Distracted Driving

Let’s face it; we are all distracted drivers some of the time. I tie my tie or floss my teeth sometimes when I’m driving to work and I’ve seen others even reading newspapers! But the explosion in cell phone use has markedly increased the frequency and consequences of distracted driving. Studies show that a driver simply talking on a cell phone has a 4-6 times risk of having a crash as the same person talking, and is at the same risk as one driving with a blood alcohol level of .08 g/dL. Texting while driving is 5 times worse; people texting when driving are 25 times as likely to crash. Studies show that while texting, drivers have their eyes off the road 4.6 of every 6 seconds! Not surprisingly national data from 5 years ago showed 2000 fatalities annually associated with texting, 16% of the total auto crash deaths.  But since many more people use cell phones than text, more die from simply using their cell phones. Hands-free cell phones may not reduce the risks much.

I’ve found myself sliding toward the edge of the road and hitting the rumble strip a few times even when I’m using a hands-free phone and able to dial numbers by voice. I bet many of you have too, right? But most drivers using cell phones don’t have the luxury of such equipment. The risk is made worse when cell phone use is added on top of other impairments, like alcohol intoxication, illicit or prescription drug use, fatigue (especially from obstructive sleep apnea, usually in obese snorers), inexperience (teenagers), eating in the car, night driving and/or bad weather conditions, unfamiliar roads, kids in the back seat fighting, impaired vision, or your GPS talking to you while your cellphone rings.

So how can you protect yourself from these risks?

First, be careful! Minimize your use of cell phones and don’t text while driving at all. Insist your family follow these rules too. New drivers should not use phones at all for the first several years they drive. Use Bluetooth hands-free systems if you can afford them.

Secondly, and because precautions you take don’t reduce your risk of being hit by another texting or cell phone-using driver, support reasonable legal restrictions. 10 states prohibit hand-held phone use while driving, 32 states do so for novice drivers, and 39 ban texting for all drivers. Maine does restrict texting for teens by law. However such laws are difficult to enforce and sometimes, like seat-belt laws, can only be enforced if a driver is stopped for another violation. Phone records can serve as an enforcement tool like blood alcohol levels can for drunk driving. But it is cumbersome. In the future, technology fixes, like cars that disable phone use when in motion may be possible, but how do they distinguish the driver from a passenger?

This is a big and increasing problem that will require all drivers to consider their answer to these important questions: how will you reduce your own and your family’s risks and how can you support reasonable new legal constraints on distracted driving.

Dan Onion, MD, MPH: 293-2076, dkonion@gmail.com

Mt. Vernon Health Officer

How to break a smoking addiction

Everybody knows that smoking is bad in all kinds of ways, but most smokers have found that it is extremely hard to stop! That’s because one’s body becomes both habituated and usually addicted to smoking and the nicotine it delivers. And smoking has become financially very expensive as well. In this article, I want to offer suggestions, based on decades of trying to help 100s if not 1000s of smokers, about what strategies seem to help people kick the habit.

At the risk of overkill, let me review quickly the damage smoking does. Most importantly it increases bronchitis and emphysema usually by age 50+ that then kills people by suffocating them over the next 10-15 years, unless they die from smoking-related lung/throat/gullet/bladder cancers, or heart disease, sooner. It markedly increases those diseases as well as asthma in adults and children living in the same house. Smokers die about 10+ years sooner than those who do not. Does smoking help anything? The answer is not much. It does keep smokers’ weights down about 5-10 lbs; a few patients with rare conditions like Crohn’s disease of the bowel get some disease improvement, and it transiently relaxes those who are habituated/addicted.

First some general principles on quitting: if possible, undertake quitting with others, friends or in a class; formal and informal social pressure helps (Maine Tobacco Helpline 800-207-1230, http://www.tobaccofreemaine.org/ quit_tobacco/ MaineTobaccoHelpLine.php; and, http://www.Tobacco independence.org/images/userfiles /file/Tobacco%20Treatment%20Services%20Guide(2).pdf). Avoid situations you habitually associate with smoking, like bars, a cup of coffee in your old smoking haunts, or former smoking companions not interested in quitting. Set a quit date and perhaps taper to it; suddenly quitting works for many, tapering for fewer; and stopping in the middle of a respiratory illness like a cold is often easier. Don’t be discouraged by relapses; most people who stop and then go back to smoking several/many times before succeeding.

Second, use some aids:

Hypnosis helps some people.

Medications (with a clinician’s prescription) help many succeed; there are 3 classes used and most health insurances, if you have it, cover some of the cost. Even though the last Maine legislature cut coverage for these prescriptions for MaineCare patients, I expect and hope that decision will be reversed soon next year.

•First are the various forms of low dose nicotine. The nicotine patch (Nicoderm, Habitrol, Prosten), changed every 24 hr, using 21 mg patches the first 2-3 wk, then 14 mg patches for another 2-3 wk, then 7 mg ones for a similar or longer period of time, helps achieve cessation in about 25% of people at one year and costs about $100/month. The 2 or 4 mg gum pieces (Nicorette, and other brands I’m sure now) chewed, up to 20 pieces a day, costs about the same and achieves similar cessation rates. Nicotrol inhalers and nasal sprays cost more but do as well as the gums and patches. The newest are the electronic cigarette systems, which deliver nicotine via a plastic “cigarette” without the tobacco smoke. All nicotine treatment, carry the risk of side effects like addiction, sleeplessness, high blood pressure, worsened angina or congestive heart failure, and leg ulcerations.

•Bupropion (as long-acting Zyban or generic forms) works when taken as 150 mg daily for the week before stopping smoking, then increased to twice a day and used for at least 2 months. Costs are in the same $100+/month range and success rates, when used alone, are also 25% at one year; but can be as high as 36% when used in combination with nicotine medications as described above.

•Varenicline (as Chantix, no generic) taken ½-1mg by mouth twice a day, started a week before quitting and for at least 3 months afterward, reportedly results in 43% stop rates at one year, but costs $250/month and can cause agitation and even suicide rarely.

Finally, work, play and eat, if you can, in places where newer state no-smoking laws prohibit smoking, including in outdoor eating and other public places

So it’s not easy and, most importantly, don’t be discouraged if you don’t succeed the first time. Most people don’t. The majority succeed over several years. So don’t give up; keep trying! It is the single most important thing you can do for your own and your family’s health.

Dan Onion, MD

Vienna Health Officer

dkonion@gmail.com

293-2076

1/8/13

Lyme Disease and Tick Bites

5/1/13

It is spring and the flowers, black flies and ticks are blooming! Flowers and black flies rarely cause significant health problems, but deer ticks can. They can transmit Lyme disease by transmitting Lyme bacteria when they attach to their victim. They can also transmit the rarer diseases called ehrlichiosis, babesiosis and, even more rarely, tularemia and Lyme variants, recently reported to cause a dementing illness especially in the elderly. Our region used to be on the edge of the deer tick/Lyme disease infestation area, which was the southern New England states and southern Maine. But with long term warming and less winter kill of ticks, the population has increased substantially so that it is now much more common to see tick bites and consequently increased Lyme disease incidence.

There are two common types of ticks locally, the benign common dog tick (apple seed-sized), and deer ticks, which are sometimes (not always) carriers of Lyme and other diseases. Deer ticks are half the size of dog ticks, and lack the latters” white "racing stripes" down the back. But the deer tick nymphs, more common this time of year, are as small as poppy seeds, that is until they attach to people or animals and fill with blood to 10 times that size over several days. The longer a deer tick stays on a person, the more likely they are to contract Lyme disease, if the tick is a carrier. If the tick is attached for less than 24 hours, disease rarely follows; most patients with Lyme disease have had a tick on for over a week.

The disease itself usually causes a circular (usually over 3 inches in diameter), non-tender rash, called erythema chronicum migrans, which looks like a red "ringworm" rash around a bite site or a bulls eye and follows the bite one to several weeks later. Fever in 60% of patients, aching body and joints (90+%), and headache (65%) also occur as the rash reaches its peak and begins to fade. If not treated, later complications involving heart, nerves, brain, and joints can occur weeks and months later. But don’t be alarmed about the small mosquito bite-like red spot appearing at the site of the bite itself within a day or two; it just reflects the bite injury, not a Lyme infection.

So how can you avoid these troubles without moving to Northern Canada? First the most important thing to do is use DEET-containing bug dope to discourage their climbing on you. Secondly, you should check yourself and your children for ticks every day in the spring and summer after being outside. This can be hard in difficult places to see, like the back side of your knees or trunk. I thought I'd grown a big skin tag behind my knee for several days until I looked with a mirror and saw it was an engorged (swollen) tick. And wash, or at least heat in a dryer, clothes worn outside that may or do have ticks on them.

If you find a tick, and it's not swollen, and you are pretty sure it hasn't been on for more than a couple days, there is no need to submit it to the state lab; just remove it and your chances of developing disease are very small. Slow steady pressure to pull it off usually works. Don't try to burn it off. Use tweezers or a leatherman to pull steadily but gently for the several minutes it takes to get the tick to release. Breaking the head off in the bite leaves some, though substantially less, risk of infection.

If the tick is engorged and may have been on for several days, then taking a single preventive dose of doxycycline, a prescription you can call and ask your doctor for, will reduce your chances of getting Lyme from 3% to 0.6%, if the tick was infected.

If you develop a ring rash around the bite site weeks later, or in a place where you weren't aware you'd been bitten, then you should be given a course of antibiotics for 2-3 weeks, doxycycline/tetracycline for most, amoxicillin or cefuroxime for pregnant women and children, in whom the tetracyclines are not safe. The downside of the latter alternative antibiotics is that they don't also cover the rare co-infections with ehrlichiosis and babesiosis. You will probably need to see a doctor to evaluate any such rash, but ask for an urgent appointment. The rare late complications are also treated with antibiotics after being proven due to Lyme by blood test immune titers.

So use bug dope. Check yourself and the kids. Pull ticks off before they get engorged. And get antibiotics if you develop the characteristic rash or other symptoms.

For more information, check out these websites:

•www.mmcri.org/lyme/lymehome.html

•http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/vector-borne/lyme/index.shtml

•http://www.cdc.gov/lyme/.

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076, dkonion@gmail.com

Maine CDC just sent out this message about Lyme disease on the Health Alert Network (HAN):

Lyme disease is a bacterial infection that is carried by Ixodes scapularis (the deer tick). Cases have been increasing each year in Maine, and occur in all 16 counties. Over 1,100 cases of Lyme disease were reported statewide in 2012, a record high for Maine. Lyme disease is most common among school age children, middle aged adults and adults over the age of 65. Most infections occur during the summer months, and as the weather continues to warm up, more ticks will be out in the open, and we are likely to see more cases of Lyme disease. Cases have already been reported in 2013, and the number will rise as we enter the summer months. * A full version of this advisory can be downloaded from the Maine CDC website as a Microsoft Word document (.doc) or Adobe PDF (.pdf) by clicking www.mainepublichealth.gov and looking under the Recent Health Advisories section of the page that loads. Please contact the MaineHAN Helpdesk at HAN@maine.gov if you have trouble accessing this document.


Web links:

Maine CDC page Lyme Disease

Resources for Maine Residents

∙         Lyme Fact Sheet (Word* | also in PDF*)

∙         Tick Identification

∙         Distribution of Deer Ticks in Maine 2008 (PDF*)

∙         Prevention of Tick-Borne Diseases

∙         Lyme Disease Q&A

∙         Lyme Disease Awareness and Prevention Movie

Maine CDC Surveillance report Lyme Disease - 2012  Tick Borne Diseases - 2011

Maine CDC Tracking Network – Lyme Disease  Maine Tracking Network: Lyme Disease

Maine CDC Vector-Borne Disease Website: http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/vector-borne/index.shtml

Disease.reporting@maine.gov

Phone numbers:

Maine CDC disease reporting and consultation line:    1-800-821-5821

Maine Medical Center Research Institute – Vector-borne Disease Lab:   662-7142

& to find out where ticks are most prevalent, take a look at these geographic distribution maps

How To Break A Smoking Addiction And Live Longer

Last month I promised to write about how individuals and families can make their habits healthier, starting with one of the hardest but most important of all, stopping smoking. Everybody knows that smoking is expensive and bad in all kinds of ways, but most smokers find it extremely hard to stop! That’s because one’s body becomes both habituated and usually addicted to smoking and the nicotine it delivers. I base the following suggestions on decades of trying to help 1000s of smokers kick the habit.

Let me review quickly the damage smoking does. Most importantly, by age 50+ it increases bronchitis and emphysema, which then kill people by suffocation over the next 10-15 years. That is unless they die sooner from smoking-related pneumonia, lung/throat/gullet/bladder cancers, or heart disease. Smoking also markedly increases asthma and those same diseases in adults and children living in the same house. On average, smokers die 10 or more years earlier than non-smokers. Does smoking help anything? Not much! It does lower smokers’ weights by 5-10 lbs; a few patients with rare conditions like Crohn’s disease of the bowel get some disease improvement. And it transiently relaxes those who are habituated/addicted.

Some general principles on quitting. Set a quit date and perhaps taper to it; suddenly quitting works for many, tapering for fewer. Stopping in the middle of a respiratory illness, like a cold, is often easier.  If possible, undertake quitting with others; formal and informal social support helps. After quitting, avoid situations you have habitually associated with smoking, like coffee in your old smoking haunts, or companions not interested in quitting. Work, play and eat, if you can, in places where newer state no-smoking laws prohibit smoking, including bars/restaurants and other public places. Don’t be discouraged by relapses; most people who stop successfully do so after going back to smoking several/many times. Use the Maine resources available by phone or on-line: Maine Tobacco Helpline 800-207-1230; http://www.tobaccofreemaine.org/quit_tobacco/index.php.

Use some aids. Hypnosis helps some people.  Medications (with a clinician’s prescription) help many succeed. Three drug classes are available and are covered by most health insurances. MaineCare cut coverage for these prescriptions last year; but it looks like that penny-wise, pound-foolish decision will be reversed in 2014.

•Low dose nicotine in various forms: Nicotine patches (Nicoderm, Habitrol, Prosten) achieve 25% one year quit rates and cost about $100/month. They are changed every 24 hr, using 21 mg patches the first 2-3 weeks, then 14 mg patches for another 2-3 week, then 7 mg ones for a similar or longer period of time. The 2 or 4 mg gum (Nicorette, and other brands), up to 20 pieces a day, costs about the same and achieves similar cessation rates. Nicotrol inhalers and nasal sprays cost more but also do as well as the gum and patches. The newest are the electronic cigarette systems, which deliver nicotine via a plastic “cigarette” without the tobacco smoke, are expensive and no data yet on 1-yr quit rates. All nicotine treatments have side effects like sleeplessness, high blood pressure, and worsened angina, congestive heart failure, or leg ulcerations.

•Bupropion (as long-acting Zyban or generic forms) works when taken as 150 mg daily for the week before stopping smoking, then increased to twice a day and used for at least 2 months. Costs are in the same $100+/month range and success rates, when used alone, are also 25% at one year; success can be as high as 36% when used in combination with nicotine medications as described above.

•Varenicline (as Chantix, no generic) taken ½-1mg by mouth twice a day, started a week before quitting and for at least 3 months afterward, reportedly results in 43% quit rates at one year, but costs $250/month and can cause agitation and rarely suicide.

Flu shots are crucial for smokers! Smokers have a much higher likelihood of getting bacterial pneumonia if they get the flu. Don’t let anybody tell you that they “cause the flu”; that’s impossible with a killed vaccine. The immunization ameliorates or prevents influenza in 75% of those exposed.

This just out from the Maine Center for Disease Control: “Influenza activity in Maine is widespread with laboratory confirmed influenza reported in all counties. Influenza A/pH1N1, Influenza A/H3, and influenza B have been confirmed in Maine indicating all three strains are circulating. Maine CDC has followed up on six outbreaks of influenza as of Tuesday, January 7th. Influenza vaccination is still strongly encouraged and is widely available, especially to protect those persons at risk of severe disease. The vaccine appears to be a good match to the circulating strains this year, and it is not too late to get vaccinated." Smokers and/or people with lung and heart disease and/or their families should not pass up this effective prevention.

Quitting is not easy; don’t give up; keep trying!  It is the single most important thing you can do for your own and your family’s health.

Dan Onion, MD

Vienna Health Officer

dkonion@gmail.com

293-2076

1/17/14

Marijuana Legalization And Use: What We Know and Do Not Know

Laws and norms about marijuana are shifting rapidly. Starting with medical use legalization several years ago, laws have now been passed or are being considered in many states, including Maine, to decriminalize possession and use. Will that be a good thing for the public health of Vienna and Mt. Vernon?

At the risk of sounding like an old fuddy duddy, I have reservations; my greatest is the likely impact on youth. We know they already use marijuana commonly (50% have tried it by 12th grade), and that use will likely increase if it is more available, even if use by minors is prohibited. There will be more around. Several case-controlled studies over the last decade indicate permanent cognitive damage to users under 18, even after they grow up and stop smoking weed. The permanent deficits are in executive function, memory, and reaction times. Those deficits are measurably worse than those in non-users. And many studies of chronic users show functional and anatomical brain scan changes in the hippocampus and frontal lobes, just those areas still maturing in teenagers. And there are a worrisome number of case reports of marijuana use acutely inducing a first episode of schizophrenia in teens. However, overall schizophrenia prevalence in users is no higher than in non-users, so it may be just that the disease is triggered in young adults already predisposed to develop it?

I also have concerns about the potential bad effects of smoking the marijuana. Because that delivery method is so quick and effective, it is unlikely users will ever prefer to ingest it, let alone use suppositories. We know tobacco smoking clearly kills people at least 10 years prematurely from chronic bronchitis/emphysema, heart disease and cancers. It cannot be good to inhale hemp smoke either, as Dennis Keschl pointed out at the mid-February Mt. Vernon Community Center open meeting with local legislators. What little research we now have suggests there is less damage and risk in smoking marijuana than tobacco. But I’d like more research; it took 40-50 years for the grim data on cigarette smoking to become clear. I also suspect that smoking dope increases the likelihood that a person will also continue or take up tobacco smoking.

As the chairman of the Bureau of Motor Vehicles Medical Advisory Committee, I’m also concerned about marijuana-related driving crashes in all age groups. Acute intoxication clearly impairs reaction times and distance judgments. Unlike alcohol however, marijuana tends to slow driving speeds and recklessness down, so crash rates are a tenth as frequent as in alcohol drunk drivers, but still about twice those of sober drivers. Unfortunately we don’t have good screening tests for police to use in the field and there is no consensus about what constitutes an intoxicating blood level of tetra-hydro-cannabinol, the measurable marijuana psychoactive component. So identifying dangerous marijuana intoxication is going to become an increasing public health issue that needs work now.

Assertions that marijuana is a “gateway” drug to narcotic and other illicit drug use are reassuringly unsupported by the medical literature. But the published research on the drug is still pretty meager, reflecting, for the most part, the total Federal prohibition. Scientific investigators can’t get standardized doses to study; plants and their various parts vary greatly in the cannabinoid concentrations. Most of the reports available now are only case control studies. But one large 40-year study from New Zealand is a continuous study of 1000 children (a cohort) born in the 1970s who were tested for IQ and other cognitive skills throughout the study period. However, even with a cohort study, we can’t be sure that those who use marijuana aren’t doing so to self-treat a learning disorder or because of a particular behavioral trait. In other words, the study may still suffer from selection bias because participants decide themselves if they choose to use marijuana. We need a lot more research ASAP!  

So I favor legalization, control, and standardization. We would never let a pharmaceutical drug go to market with so many unknowns and potential risks. Medically marijuana has its uses; I’ve always encouraged my patients on chemotherapy to try it for their nausea. But the current environment in which it is only available legally with a doctor’s prescription, results in recreational users pressuring clinicians to prescribe it for questionable symptoms, a waste of everyone’s time. If it hurts teens, we need to know that and develop more effective ways to prevent their using it. The current prohibition system is not working well to protect the potentially most vulnerable or to encourage further research in the many other areas of possible unintended consequences. We need more research and data fast, and that’s most likely to happen in a controlled legalization.

Dan Onion, MD, MPH

Vienna Health Officer

dkonion@gmail.com

293-2076

“Bee” Stings

Dan Onion MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076, dkonion@gmail.com

7/9/14

Not all “bee stings” are from real bees. Here in Maine, probably more stings are by yellow jackets, which are actually a type of ground-dwelling wasp and the most aggressive of local stinging insects. Since summer and fall are when most stings happen, I’ll review for you how to avoid, evaluate, and treat stings when they happen to you or a family member.  

Stings by bees (honey bees and bumble bees; insect order Hymenoptera, family Apidae) and wasps (yellow jackets, wasps, and hornets; insect order Hymenoptera, family Vespidae) are interesting. The stinger is a modified “ovipositor”, the female’s egg-laying organ; hence all these stinging pests are female. Stinging is used for both defense, and in the case of wasps, for prey immobilization as well. Honeybees deliver the most venom per sting, but make up for it by being less aggressive than yellow jackets, wasps, and hornets, which often inflict many more stings when they attack us in swarms.

Venom contains vasoactive amines including histamine and dopamine along with norepinephrine and kinins, which account for the painful red swelling and itching at the sting site, with swelling over 4 inches in diameter classified as “large”; sometimes raised, itchy rashes, called hives (medically: “urticaria”), occur over larger areas, distant from the sting site. Venom also contains protein enzymes, which contribute to local victim cell breakdown and pain but can also sensitize (make allergic) a person so that subsequent stings, weeks to years later, can result in potentially fatal hypersensitivity reactions (anaphylaxis) in 3% of adults and less than 1% of children. In other words, the human body can become its own worst enemy by releasing massive amounts of vasoactive amines in response to stings. This response causes shock (dangerously low blood pressure) and/or airway obstruction (severe asthma, swollen throat).

Small comfort though it is, sensitization to bee stings does not cause sensitization to wasp stings. But that’s not a lot of help because we can rarely choose or know whether we’re being stung by one insect family or the other. The size of a local reaction does not correlate well with later systemic hypersensitivity reactions; so don’t panic if your sting swelling has a 5-inch diameter, unless it is in your mouth (common with yellow jackets, which often feed on sugary foods/drinks). Once a person has had an allergic reaction, then they are highly likely to have another if stung by the same family of insects.

Local treatment for a sting for all should include a rapid search for a honeybee stinger (the size of a very small tick), which continues to pump venom for 20-30 seconds into the wound even after the bee has been brushed off. Look immediately and if found, scrape it off fast with a credit card or fingernail. Cold packs, antihistamines (25 -50 mg of diphenhydramine (like Benadryl ) every 6 hrs; half that in toddlers or small children), and aspirin can help the pain/itching. It may be reasonable to also get an EpiPen (prescription injectable epinephrine, at least 2 doses of 0.3mg in adults; these can be injected through clothing) or other form of injectable epinephrine to have around in case a future sting causes shock or respiratory symptoms.

Although most stings are inconsequential, some are serious and kill 40 or more people a year in the US. Two young acquaintances of mine here in Central Maine have died that way, both probably from yellow jackets. Any signs of allergic hypersensitivity reactions manifest by low blood pressure and/or shortness of breath should be immediately evaluated in an emergency room. After an anaphylactic reaction, even a mild one, a person should assiduously avoid places of likely contact with stinging insects; don’t keep bees and don’t mow lawns, drink soft drink cans outside, or pick raspberries where yellow jackets hang out. They should also carry at least two doses of some form of injectable epinephrine as described above, which is truly live-saving. Given the potentially fatal consequences of developing anaphylaxis, patients who have survived a systemic  allergic reaction should also be medically skin tested and desensitized with multiple injections of small amounts of venom over months-years. And, because they worsen an already bad situation, stopping chronic blood pressure medicines especially beta-blockers (like atenolol) and ACE inhibitors (like lisinopril and enalapril) should be considered.

I hope I haven’t scared you too much. Most stings are just a bother but a very small percent of people can die from them. I hope following the above guidelines can help you and yours be safe and enjoy the summer.

Three-Community Transportation Project

Dan Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076; dkonion@gmail.com

Last year I wrote about the issues around senior driving and what can be done to diminish crash risks without isolating our seniors. As a result of those and other conversations in town, the Mt. Vernon Community Partnership has undertaken a project to create a volunteer transportation system in Mt Vernon along with Vienna and Fayette. Several town forums have been held in November to solicit ideas of how this might be done and how it might work. We encourage all seniors who can to “age in place”, rather than move away to family or assisted living even if they can no longer safely drive. Younger citizens without cars or driver’s licenses, could also be served by the system being planned.

Nearly everybody over 45 has worried about an elderly parent or other loved one’s safety when driving. Crashes caused by older drivers are a significant public health issue, especially in Maine, which has the oldest median age of all the states and a predominantly rural environment lacking public transportation. In those rural areas, like Mt. Vernon, nearly 20% of the population is already over 65, a percentage the rest of the country is not predicted to reach until 2030. So seniors who live here must have a car and be able to drive to do most things they need to do, from shopping, to medical care, to entertainment.

At about age 70, national and Maine fatality rates per-mile-driven for drivers start to climb from those of younger adult rates; but they don’t exceed the teen rates until age 85. Not all this fatality increase is from increased crash severity or frequency; at least half the fatalities occur because older people are more fragile and break more easily than do younger riders in a similar crash. Older Mainers do “compensate” for this increased rate of crashes per mile driven by driving less than younger adults.  

Not everybody ages at the same rate, so age group definitions are unfairly limiting. And not all medical limitations preclude driving with modest limits like fewer miles, daytime only, no throughways, or just in local areas. Older drivers with intact cognition usually self-impose many such restrictions; the more troublesome group are those with early dementia. They are likely to worsen over a few years and, and, because their judgment is often impaired, must rely on others to suggest or impose limitations, for their own and others’ safety. The reality is that the average person has to retire from driving 5-10 years before they die. So we all need to plan for how to recognize and decide when it’s time.

The press too, seems to recognize the problem, so we frequently hear news reports of crashes involving elderly drivers. Drivers themselves and their families must be vigilant to recognize serious limitations as they develop. Common signs are: hitting the gas instead of the brake, experiencing minor or major car damage/crashes, failing to stop for stop signs or lights, trouble making left turns, driving too fast or slowly for the traffic conditions, and family feeling it is not safe for others (like children) to ride with the senior driver. Family members can check by riding with or following the senior driver. If there is still doubt, self-screening can be done with a very helpful on-line series of tests from the American Automobile Association called Roadwise Review (http://seniordriving.aaa.com/evaluate-your-driving-ability/self-rating-tool).

And finally, to make the transition easier, planning for how the senior driver can get along without driving is crucial. That is where the Three Community Transportation Project may help. Our vision is that we will recruit volunteer drivers for each of the 3 towns. They would be scheduled by a part time dispatcher/coordinator to pick up users at their homes and transport them to Augusta or Farmington, and perhaps Livermore Falls (for Fayette, especially) on a different day each week; in other words, Tuesdays would be Farmington and Thursdays Augusta. The volunteers would drop the riders where they want to go and wait, or at a public transportation stop and go back later for the return home. For instance, in Farmington, the drop off stop would probably be the Hospital, from which riders could, for $1, ride to Walmart, Hannafords, and/or downtown on scheduled Western Mountain transportation vans. To start up, temporary grants may help; but long term, modest user fees and town support may be necessary. The public forums are helping to judge whether we can recruit drivers and riders for such a system, and how to modify the plan to maximize use and success. If you have ideas, suggestions, want to volunteer as a driver, or think you might like to use the service next summer, email or call me or Sandy Wright (scwright@fairpoint.net), who chairs the committee.

11/12/14

Do Healthy Behaviors and Risk Factor Reductions Really Help?

A Local Example

We hear constant claims that various behaviors and treatments can prevent disease, on TV, in the newspapers, from neighbors and friends, as well as from doctors and other clinicians. The scientific proof of these claims can come only from large, population-based, long-term studies. Not many such studies have found significant (odds of helping better than just chance) benefits for most proposed interventions, but some have. The National Institutes of Health began funding such population studies in Framingham, Massachusetts, in the early 1960s. They found and continue to find poorer health outcomes in people who smoke, have uncontrolled high blood pressure, high cholesterol, and are obese. By the early 1970s, related studies were clearly showing that high blood pressure control and smoking cessation reduced the incidence of heart attacks and strokes. And by the early 1980s, other studies clearly demonstrated further reductions in heart disease and stroke with cholesterol and obesity reductions. They show gradual but persistent improvements in cardiovascular mortality rates from nearly 400 deaths per 100 000 people annually down to now less than 150/100 000 nationally, in Maine overall and in most Maine counties.

I practiced, supported, and saw the benefits to my patients of several such risk reduction programs in Farmington in the 1970s and 80s, and am now a member of a group there, that includes Dr. Jay Naliboff from Vienna, to analyze Franklin County against national and Maine averages since 1970. We are finding that Franklin, led by Dr. Burgess Record, was ahead of the curve in improving the detection, treatment and control of high blood pressure and later of high cholesterol. Some of those programs were implemented through doctors’ offices, but most took place in the communities and workplaces. By the late 1970s, Franklin County went from only 1/3 of people with hypertension detected and only 1/3 of those controlled on medicines, to the inverse of that with 2/3 detected and controlled. Within less than 5 years, Franklin County heart attack rates and mortality dropped from well above, to 15% below, Maine averages, and even more dramatically below adjacent Somerset and Oxford counties, which have similar socio-economic profiles. Gradually the rest of Maine caught up to Franklin County. Then, when public screening and more aggressive cholesterol treatments were shown to clearly help and were implemented in Franklin, another improvement in Franklin rates occurred decades before other adjacent counties gradually caught up. Other Franklin public programs to promote exercise, reduce obesity, eat more healthily also likely contributed. Early improvements in the medical treatment of heart disease, like the use of aspirin and balloon opening of heart arteries, contributed to the improved survival too, though to a much lesser extent.

Another major contributor to these cardiovascular mortality results was the dramatic drop in Franklin County smoking rates from area-wide intensive efforts to curb them. Predictably, other smoking-related mortalities, from lung and head and neck cancers, asthma, and chronic lung disease dropped below state and adjacent county rates as well. Again, rates in Maine and nationally, have been dropping for decades, but Franklin led the way in restricting smoking in public places, starting with the hospital. And it now has the lowest rate of teen smoking in the state. Public/community expectations have shifted and support such changes in behaviors. Most of this change has been effected by public education.

So the lessons of this experience are that we should focus our limited energies and resources on decreasing the prevalence of those risk factors scientifically known to be susceptible to proven community-wide interventions. When we do, we can expect to be able to see within a few years. Continued measurement of outcomes, especially mortality, strengthens the case for continuing; people can, in fact live longer, more productive lives if we set up and support community-wide adoptions of healthy behaviors and reductions of significant risk factors.

Daniel K. Onion, MD, MPH

Vienna Health Officer

293-2076

dkonion@gmail.com

1/13/13

Income Inequality

I’m worried. Income inequality and its consequences are worsening in Maine and across the world. My colleagues and I demonstrated that phenomenon recently in our published lead article about Franklin County in the Journal of the American Medical Association. There we showed the very strong correlations of Maine counties’ household income with age-adjusted mortality. Franklin, where we implemented multiple programs to improve health, did as well as Cumberland and other affluent communities; and it was one of only 17 counties in the US that lower mortality than predicted by income. So we conclude that, unless there are concerted efforts to improve access and reduce risk factors like hypertension and high cholesterol, smoking and inactivity, people living in the vast majority of low income US counties, die at significantly higher rates than their more affluent peers.

In addition, over the 50 years we studied, the degree to which income explained county mortality differences in Maine increased from 14% in the 1960s, to 38% during 1970-1990, and finally to 81% from 1990-2010! In other words, now 81% of the mortality differences among counties can be explained by the average household income in each county. That is a dramatic increase over 50 years.

Yet another finding in our paper about Maine counties, was that from 1960 to 1990, county household income varied only about $15,000/yr between the most and least affluent counties. However, from 1990-2010, that difference increased to $20,000 (Fig 5 in our paper). And finally, both Franklin and Kennebec counties became poorer relative to the rest of Maine; Franklin went from 5th most affluent down to 11th, while Kennebec moved from 2nd down to 6th most affluent.

So right here in Kennebec and Franklin counties, we observed fairly rapidly increasing income disparity over the past 50 years. Since we know from our study and others that lower incomes correlate with poorer health and mortality, this is not good from a humanitarian view as well as an economic one. We demonstrate in our Franklin County study that, along with fewer deaths, the interventions were associated with substantial cost savings in hospitalization costs alone, about $5.5 million/yr.

And just recently (Jan 24), the Kennebec Journal editorialized about the need for aggressive public school actions to counteract the educational impairments created by poverty because now more than half their students are from low-income households.

Access to health care is crucial to disease prevention; for instance, physicians or other clinicians must be available to start and supervise medication use for hypertension, high cholesterol, and smoking cessation. Recent actions by the current state administration are now taking us in exactly the wrong directions. The tobacco settlement monies, previously directed by Gov Angus King to statewide multiple smoking cessation programs modeled on the Franklin Co successful experience, are being cut and redirected elsewhere. Medicaid (MaineCare) expansion of health care coverage for the mostly working poor through the federally subsidized Affordable Care Act continues to be rejected. And where are the expanding pre-K and other educational interventions?

I despair. Someone please give me hope that we can reverse these trends, educate our children, high and low income together, and work strenuously again to prevent disability and disease, as we have showed we can. By doing so, we could save medical costs, create a healthier stronger, smarter workforce, which can better care for our increasingly elderly state. Or are we to take the Dickensian Scrooge approach to the poor: “let them die and decrease the surplus population”.

Daniel K. Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076

dkonion@gmail.com

1/25/15

Bed bugs (Cimex lectularius)

Daniel K. Onion, MD, MPH

Mt. Vernon/Vienna Health Officer

293-2076

dkonion@gmail.com

3/25/15

My daughter’s family accompanied her on a work trip to western New York State last spring. She always shops hard for good deals and found a cozy local country inn and had a pleasant weekend. She and her 3-year-old noticed mosquito-like bites when they got home; her husband had none. Because New York has been reporting bedbug infestations recently, she suspected that was the problem. Online she discovered that previous guests at that inn had had similar experiences. With a lot of effort (see below), she and her family avoided home infestation. But her experience is increasingly common, even here in Maine, and certainly for those who travel out-of-state now.

Bed bugs rarely transmit human blood-borne diseases but certainly can be a nuisance. They are small insects that feed on human blood and are active at night when people are sleeping. Unlike head lice, bed bugs do not live on a person. However, they can hitchhike from one place to another in backpacks, clothing, luggage, books and other items.

Adult bed bugs have flat, rusty-red-colored oval bodies. As bed bugs feed, their bodies swell and become brighter red.  About the size of an apple seed, they are big enough to be easily seen, but often hide very successfully in cracks in mattress and box springs rim beading and other bedding, furniture, floors, or walls. Where you find one, you almost always find more; often they cluster together, probably to prevent the young bugs from drying out. They can live for months without feeding if they must, but prefer to feed nightly. They inject anticoagulants and anesthetics when they bite, so the victim rarely ever sees the bug and usually feels nothing while the bugs sip dinner for 10-15 minutes.

Their bites usually cause small, itchy red skin “mosquito bites”, often in a line, and most often on the face, neck, hands and arms, within a day or two, but can be delayed as long as a week. The bites result from both the small injury to the skin, but much more from allergic reactions in that injured skin to the bugs’ saliva and/or feces. Some people (30%), like my son-in-law, don’t react and hence get no visible bites. The bites, though itchy, should be scratched as little as possible and kept soap-and-water clean to prevent secondary skin infections. 

Infestations are very difficult and expensive to control. The best strategy is to prevent exposure. First, beware garage sales, especially of bedding!! When traveling, check on-line bed bug reports (http://www.bedbugregistry.com/) when picking a place to stay; and when you get there, put your bags temporarily in the tub bath while you tear the bed apart a little to look for the buggers along the mattress beads and other tight corners. No hotel, no matter how fancy, can be guaranteed forever bed bug-free. If you find them, go somewhere else and report both to the hotel and the state Center for Disease Control. The big hotel chains do have generally better surveillance and prevention policies.

If you do bring them home, first try environmental measures such as laundering and drying bed linens at maximal temperature settings, vacuuming rooms, and cleaning as well as encasing mattresses and box springs in tight plastic covers. Because of their toxicity to humans and pets, insecticides should be applied by a professional exterminator if they are needed.

For more information, the Maine CDC has a good website (http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/bedbugs/)

   adult bed bug

Recent reported cases of hotel/inn/bed-and-breakfast bed bugs from bedbugregistry.com.