March 2015 Texas Medicine: Inbox

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Inbox — March 2015 

Thank you for your recent article regarding the change in hydrocodone combination products from Schedule III to Schedule II. (See "Feeling the Pain," January 2015 Texas Medicine, pages 37-41.) 

I know this country has a drug problem, but there must be ways to combat the problem without intimidating and inconveniencing doctors and preventing people with real pain and incapacitating anxiety from getting the medications they need. Physicians are afraid to prescribe Xanax, Valium, Soma, and similar drugs, even in patients who clearly need the medications and are not abusing them. 

This change in schedule for hydrocodone combination products requires physicians to remember to take with them their own controlled substance scripts each time they go to the hospital, leave the scripts in the car (not a good idea), or make the patient come to the office for a script after discharge. 

I am an obstetrician-gynecologist. A C-section is a major surgery. A number of patients want to leave on post-op day 2. Because of the change regarding hydrocodone combination products, many, if not most, of the OBs in our hospital are sending C-section patients home with nothing stronger than Tylenol #3 and Motrin. In my opinion, that is not adequate after major surgery, but we are forced to send the patient home with inadequate pain relief or keep her at least another day (driving up hospital costs).  

Making the non-narcotic Tramadol a controlled substance is another problem. 

Shouldn't we stop treating all our patients as if they were drug abusers and start to really deal with their pain and anxiety, unless they give us indication they are misusing their medications?

Ronald K. McCraw, DO

Thank you for presenting the excellent commentary "Focus on Prevention, Population Health" by Levin, Deslatte, Woelkers and Calhoun (January 2015 Texas Medicine, pages 11-12). As local health authority and director of the San Antonio Metropolitan Health District (Metro Health), I am encouraged that they and other clinical and academic physicians recognize that a U.S. health care system that disproportionately focuses on "health problems in their advanced stages" is unsustainable and that resources must be directed away from "high-dollar, low-value services and delivery methods" and toward "public health and prevention." The authors credit Code Red 2012 with popularizing these concepts in Texas and guiding the development of the Medicaid 1115 waiver, which has since brought down $17 billion in new federal funding to help health care systems improve access, quality, and efficiency and, for the first time, support community mental health and local public health "to push forcefully upstream along the continuum of prevention."

In Bexar County, $1.1 billion has been allocated and deployed by 25 organizations to fund more than 100 projects through 2016. Metro Health is using its share, $50 million, on prevention programs in teen pregnancy, oral health, tuberculosis, syphilis/HIV, obesity, and diabetes. These upstream activities already have saved the county millions of dollars in avoided medical costs. For example, the Metro Health program "Project Worth," which combines school-based and community-based education, outreach to physician offices, case management of teen moms, and access to effective contraception in clinics and birthing hospitals, has played a significant role in reducing teenage births, saving about $23 million annually. 

But perhaps the area in which we can have the greatest impact is diabetes. In Bexar County, 13% of adults are diagnosed diabetics; another 5% are undiagnosed. Medical advances in dialysis and transplantation, wound care and amputations, and vision preservation are welcome but barely make a dent in this enormous problem. Real progress will be made only, as the authors suggest, when clinical medicine and public health work together on upstream solutions. Metro Health hopes to do just that. With support from the Robert Wood Johnson Foundation, public health agencies with waiver funding in San Antonio, Houston, and Austin will construct professional/community coalitions to identify the key drivers of the diabetes epidemic and create and execute action plans for primary, secondary, and tertiary prevention. The decades-long, rising tide of diabetes in our communities demonstrates that what we in the health care system have been doing up to this point individually, no matter how excellent, is failing. Our hope is that working together with clear focus will succeed.

Thomas Schlenker, MD
San Antonio 

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