids, and the nervous system reacts to them in similar ways. They share harsh withdrawal symptoms that cause people to become violently ill. Addicts become desperate to prevent withdrawal, Valuck said, and some will begin buying pills from drug dealers to avoid the pain.

“People who go through withdrawal say they would rather die than go through that again,” Valuck said.

Anecdotal evidence from law enforcement officers and health care providers supports the connection between the epidemics. But government officials and public health experts developing strategies for combatting the epidemic needed better data. One of Kato’s tasks for the state health department was to collect data about why and how people became addicted to heroin.

“We had a hunch about the connection between prescription drug abuse and heroin,” Kato said. “We wanted solid evidence, and we wanted to understand heroin abuse from the perspective of people who have experienced heroin addiction.”

Researching in methadone clinics

Heroin and opioid abuse in Colorado

 

160 people died of heroin overdoses in 2015

 

37 died of overdoses in 2000

 

70 percent of recovering heroin users abused prescription opioids

 

329 people died from misusing prescription opioids in 2015

To conduct the study, Kato and five ColoradoSPH students interviewed patients in nine methadone clinics around Denver. The clinics help patients recover by distributing methadone, which mitigates opioid withdrawal. The medication itself is a long-acting opioid, but unlike heroin or prescription opioids, it does not get users high. Patients receive their doses at clinics, and doctors supervise their treatment.

Kato and the team administered an in-person survey with 46 questions. They asked the clinics’ clients about their backgrounds and why they began using drugs. Kato also sought to find what recovering addicts thought about their treatment and what helps them stay sober.

Interviewers often started at 5 a.m. to meet people who went to the clinic before work. They conducted 713 surveys in 25 days.

What Kato found shocked her, especially what she saw during her first visit to a clinic.

“We couldn’t tell who was a client from who worked there,” Kato said. “Society paints a certain picture of addiction, we think of particular demographic, and that’s the stigma around methadone clinics. But it was so diverse — there were people in suits who looked like they could be professors, classmates or even your grandmother.”

Kato also found that about half of the recovering patients had college educations, more than a third were employed, and the majority rented or owned homes. The data confirmed what Kato saw happen to her friends. About 70 percent of the clients cited prescription pain medication use as one of the main reasons for transitioning to heroin.

Their stories shared certain traits—sometimes people got hooked as kids, sneaking a family member’s meds. Some became dependent on legitimately prescribed painkillers for a medical problem. When doctors stopped prescribing, they would borrow or steal pills from friends or family.

At that point, Kato found prescription drug abusers reached a crossroads. Some sought treatment, while others turned to drug dealers. Some of the latter were able to limit their addictions to prescription medications. Others couldn’t and tried heroin.

Someone in this situation isn’t necessarily trying to find a better high, Valuck said. Heroin is cheaper and easier to find on the drug market than prescription meds, and he said it is not uncommon for people to sell their prescription medication and use the money to buy heroin.

Creating a unified response

Controversy still lingers around methadone. Doctors and public health experts consider methadone a legitimate and effective treatment. Valuck said giving patients carefully managed doses that decrease over a few years has proven safer and more effective than making them quit cold turkey.

“We couldn’t tell who was a client from who worked there…. They could be professors, classmates or even your grandmother.”

Law enforcement officers historically have not been involved in drug treatment, Kato said. She believes that police see the crimes committed by drug addicts and often identify with victims affected by these crimes, rather than identifying or empathizing with the individuals experiencing addiction.

The difference in perception shows the different approaches between those who see drug abuse as a criminal matter or a medical issue. Kato plans to spend her career working to bring the sides together to help coordinate an effective response. Already, she’s seeing attitudes change among leaders in the law enforcement community.

“They have come to terms with knowing they’re not going to solely arrest their way out of this problem,” Kato said.  “They are actively seeking to understand the process of addiction and how they can be involved in a public health approach.”

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Our students don chefs’ hats to further their education

Students from the Culinary Medicine/Culinary Dentistry present a meal they prepared
Students from the Culinary Medicine/Dental Medicine present a meal they prepared

On a recent Friday, Gabriela Andrade, a second-year dental student from the CU Anschutz School of Dental Medicine (SDM), was putting the finishing touches on a group project. She stacked sandwiches on a platter, and her group lined up to explain to their instructors and classmates about an extra ingredient they added to the hummus: chipotle peppers.

Because of a program funded by Delta Dental of Colorado to support interdisciplinary education among health professionals, called the Frontier Center, the classmates, 17 CU dental and medical students, join culinary nutrition chefs side-by-side each week in a Culinary Medicine/Dental Medicine elective course. The class is a venture of the School of Medicine (SOM), the SDM and the College of Culinary Arts at Johnson & Wales University (JWU). Every Friday the students gather in JWU’s production kitchen to talk about and taste food—for academic credit.

As Andrade’s group described how the peppers contributed a pleasing heat and flavor, as well as added nutritional benefits, their instructor chimed in with suggestions for ingredient substitutions. Then the class heard the words they had been waiting for all afternoon: “let’s eat.”

Gabriela Andrade, a School of Dental Medicine student, practices her knife skills
Gabriela Andrade, a School of Dental Medicine student, practices her knife skills

An interdisciplinary education in nutrition

The class, which will meet for eight Fridays, consists of a two-hour discussion and quiz on nutrition, followed by hands-on training in cooking techniques, including knife skills, working with fresh produce, and making healthful substitutions in recipes. Students work in small groups to produce different parts of a complete meal: appetizers, salads and a main course. Clinical nutrition students from JWU are on hand to provide guidance and experience.

Tamanna Tiwari, a clinical instructor at the School of Dental Medicine
Tamanna Tiwari, a clinical instructor at the School of Dental Medicine

The interdisciplinary focus of the course is one of its primary benefits, according to Tamanna Tiwari, MPH, MS, BDS, a clinical instructor at the SDM. “As the first School of Dental Medicine to offer an elective for Culinary Dentistry, we are adding to our innovative, interdisciplinary curriculum,” she said. “Our dental students work as a team with medical students. They take ownership of projects together.”

The course aims to fill a gap in medical education by providing students with the latest research on clinical nutrition and instruction on how to communicate lessons about nutrition to their future patients. “Diet has a huge effect on the whole person,” said Mark Deutchman, PhD, SOM professor. “This class fills in a knowledge gap. It will make our students better practitioners and help them to address all aspects of a patient’s health.”

Adding tools to their toolkits

For medical student Nick Stephanus, the class is an opportunity to add more tools to his toolkit. “In primary care, many illnesses are chronic, and can be managed by careful monitoring of one’s diet,” he said. “This class teaches us how to give good advice to future patients, so that physicians can say more than just ‘manage your calorie intake.’”

Mark Deutchman, professor at the School of Medicine
Mark Deutchman, professor at the School of Medicine

Andrade, too, plans to use the skills she gains in the class to help her future dental patients. “I plan to work with Hispanic populations and with patients with a lower socio-economic status,” she said. “They may not have had a lot of education about nutrition, and this class will help me to better communicate tips for a healthier lifestyle and oral health.”

Although the Culinary Medicine/Dental Medicine course focuses on skills that students can use to help their future patients, the class agrees that they are already benefiting by taking their work home. The skills they are learning have allowed them to cook meals that are more nutritious for themselves. They’ve also cultivated camaraderie with the nutrition students from JWU, who will go on to work in the medical field as dietitians and clinical researchers.

“The JWU students enjoy the interchange of information with CU,” said Marleen Swanson, RD, the department chair of the JWU Culinary Nutrition program. “They glean a better understanding of the medical world through case studies that they review with CU students.”

School of Medicine students like Nick Stephanus learn cooking skills and how to communicate nutrition tips to their patients
School of Medicine students like Nick Stephanus learn cooking skills and how to communicate nutrition tips to their patients

Following their taste buds

With a growing awareness of the important role nutrition plays in preventive care, and the lack of nutrition education in medical and dental schools across the country, the Culinary Medicine/Dental Medicine course will make a significant contribution to medical education. The interdisciplinary approach at CU Anschutz, along with the partnership with JWU, are producing medical and dental professionals who are knowledgeable and enthusiastic about healthy eating.

For good reason. The smells wafting from the kitchen classroom every Friday are mouthwatering, and the energy in the room is contagious. Both Andrade and Stephanus look forward to the class each week. “Cooking is an experiment,” Andrade said. “I’m learning as I go, but I’m also following my taste buds.”

 

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Study finds an association between proximity to oil and gas development and childhood leukemia

Young Coloradans diagnosed with acute lymphocytic leukemia are more likely to live in areas of high-density oil and gas development compared to young Coloradans diagnosed with other types of cancer, according to researchers at the Colorado School of Public Health at CU Anschutz. The researchers observed no association between non-Hodgkin’s lymphoma and high-density oil and gas development.

Dr. Lisa McKenzie
Dr. Lisa McKenzie

“Over 378,000 Coloradans and millions of Americans currently live within a mile of at least one oil and gas well, and petroleum development continues to expand into residential areas,” said lead investigator Dr. Lisa McKenzie, assistant research professor at the Colorado School of Public Health. “The findings from our registry-based case control study indicate that young Coloradans diagnosed with one type of childhood leukemia are more likely to live in the densest areas of oil and gas sites. More comprehensive research that can address our study’s limitations is needed to understand and explain these results.”

Funded by the CU Cancer Center and published today in the journal PLOS ONE, the study shows children and young adults between the ages of 5 and 24 with acute lymphocytic leukemia were 4.3 times more likely to live in the densest area of active oil and gas wells than those with other cancers. The study focused on rural areas and towns in 57 Colorado counties and excluded urban areas of more than 50,000 people.

According to the report, U.S. oil and gas development has grown rapidly over the past 15 years and this industrial activity has the potential to emit toxic substances into air and water, including carcinogens like benzene.

According to current research, over 15 million Americans now live within 1.6 kilometers (1 mile) of oil and gas development. There are hundreds of oil and gas wells within one mile of a home in Colorado’s most intensive areas of oil and gas development. The study indicates that people living in areas of oil and gas development may be at an increased risk for health effects, including cancers, resultant from such industrial exposures.

The report concludes that future research should incorporate information on oil and gas development activities and production levels, as well as levels of specific pollutants of interest like benzene, near homes, schools and day care centers. It recommends such research consider specific ages and residential histories, compare cases to controls without cancer and address other potential confounders and environmental stressors.

Data for the study was obtained from the Colorado Central Cancer Registry and the Colorado Oil and Gas Information System. The study included 743 young Coloradans aged 0-24 years living in rural Colorado and diagnosed with cancer between 2001 and 2013.

Researchers used information from the Colorado Oil and Gas Information System to build a geocoded dataset with coordinates of all oil and gas wells in rural Colorado and determined dates for when each well was active.

Geocoded residential addresses of cancer patients at the time of diagnosis were linked to active well locations in the year of diagnosis and active well locations in each of the 10 years preceding the cancer diagnosis. They then took the inverse of each distance and summed the inverse distances to calculate inverse distance weighted oil and gas well counts within a 16.1 km radius of each participant’s residence at cancer diagnosis for each of the 10 years prior to the date of the cancer diagnosis. The inverse distance weighted well count method gives greater weight to the wells nearer the home. Age, race, gender, income, elevation of residence and year of cancer diagnosis all were considered in the analysis.

The study was limited by the low occurrence of leukemia and non-Hodgkin lymphoma in rural Colorado, lack of specific age at cancer diagnosis and the fact that all study participants had been diagnosed with cancer. The study also was limited by the lack of information on specific activities at the well sites, place of residence before cancer diagnosis, other sources of pollution around the residence and individual characteristics such as common infections and family history of cancer.

The other study authors are William Allshouse, Tim Byers, Berrin Serdar and John Adgate of the Colorado School of Public Health at CU Anschutz and Edward Bedrick of the College of Public Health at the University of Arizona.

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