Bed Bugs: A Most Unwelcome Nuisance

August 29th, 2014 by Will Humble 1 comment »

12705_thumbJust the idea of bed bugs makes folks squirm…which is understandable, but here in Arizona we have scarier bugs like Rhipicephalus sanguineus or Culex quinquefasciatus that actually transmit diseases like Rocky Mountain spotted fever and West Nile virus.  Bed bugs don’t transmit disease but they can cause skin reactions and psychosocial stress (e.g., anxiety and sleeplessness).

Bed bugs feed on human blood, and can cause itchy skin welts.  If people scratch their welts with dirty hands, it’s possible they can get a skin infection, but bed bugs themselves don’t spread disease.  Bed bugs like to hide in small dark places close to humans or animals (think mattress seams, stuffed animals, and piles of dirty clothes).  They typically live within a meter of where people sleep and they shed their exoskeleton routinely, so you might suspect a problem if you see bed bug shells or rusty-colored blood spots around your sleeping area.

Aristotle and ancient historians tried desperately, but unsuccessfully to eradicate bed bugs from their homes by spreading dust, hanging a dead rabbit at the foot of the bed, and placing legs of the bed in pans of water.  Modern attempts seem equally scattered, we’ve tried using natural predators, insecticides, and even room heaters.  The current standard is to employ integrated pest management – a combined approach of chemicals and common sense practices to eliminate bedbugs from the home.

The best intervention is really prevention.   Bed bugs usually hitchhike into your home (they can’t fly)…so watch what you bring inside.  Leave the “free” curbside couch on the street, carefully inspect consignment store purchases, spread your own sheets when other children sleep over, and leave your luggage outside for a few nights after returning from a trip.  If you see or suspect a bed bug, act immediately.  If not, you might be tempted to add dust, rabbits and pans of water to your extermination plan!

Two More Medical Marijuana Lawsuits This Week

August 29th, 2014 by Will Humble 1 comment »

LAW hammer on computer folder. 3D Icon isolated on white backgroA few weeks ago I issued a Director’s Decision authorizing the use of marijuana for medical marijuana patients undergoing conventional treatment for PTSD.  Beginning January 1 physician certifications will be valid for palliative care of PTSD symptoms as long as certifying physicians attest that the patient is currently undergoing some kind of conventional treatment for PTSD before signing the certification.

I was sued Monday by the Cannabis Nurses Association regarding that decision.  They’re challenging the criteria in the Decision (e.g. the requirement that a physician attest that their patient is receiving some kind of treatment for PTSD and the January 1 implementation date).  This article from a weekly newspaper in Tucson provides a pretty good summary of the issue.

Yesterday, I was served with yet another medical marijuana lawsuitThis suit argues that the provision in the Arizona Medical Marijuana Act limiting cultivation rights to patients that live more than 25 miles from a dispensary is unconstitutional under the 14th Amendment US Constitution (Equal Protection Clause) and Article 14, Section 15 of the Arizona Constitution (Monopolies and Trusts).

Preventive Services Widget for Clinicians

August 28th, 2014 by Will Humble No comments »

SONY DSCThe Agency for Healthcare Research and Quality recently announced the release of the “ePSS widget” – which provides primary care clinicians and health care teams with timely decision support regarding appropriate screening, counseling, and preventive services for their patients.

The tool is based on the current, evidence-based recommendations of the US Preventive Services Task Force and can be searched by specific patient characteristics, such as age, gender, and selected behavioral risk factors.  The tool brings information on clinical preventive services that clinicians need – recommendations, clinical considerations, and selected practice tools – to the point of care.

It uses an Electronic Preventive Service Selector (ePSS) application platform on existing websites.  You can access the web application, download mobile app’s and download the ePSS Widget on-line.  Let your Stakeholders know about these easy to use tools.

The 5th “Vital Sign” & the Painkiller Epidemic (Part V of V)

August 27th, 2014 by Will Humble 1 comment »

clinicianIn Parts I, II, III, and IV of this series we established the acute and growing effects that the opiate painkiller epidemic is having in America, and how it has been driven (in part) by aggressive pain management strategies that were implemented since Pain was identified as the 5th Vital Sign.  Since then, public health and other sectors have been responding by developing and implementing strategies (presented in Part IV) to break the cycle of opiate misuse and abuse.  Today, we continue presenting interventions being conducted to address the epidemic.

In 2008 the Arizona Legislature passed and Governor signed a law establishing the Controlled Substances Prescription Monitoring Program.  The law required the Arizona State Board of Pharmacy to establish a controlled substances prescription monitoring program requiring pharmacies and medical practitioners who dispense controlled substances to report prescription information to the Board of Pharmacy on a weekly basis.  The Monitoring Program is one of the most important tools health care providers can use to manage patients.

The passage of a new law this year allows prescribers to appoint an office designee to access their patient’s medication history from the Monitoring Program just like they do patient charts.  This will cut down on prescriber time and still ensure patient safety and minimize liability concerns.  The system will be ready to accept designees starting in early September.  The new legislation requires updates every 24 hours (rather than weekly) and will help reduce dangerous drug combinations and high-dose prescribing.

At the national level, the U.S. Drug Enforcement Administration is revamping rules on providing prescription drug drop boxes in the community.  Currently the only place that can have a drop box is at the police department.  People may be more likely to properly dispose of unused drugs if they can do so year-round in places other than at a police or sheriff’s department.  Existing drop box locations are posted on the Arizona Prescription Drug Misuse & Abuse Initiative website.

The University of Arizona’s Office of Continuing Medical Education in conjunction with the Center for Rural Health is developing an online prescribing education tool that provides controlled substance prescribers in Arizona continuing graduate medical education credits for free upon completion of the interactive program.  The online education will align with and help promote Arizona’s Opioid Prescribing Guidelines.

Non-traditional approaches to pain management are finding their way into the conversation as alternative means individuals can embrace in order to manage their pain experience without having to depend on prescription drug therapy.  Meditation, yoga, acupuncture, changes to diet, chronic disease self-management, and a number of other choices are being adapted and adopted as viable alternatives to traditional pain management therapies.

The key to winning this battle is to align and focus our future efforts in a comprehensive manner.  The Institute of Medicine set this strategy in motion with their 2011 publication, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.  The Blueprint emphasized steps individuals, providers, and communities can take to prevent pain from occurring in the first place.  For example, public health partnering with primary care to provide community education to address behavior and lifestyle choices that lead to chronic disease, i.e., obesity, that contribute directly to the prevalence of chronic pain.

The painkiller misuse and abuse problem represents a perfect storm.  In the last several years a number of forces have coalesced to create a complex and dynamic public health problem for which no single silver bullet policy has been able to successfully take down.

Steps continue to be taken to develop, implement, and assess the effectiveness policies are having on reversing the deleterious effects of this epidemic – but the jury is still out on the question of whether the constellation of interventions that are being implemented at the federal, state and local level are enough to turn the tide on this critical public health crisis.

Forensic Campus Hits the Mark

August 26th, 2014 by Will Humble No comments »

forensichospitalinspectionA few weeks ago Medical Facilities Licensing conducted a surprise complaint investigation of our Arizona State Hospital’s Forensic Campus.  Last week we received notification that no deficiencies were found during the 3-day on-site inspection - which included an in-depth review of policies, procedures, documentation and patient care standards.  Congratulations to the entire Forensic Campus team for a job well done – especially folks working in Direct Care, Nursing, Medical Services and Quality Management.

Public Health & the Panama Canal

August 25th, 2014 by Will Humble No comments »

mosquito sucking blood from human handThe Panama Canal celebrates its 100th anniversary this week.  Hailed as both a Wonder of the Modern World and a Monument of the Millennium, the Panama Canal has public health, engineering, and laborers to thank for its completion.  You may remember from history class that the construction of the Canal took decades longer than anticipated.  One reason for the delay was the debilitating illness caused by malaria and yellow fever.  French workers were said to be fleeing Panama out of fear of death and no wonder – 80% of their coworkers were being hospitalized.

When the US acquired the Panama Canal Zone in 1904, Colonel William Gorgas was assigned as the Chief Sanitation Officer.  He came up with a new concept - that mosquitoes were spreading malaria and yellow fever.  His team implemented a multilayered approach to mosquito control in Panama.  They drained pooled water within 100 meters of houses, killed mosquito larva with chemicals, put screens on windows to prevent mosquito entry, and more.  By 1906, the Zone was free of yellow fever, and eradication of malaria soon followed.  Within the next decade, the Panama Canal was finally able to be completed.

Infectious diseases weren’t the only public health challenges faced by workers.  Work on the Panama Canal could be treacherous - and occupational health and safety was a real problem.  In fact, the death rate for Canal laborers in the early years was between 4-5% per year.  Perhaps the most dangerous job was dynamiting - because the explosives were sometimes in poor condition and unstable - or would remain unignited until exploding later by accident.  Landslides were another serious occupational hazard.  In all, more than 5,000 people perished building the Canal.

There’s a good PBS Special American Experience: Panama Canal.  You can watch on-line, buy the DVD, or get it through iTunes.

Snus Causes Cancer Too

August 22nd, 2014 by Will Humble 2 comments »

ash-logoSmokeless tobacco has made recent headlines with former MLB players citing their habitual use for their cancer diagnosis, including Tony Gwynn, who recently died after battling salivary gland cancer, and this week, Curt Schilling, who publicly announced his diagnosis of squamous cell carcinoma (cancer of the mouth).  Both attributed their cancer to their 30+ years of chewing.

The percentage of adults using chew in Arizona has remained steady at just over 3% (about 17% of Arizonans smoke cigarettes).  The “chew” rate is three times higher in rural AZ.

Smokeless tobacco isn’t safe.  It affects the mouth and throat more directly than smoking, and is absorbed directly into the gums causing immediate as well as long-term damage.  It increases a person’s chance of being diagnosed with oral, esophageal, pancreatic and stomach cancer.  Smokeless tobacco users are four times more likely to develop oral cancer than non-users, and their risk for cancer of the cheek or gums increases 50-fold.

But there’s good news.  The Arizona Smokers’ Helpline helps smokeless tobacco users too.  Since a support system like ASHLine can make the difference for people who decide to stop using any form of tobacco, it’s important that chewers know that ASHLine coaches are here for them too.  The ASHLine has almost twice the success rate of other quit lines nationally, and offers free telephone quit coaching at 1.800.55.66.222 and free online quit coaching services via WebQuit ™ at

Healthy Aging Brief

August 21st, 2014 by Will Humble No comments »

women_iconThe Association of State and Territorial Health Officials recently investigated ways in which public health can support healthy aging. The results are now available in an issue brief that outlines key recommendations to help state health agencies support healthy aging, identify collaborative opportunities, and integrate public health and healthy aging.

The 5th “Vital Sign” & the Painkiller Epidemic (Part IV of V)

August 20th, 2014 by Will Humble 1 comment »

feetIn Parts I, II, and III of this series we established the acute and growing effects that the opiate painkiller epidemic is having in America, and how it has been driven (in part) by aggressive pain management strategies that were implemented since Pain was identified as the 5th Vital Sign.  Since then, public health and other sectors have been responding by developing and implementing strategies to break the cycle of opiate misuse and abuse.

The CDC recently recommended a number of strategies states can employ including: 1) electronic Prescription Drug Monitoring (which AZ has through the Arizona Board of Pharmacy); 2) patient review and restriction programs within state Medicaid programs to monitor prescription claims data for inappropriate use of controlled prescription drugs (AHCCCS does this); 3) implementation of health care provider accountability programs to ensure providers are following evidence-based prescription guidelines (we have Guidelines); 4) enacting state laws to prevent doctor shopping and the rogue operation of “pill mills” (some AZ laws exist); and 5) providing affordable, comprehensive, and meaningful substance abuse treatment programs (we do this through our behavioral health services division).

The Arizona Substance Abuse Partnership endorsed a Prescription Drug Reduction Initiative, known as the Arizona Prescription Drug Misuse and Abuse Initiative. Using the strategies proposed by the Office of Drug Control Policy as a starting point the partnership developed a set of data-and-research-driven strategies to be used in a multi-systemic, multi-agency collaborative approach to reduce prescription drug misuse in Arizona.  Initiative participants have also developed Arizona Guidelines for Dispensing Controlled Substances and the Arizona Guidelines for Emergency Department Controlled Substance Prescribing as well as draft new Arizona Opioid Prescribing Guidelines for all healthcare providers.

At the national level, the Joint Commission issued a new Sentinel Event Alert recommending that health care organizations take defined steps to improve their response to and reporting of prescription drug misuse and abuse including: 1) monitoring patients who are receiving opioids on an ongoing basis; 2) using pain management specialists or pharmacists to review pain management plans; 3) providing education and training for clinicians, staff and patients about the safe use of opioids; and 4) using standardized tools to screen patients for risk factors such as over-sedation and respiratory depression.

At the state health department level, the Association of State and Territorial Health Officials’ 2014 President’s Challenge is to “reduce the rate of nonmedical use and the number of unintentional overdose deaths involving controlled prescription drugs 15% by 2015”.  The President’s Challenge includes a strategic plan to implementing evidence-based Prevention Strategies, Monitoring and Surveillance, Control and Enforcement, and Treatment and Recovery to reach this important goal.

Now that we’ve discussed responses to the prescription drug abuse and misuse…the next question to ask is whether these collective intervention efforts are enough to turn the tide.  We’ll tackle that in Part V.

Updated Infection Control Prevention Guidelines

August 19th, 2014 by Will Humble No comments »

hospital settingThe Society for Hospital Epidemiology of America and the Infectious Diseases Society of America partnered with several healthcare organizations to publish evidence-based and best practice recommendations for preventing healthcare-associated infections in acute care hospitals.  Referred to as the “SHEA Compendium”, these recommendations have served as a cornerstone of infection control and prevention since their publication and are a staple on the desks of infection preventionists and healthcare epidemiologists worldwide.

The Compendium focuses on strategies to prevent healthcare associated infections like surgical site infections, central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, Clostridium difficile, and Methicillin-resistant Staphylococcus aureus.  The Compendium includes information on outbreak management and special circumstances, and recommends performance measures to monitor implementation and outcomes.

The revised 2014 version of the Compendium sections is published by the journal Infection Control and Healthcare Epidemiology and is freely available online.  This year’s update also features a new section focusing on strategies to prevent infection through hand hygiene, which is the simplest and most effective approach to infection prevention.