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Dr. Ezekiel Emanuel is used to feeling like the only person in the country who still cares about COVID-19. He ignores the side-eye he gets for wearing an N95 mask at parties—a self-imposed policy that makes him “look odd” but kept him safe after a recent work dinner turned into a superspreader event. The oncologist, bioethicist, and professor at the University of Pennsylvania provides each of his students with an N95 and runs four HEPA air filters during lectures. He rolls down the windows when he gets in an Uber and goes hungry on planes so he can wear his mask the whole time. He’s given up one of his favorite pastimes—dining at restaurants—even now that many people don’t think twice about eating indoors.

Emanuel, 65, takes these precautions even though he’s vaccinated and boosted and thus well protected against severe COVID-19. The acute disease doesn’t scare him much—but what could come after does. “The only thing that’s preventing me from leading a normal life is the risk that I’ll get Long COVID,” Emanuel says. “I can’t say why people aren’t [reacting like] their hair’s on fire. This is a serious, serious illness.”

Emanuel’s not totally alone. In a July Axios-Ipsos poll, 17% of people said their biggest fear related to COVID-19 is the possibility of getting Long COVID, a potentially disabling condition in which symptoms linger or emerge well after an acute infection. But at a time when the majority of U.S. adults think there’s little risk in returning to normal, mask wearers, test takers, and social distancers walk a lonely road.

Even public-health agencies seem over it. Throughout 2022, the U.S. Centers for Disease Control and Prevention (CDC) has rolled back many of its recommended COVID-19 precautions. CDC guidance no longer recommends social distancing, mask-wearing, or screening tests for most people who don’t have symptoms, and unvaccinated people don’t need to quarantine if they’re exposed to the virus. In a 60 Minutes interview that aired Sept. 18, President Joe Biden said “the pandemic is over,” even though “we still have a problem with COVID.”

The following day, chronic disease advocates protested in front of the White House, arguing that Long COVID and the related condition myalgic encephalomyelitis/chronic fatigue syndrome constitute a public-health emergency and demanding that the Biden Administration improve its public-education campaigns, financial support for patients, and research efforts.

The CDC says its COVID-19 guidance is meant to prevent “medically significant COVID-19 illness,” which includes both severe acute disease and Long COVID. The agency contends its lighter touch is warranted now that the vast majority of the U.S. population has good protection against severe disease from being vaccinated, contracting COVID-19, or both. “Our emphasis on preventing severe disease will also help prevent cases of post-COVID conditions, as post-COVID conditions are found more often in people who had severe COVID-19 illness,” Dr. Barbara Mahon, who oversees work on coronaviruses and other respiratory diseases at the CDC, said in response to questions from TIME about the agency’s Long COVID guidance.

But even with high levels of population immunity, Long COVID cases continue to pile up. By the CDC’s own estimate from June, one in five U.S. adults with a known prior case of COVID-19 had symptoms of Long COVID. Having COVID-19 also raises a person’s risk of developing chronic conditions including heart disease, asthma, and diabetes, according to CDC research.

Long COVID can take many forms, including exhaustion, cognitive dysfunction, neurological issues, and chronic pain. People can develop it whether they’re young or old, sick or healthy, vaccinated or not. And while some people get better in a matter of months, recent studies and many patient experiences show symptoms can last years. There is no known cure for Long COVID, and the only way to prevent it is not to get infected at all.

That, a vocal group of experts and advocates say, is why people should resist the U.S.’ collective shrug to the unchecked spread of COVID-19. The virus may not kill or hospitalize as many people as it once did, but it still upends lives every day. Around 1.2 million people in the U.S. became disabled as a result of the virus by the end of 2021, according to the Center for American Progress, a progressive think tank. Up to 4 million people in the U.S. are out of work because of Long COVID. Specialists who treat Long COVID report months-long waitlists. And in the current “let it rip” phase of the pandemic, all of that may get worse.

“We’re in the middle of the greatest mass-disabling event in human history,” says Long COVID patient and advocate Charlie McCone. And unless people wake up to the long-term consequences of COVID-19, it is “going to continue taking folks out like fish in a barrel.”

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President Joe Biden ran on a promise to defeat COVID-19. And for a while, it looked like he would deliver. In the spring and early summer of 2021, the U.S. was recording about 12,000 cases per day. Vaccines were working. Masks were coming off. Life was good.

Then Delta hit, followed by the tsunami of Omicron, and the path out of the pandemic no longer looked clear. The messaging began to shift: the U.S. would learn to live with COVID-19, rather than defeating it. We couldn’t stop all infections, but we could defang them through vaccines, boosters, and treatments like the antiviral Paxlovid. The masks could stay off, even if the virus wasn’t gone.

Many Americans welcomed the return to normalcy. But to McCone, 32, that approach is “a crime against humanity,” given what we now know about Long COVID.

McCone got sick in March 2020. COVID-19 knocked him flat. He almost went to his local emergency room because he was so short of breath, and it took weeks for his respiratory symptoms to improve. After about a month, he finally felt well enough to ride his bike. “I just fell apart,” McCone remembers. The 15-minute ride left him with unshakeable exhaustion—and a sign that this would be no ordinary recovery.

More than two years later, McCone barely leaves the house, except for medical appointments. He still has severe fatigue, chest pain, shortness of breath, and nervous system dysfunction. He can’t work because of his symptoms, and his partner has become his caretaker. His symptoms got even worse after catching COVID-19 again in September 2021, so he’s “petrified” of getting reinfected—a fear he wishes more people shared.

“We’re letting millions of Americans and people across the globe walk, unwittingly, straight into this pit,” he says.

Hannah Davis, a machine learning expert who began researching Long COVID after her own diagnosis, also got sick in March 2020. Davis has testified about Long COVID before Congress and advised federal health officials about the condition. She says those experiences have shown her that health officials understand that Long COVID is a substantial problem, and that, while vaccines reduce the risk of developing it—by some amount between 15% and 50%, studies suggest—they are not failsafe. The U.K.’s Office for National Statistics recently reported that roughly 4.5% of triple-vaccinated adults developed Long COVID after being infected by Omicron. But the government doesn’t seem to want to dwell on these scary stats, Davis says. “It really looks like it’s being hidden intentionally,” she says.

Davis believes that’s because the Biden Administration leaned heavily on vaccines as a ticket out of the pandemic and is wary of walking back that messaging now, even as fully vaccinated and boosted people contract Long COVID. A representative for the U.S. Department of Health and Human Services (HHS) did not directly respond to that allegation when asked by TIME, but emphasized the importance of vaccination and said the department is still working “to understand this new post-infectious landscape.”

“Individuals, communities, and organizations must make decisions that create the right balance between the need to protect themselves and others from the effects of COVID-19 and the need to stay healthy in every sense of the word—such as mental health, getting an education, preventive and chronic disease care, and social interaction,” the CDC’s Mahon said in a statement.

Health officials are not doing enough to prevent transmission of the virus and help people understand its risks, says Kristin Urquiza, who founded the advocacy group Marked By COVID after her father died from the virus in 2020. “Leaders have thrown their hands up in the air and basically said, ‘You do you,’” she says.

The federal government has taken some action on Long COVID. In late 2020, Congress gave the National Institutes of Health (NIH) more than $1 billion to study it. But so far, this funding has yielded no treatments, no preventative tools, and little research that is immediately useful to patients. The NIH’s cornerstone Long COVID research project aimed to enroll 40,000 people; as of August, it had enrolled only about 8,000. That’s in large part because of the complexity and scope of the trial, according to the NIH.

Lawmakers have introduced bills meant to improve research and support for Long COVID, but they’ve reportedly stalled due to a lack of support in Congress. And in August, HHS released two highly anticipated reports on Long COVID—one describing resources available to patients, the other outlining the government’s research agenda—that were largely panned by Long COVID advocates as more symbolic than substantive.

“Many of the resources provided in the reports seem like cold comforts and temporary Band-Aids when a tourniquet and emergency surgery is needed,” Urquiza said in a statement to Rolling Stone about the reports.

The HHS representative told TIME the reports are just the beginning, and the Administration’s work on Long COVID is ongoing. For people with Long COVID, “It can feel like the world is moving on, while leaving them behind,” the spokesperson wrote in the statement. “The Administration’s message to them is that, ‘We see you, we hear you, and we are taking action to help.’”

Some Long COVID advocates and scientists have called for an initiative like Operation Warp Speed—the Trump Administration program that quickly yielded multiple effective COVID-19 vaccines—for Long COVID treatments. But the NIH hasn’t built anything of the sort, says David Putrino, a Long COVID researcher at New York’s Mount Sinai health system. Despite its $1 billion budget for Long COVID research, “There’s been no process change between how they fund things outside of a health emergency and how they’re funding things in the midst of a health crisis,” he says. “We’re still following the same grant application procedures, the administrative load is the same if not more, and they have not hired additional people to program manage the grants.” In a statement, the NIH said application review is handled by an “ample and diverse set of experts.”

Dr. Eric Topol, founder of the Scripps Research Translational Institute and a prolific parser of COVID-19 research on Twitter, says the NIH is doing good research on the underlying science of Long COVID, but he’d like to see more trials focused on treatments. “You need to do both, because we can’t wait another year or two for the biology to be better defined,” Topol says. (The NIH says it will begin treatment-focused trials this fall. Mahon says the CDC also continues to research Long COVID symptoms, prevalence, and risk factors.)

Research delays are not for lack of intriguing leads. A tremendous amount of Long COVID research has been published in the last two years, most coming out of independent laboratories, Putrino says. From this work, scientists have found multiple possible explanations for Long COVID symptoms: SARS-CoV-2 virus lingering in the body, abnormal immune system activity, reactivation of other viruses previously lying dormant, tiny blood clots throughout the body, and more. These disparate findings suggest that there may be different root causes or subtypes of Long COVID, which means all patients might not respond to the same therapy. But each one suggests a possible path to treatment worth testing sooner rather than later, Topol says.

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Nobody knows exactly how prevalent Long COVID is, and some researchers argue that the CDC’s estimate of one patient per five COVID-19 cases is high. But, even using more conservative prevalence estimates, the volume of infections in the U.S. means the scale of the problem is massive. About 60,000 people in the U.S. currently test positive for COVID-19 daily. Even by more modest estimates, that means the seeds for a possibly debilitating condition are planted in thousands of people every day. During just the first two years of the pandemic, at least 17 million people in Europe developed Long COVID, according to a Sept. 13 report commissioned by the World Health Organization.

“If we have millions of people being infected, we’re going to have millions of people getting Long COVID,” Emanuel says. “That’s going to be an ongoing, serious national problem that is going to weigh down the economy, weigh down the disability insurance system, and be tragic for people.”

Journalist and author Katie Hafner, 64, was one of the unlucky people to develop Long COVID after being vaccinated and boosted. She got infected in May and was left with significant fatigue and brain fog. Her Long COVID symptoms were on the milder end of the spectrum and have improved with time, but Hafner says she can still manage only a few hours of work per day and has to carefully monitor her physical and mental energy levels. Her anxiety has also escalated since getting sick.

Hafner’s husband is Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco. Between his wife’s experience and his close monitoring of COVID-19 research, Wachter is concerned enough about Long COVID to avoid indoor dining and wear a good mask in crowded areas. For people who aren’t immersed in the research, though, “the cognitive load of doing all this three-dimensional chess [around risk calculation] is too much,” he says. “To me, the CDC hasn’t been very vigorous on Long COVID,” providing less guidance about prevention and risks than it did for acute infections.

Those risks are substantial. Wachter says he’s worried about Long COVID’s impact on the health care system—not just in already overloaded Long COVID clinics, but system-wide. “If it turns out that it markedly increases the rates of some of the biggest medical hazards we have in life”—including organ failure, heart disease, and dementia, as research currently suggests— “the toll of that over years and years will be tremendous,” Wachter says. “I don’t think [the CDC has] done a good job explaining that at all.”

The economic toll could also be massive. Up to 4 million adults in the U.S. are out of work because of Long COVID, costing the economy at least $170 billion in annual lost wages alone, according to a Brookings Institution report published in August. A Kaiser Family Foundation analysis suggests just 44% of people who worked before they got Long COVID are now fully employed, with the remainder either out of a job or working reduced hours.

Many long-haulers who are unable to work have turned to the disability system. But, anecdotally, many have had trouble getting their claims approved, either because they’re outright denied or forced to jump through hoops to prove they’re truly unable to work. A representative for the Social Security Administration said in a statement that, as of August, it had received about 38,000 applications that mention COVID-19, representing about 1% of recent claims—but since decisions are based on functional limitations, not diagnoses, it’s difficult to say how many people have sought support due to Long COVID.

Experts say there is more that can be done, even before new therapies are discovered or developed. To slow transmission and thus lower rates of Long COVID, Topol says the CDC should tell people to isolate for longer than five days after getting infected and campaign harder for people to get booster shots. Emanuel, meanwhile, would like to see better communication about which masks protect wearers from infection; respirators like N95s are more effective than surgical or cloth masks, but many people still walk around in droopy blue surgical masks. Public indoor spaces, like restaurants and schools, should also have enforceable requirements for ventilation and air filtration, given the virus’ ability to spread in the air.

A return to mask mandates would also be a good step, Davis says. But even if none of those changes are enacted, she says the government should at least emphasize how common Long COVID appears to be and that it can affect vaccinated people. She fears many vaccinated people think they’re in the clear and can’t get Long COVID, because the Administration has sung the shots’ praises so much. “We’re just drowning in this sea of misinformation that is not only causing people to poorly think about their own risk, but also putting other people at risk,” Davis says.

Those with Long COVID often say they feel like they’re screaming into the void, trying to get through to people who either aren’t aware of or don’t care about the condition and the possibility it could affect them, too. In grocery stores, Hafner marvels—and seethes—at the bare faces she sees. Sometimes, when she’s the only person wearing a mask, “I think, ‘Am I a pariah?’” Hafner says. “We’re at that point where the people in masks are the outliers.”

For many people who are done with the pandemic and the caution that came with it, a maskless supermarket may seem like a sign of progress. But for those with an intimate understanding of Long COVID, it feels like a bad omen.

“It’s no way to live,” McCone says of his day-to-day existence since developing Long COVID. His worst fear, and one that looks like it may come true if progress isn’t made soon, is that millions more people will have to learn that the hard way.

Write to Jamie Ducharme at [email protected].

Write to Jamie Ducharme at [email protected].

Yesterday on 60 Minutes, in an interview at the auto show in Detroit, Michigan, President Biden stated: “The pandemic is over. We still have a problem with COVID. We’re still doing a lotta work on it. But the pandemic is over.” His pronouncement caught the U.S. public health community, and even some administration officials, off guard. In the hours that followed, science commentators were scrambling to understand the basis for his conclusion that there is no longer a pandemic.

To be fair, as Boghuma Kabisen Titanji, infectious disease physician at Emory, said, “the epidemiology and public health text books don’t really say how one determines when a pandemic has ended.” The end of a pandemic is not like a light switch going off. It is not a discrete moment in time, but more of a process—one that can be messy and highly contested. What President Biden’s declaration suggests is that a pandemic’s “end” is not determined solely by science or public health data, but involves social and political considerations.

The classic definition of a pandemic, from John Last’s A Dictionary of Epidemiology, arguably the “Bible” of public health terminology, is: “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.” By this definition, it would be very difficult to conclude that the COVID-19 pandemic has ended.

Yesterday, 481,326 new cases and 1,789 deaths were reported worldwide. The World Health Organization still categorizes COVID-19 as a pandemic, although its Director General, Tedros Adhanom Ghebreyesus, said last week that “the end is in sight,” noting that daily deaths worldwide are at their lowest level since the pandemic began.

Perhaps President Biden was referring specifically to the U.S.? Yet an analysis last week by CBS News found that U.S. COVID-19 deaths were averaging 478 per day, “higher than in July 2021 when the average was 168 deaths per day and also higher than in June 2022 when the average was 258 deaths per day.”

Read More: You Can Still Long Covid If You’re Vaccinated and Boosted

An average of around 400-500 daily deaths does not indicate an end to the pandemic phase in the US. As I’ve argued before, the US cannot eliminate COVID-19 (elimination means there would be no new cases of the disease within our borders). We also cannot drive deaths down to zero, given that there will always be vulnerable people, especially among older Americans, and while our scientific tools for preventing death—vaccines, antivirals, and monoclonal antibodies—are highly effective, they are not 100% effective. But we certainly can achieve “low endemic levels”—in which there are low levels of severe illness, hospitalization, and deaths, perhaps with seasonal peaks. This scenario is akin to flu, which we strive to keep at low endemic levels, including through flu vaccination. (The CDC estimates that flu killed 12,000-52,000 people a year between 2010 and 2020, which we could drive down further by expanding access to annual flu vaccines.)

Determining when America has transitioned out of the pandemic phase of COVID-19 to a “low endemic” phase would ideally be done through an inclusive, participatory process. Ole Norheim and colleagues at the University of Bergen, Norway have argued that such a process—involving, for example, hearings, town halls, and citizen panels, “can contribute to more trustworthy and legitimate decisions on difficult ethical questions and political trade-offs during the pandemic and beyond.” There would have been less consternation about President Biden’s 60 Minutes interview if he’d brought scientists and the broader public into his deliberations. It is unclear whether President Biden even consulted his own administration colleagues, let alone the wider community, in his determination that the pandemic is done.

But the major problem with the President saying the pandemic is “over” is that it could impede our efforts to reach low endemic levels. For example, Congress is less likely to renew funding for COVID-19 measures if the pandemic has “ended.” And the public may hear the message that COVID-19 is “done” and be less likely to get the new bivalent booster—the first vaccine tailored to the current virus variants. The current US burden of illness, hospitalizations, deaths, and Long Covid can and should be driven down before declaring that “the job is done.” There are many ways in which we can achieve this, including tackling the stark inequity in the U.S. and worldwide in access to vaccines, boosters, and antiviral therapies like Paxlovid and Evusheld. Getting boosters to older Americans is an extremely high priority for averting preventable deaths.

We are not yet at low endemic levels—but these are within our grasp. Only then can we declare the pandemic over. Until then, there is much work to do.

Contact us at [email protected].

Contact us at [email protected].

When the first cases of COVID-19 began accumulating around the world, the World Health Organization (WHO) was under pressure to declare the disease a pandemic. That announcement unlocked the keys to additional funding, resources, and emergency actions to control cases.

Now, in a 60 Minutes interview, President Biden has said that “the pandemic is over.” He cited the fact that people are no longer wearing masks, that large public events such as the Detroit Auto Show have resumed in person, and that concerns about COVID-19 no longer dictate our behaviors in the way they did over the past two years.

But public health experts are wary about the declaration, concerned it will mean that people have license to abandon the already fragile networks of behaviors that are trying to keep a highly contagious virus from breaking free again to cause another wave of disease. It’s also a concerning sentiment to arrive just as health officials in the U.S. launch a booster campaign to reinstate waning protection from vaccines before the fall and winter, when respiratory viruses like SARS-CoV-2 tend to have free reign.

The reality is that while Biden’s statement that hardly anyone is wearing masks is true, that’s largely the result of weariness on the public’s part, and because a judge in Florida overturned federal mandates requiring masks in government buildings and on mass transit. Therefore, the disappearance of masks cannot be interpreted entirely as the result of reduced risk from the virus.

The President’s declaration is “counterproductive because it reinforces the impression that many people have that we don’t have to worry about COVID-19 any more,” says Dr. Eric Toner, senior scholar at the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health. “By pandemic, most people mean that people around the world are susceptible to an infectious disease for which people do not have immunity, and therefore could cause serious illness. It is absolutely true that the pandemic is much less severe than it was. But the fact is, we still have 65,000 new reported cases every day, and 450 deaths a day, which annualized is 170,000 deaths a year. So it’s not over.”

Read More: Here’s Why Experts Believe the New Omicron Booster Will Work

Yes, infections are on the decline, and yes, deaths from COVID-19 are also dramatically lower than they have been since the Omicron wave hit earlier this year. But more than 500 people are dying on average each week from COVID-19, and in a worrying sign, hospitalizations, especially among the elderly, are creeping up as the immunity provided by vaccines declines.

Declaring that the pandemic is over will inevitably lead people to a sense of complacency that infectious disease experts believe is premature. Even if we’re moving toward a reality in which COVID-19 becomes more like the flu, with an annual (or more frequent) shot, COVID-19 still causes far more infections and deaths than flu does on average. The truth is that the Omicron variant, and its latest subvariants, BA.4 and BA.5, are highly contagious. And while they don’t seem to be causing more serious disease, here’s the thing about viruses: the more infections a virus causes, and the more hosts it infects, the more chances it has to replicate. And every time it makes more copies of itself, it can generate mutations. The more mutations are generated, the more likely it might be that one or a few of those mutations could lead to a more virulent version that does cause more severe illness.

The threat from COVID-19 is certainly not the same as it once was, and vaccines and antiviral treatments have changed that. Those have been made available in the U.S. because the government declared COVID-19 a state of public health emergency, which allowed Congress to dedicate funds to provide those shots and therapies for free to the American public. The Department of Health and Human Services (HHS) recently renewed that designation until at least the end of October, and the WHO has not yet declared victory over COVID-19 either.

Declaring the pandemic over could jeopardize that continued funding, just when it might be needed most, to vaccinate people with the first Omicron booster before the winter. “When the administration is trying to get new money from Congress for COVID-19, it just seems like an ill-timed and inaccurate message,” says Toner. Already, the HHS has shifted funds from other health services to provide these booster at no cost to the public, according to Secretary Xavier Becerra during a recent briefing.

When will COVID-19 be over? There are no strict definitions for what constitutes a pandemic, nor for when it has run its course. The scale of the disease, in terms of its range around the world, is among the primary criteria for declaring a pandemic, and similarly, declines in cases and spread of illness would factor into its completion. But those decisions are as much economic as they are epidemiological—as a pandemic, COVID-19 will cost the global economy $12.5 trillion by 2024, according to the latest estimates from the International Monetary Fund. And that funding has strained governments around the world, both in the developed and developing world; if COVID-19 is no longer a pandemic, that would mean governments might be less obligated to dedicate significant resources toward things like testing, vaccine programs, and treatments. And with the White House taking the lead in declaring the pandemic over, that might encourage governors of states who are already inclined to limit COVID-19 response measures to eliminate them altogether. That in turn could lead to lower protection as more people who aren’t boosted gather indoors, unmasked, during the colder weather when viruses spread more easily.

Read More: Long COVID Experts and Advocates Say the Government Is Ignoring ‘the Greatest Mass-Disabling Event in Human History’

This winter will be an important one when it comes to seeing where the pandemic goes from here—with a new, more closely matched booster to the Omicron variant, it could continue to decline, getting closer to behaving like influenza. Or, if people believe that they don’t have to worry about COVID-19 any more, Omicron, or even a yet-to-named variant, could lead to another surge in cases.

Contact us at [email protected].

Contact us at [email protected].

The American crackdown on the drugs that kicked off the modern opioid overdose epidemic—prescription opioids—largely succeeded. According to data released by the American Medical Association (AMA) on Sept. 8, opioid prescriptions have dropped in every state over the last decade, plummeting nearly 50% nationally.

The effort to prevent overdose deaths, however, is an abject failure. Annual opioid overdose deaths more than tripled between 2010 and 2020, according to federal data. Drug overdose deaths over a 12-month period surpassed 100,000 for the first time in April 2021, with about 75% of those deaths involving opioids.

Many factors contributed to this, but the fundamental problem is that the evolution of the drug market outpaced efforts to stop drug overdoses. “The prices of these drugs have never been cheaper. And the potency of these drugs has never been higher,” says Dr. Daniel Ciccarone, a professor who researches the opioid crisis at the University of California-San Francisco.

If prescription pills were the first wave of the opioid epidemic, the second wave started in the late 2000s, amid growing awareness of the risks posed by prescription opioids, according to Ciccarone. As states and the federal government implemented programs like prescription monitoring, health care workers rapidly reduced the number of opioid prescriptions they issued in order to protect their patients—and their medical licenses. However, this quick reversal meant that many patients were suddenly cut off from prescription opioids. They received inadequate help tapering off opioid medications or coping with lingering pain, and many turned to the illegal drug market, including heroin, says Nabarun Dasgupta, who studies opioid overdose and substance use disorder at the University of North Carolina’s Gillings School of Global Public Health.

Many people continue to be left behind, he says: “There are a lot of abandoned people who were on pain medications, who cannot get access to adequate pain management anymore, and are therefore, increasingly, turning to the street. We hear those stories every day.”

In the late 2010s, however, the U.S. appeared to reach a turning point: overdose deaths seemed to level off nationally, even declining in states such as Minnesota, Rhode Island, and Massachusetts, following aggressive prevention efforts. A wide range of new programs had proliferated, including public education, expanded access to medications for opioid use disorder, like buprenorphine, and naloxone distribution programs, which may have led to the decline in deaths, says Thomas Stopka, an associate professor of public health and community medicine at Tufts University School of Medicine. The decline might also be attributable to the rise and fall of carfentanil—an opioid more potent than fentanyl—in the late 2000s, says Ciccarone.

Through this period, the illicit drug market continued to shift. First, there was the emergence of the synthetic opioid fentanyl, which in its legal form is often used to relieve pain during and after surgeries, but on the illicit market is valued because it’s cheap to manufacture, easy to move, and leads to a high that’s more powerful (but shorter lasting) than heroin. The drug manufacturing industry also became more fractured following crackdowns on poppy cultivation and fentanyl manufacturing, says Dasgupta, with a lot of the production shifting to Mexico, where there were more “little manufacturers who have less interest in quality control, and are trying to make a fast buck.”

Fentanyl and its analogs (chemically similar drugs), which first emerged on the East Coast and gradually moved West, also played a major role in rising deaths. The potency of different variations can vary dramatically, which makes it difficult for drug users to regulate their dosage. This becomes an even greater threat when substances are mixed together.

The drug supply and drug use also became riskier. Fentanyl has increasingly been used alongside stimulants like methamphetamine and cocaine. By the time substances are sold, they have often been combined with other drugs. Many experts, including Ciccarone, say it’s not clear if this is intentional. The result, however, is that many drug users, and even drug sellers, have no idea what’s in the drugs they’re buying. This is particularly dangerous because it means users can’t adjust the level they consume to their individual opioid tolerance. People who are not regular opioid users and haven’t built up tolerance might also accidentally use the drug. Plus, in addition to fentanyl and its analogs, drugs might contain a variety of other chemicals, including the animal tranquilizer xylazine and novel psychoactive substances like the opioid nitazine.

The COVID-19 pandemic made the situation even worse. Some experts have argued that the drug supply became even more corrupted over the past few years, as drug distributors favored substances that were more potent by volume. The pandemic also cut many people off from their social safety net, careers, and ordinary lives, exacerbating the mental health issues and feelings that play into substance use disorder. “Humans got hurt,” Ciccarone says. “We got isolated, we got afraid. Our social networks got damaged, our safety nets got damaged. And that just leads to more deaths.”

Going forward, the AMA and experts on drug use argue that the key will be to lift barriers preventing people from getting access to treatments for substance use disorder, including medications for opioid use disorder like buprenorphine. It will also be crucial to expand access to tools that save lives, including the overdose reversal medication naloxone (also known as Narcan), syringe exchanges, and fentanyl test strips.

Saving lives will require a major investment of both financial resources and public attention, says Ciccarone. While overdose deaths will go up and down, he says, the factors that drive many people to drug use—trauma and suffering—aren’t going away. “There’s no magic bullets,” he says. “You need bold, steady, Marshall-plan level attention to the drug consumption problem in America.”

Contact us at [email protected].

Contact us at [email protected].

The great thing about making your own snack food at home is that you control what goes into it. This Sweet and Savory Keto Trail Mix combination is no exception. You can have a little sweet and a little salty together without any fear of sending your healthy diet into a nosedive. When you make this recipe in your own kitchen, tailor it to your own preference. Add a little more or less everything but the bagel seasoning. Cut back on the chocolate if you like, or, for that matter don’t add any – the coconut flakes will add plenty of sweetness for some. However you make it, this trail mix is still a fresher, healthier option than most store-bought versions.

The combination of nuts and seeds brings plenty of healthy protein and fat to this snack mix. You can make these separately or toss them together to enjoy a combination of sweet and savory. This is a perfect non-perishable snack to take hiking or camping (it is, after all, trail mix) or, keep an airtight container in your car or at work for snacking during the day.

How to make savory keto trail mix

Briefly baking this combination of nuts and seeds gives it a rich, toasted flavor and slight crunch that’s hard to beat.  First preheat your oven to 325 degrees Fahrenheit. Then place all ingredients in a bowl and toss to combine. Lay them out on a sheet pan in a single layer. Bake the mix for 7-10 minutes, tossing them once while cooking. Keep an eye on them to ensure nothing burns while cooking. Give the trail mix another toss and allow it to cool before eating.

How to make sweet keto trail mix

For this recipe combine all ingredients together in a bowl and enjoy! For another variation, you can melt the chocolate with a small dollop of coconut oil and toss the nuts in this mixture, then lay the trail mix out on a pan in a single layer and refrigerate until a hard bark forms.

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Transcarent, a healthcare platform for self-insured employers, announced Monday it would expand into the pharmacy benefit space.

The new offering, called Transcarent Pharmacy Care, will allow members to search for the lowest-cost drug option and compare prices across pharmacies. They can also transfer their prescription within Transcarent’s app and access 24/7 support if needed.

The company said the goal is to give employers more transparency into and control of their formulary and benefit design. Transcarent argues the offering can save employers money by using large pharmacy networks, integrating pharmacy and medical care, passing through rebates to plan sponsors, and eliminating spread pricing, where pharmacy benefit managers charge more for a drug than they reimburse to the pharmacy and keep the difference. 

“There’s never been a good reason for employers to be uncertain about the true cost of their most utilized benefit offering,” Transcarent COO Snezana Mahon said in a statement. “The information that will now be available to employers will enable them to improve their benefits and the care they provide for their people, reduce costs and empower employees and their families to most effectively manage their prescription drug needs.”

THE LARGER TREND

High drug costs are a long-standing problem for the U.S. healthcare system. According to a report from the American Society of Health-System Pharmacists released this spring, total drug spending grew 7.7% in 2021 and is expected to continue to rise this year. 

A survey published last month found Medicare beneficiaries were concerned about the impact of inflation on healthcare costs, particularly for prescription drugs and Part B premiums. The Inflation Reduction Act, which was signed into law last month, allows Medicare for the first time to negotiate drug prices for 10 high-cost drugs, starting in 2026.

Transcarent emerged from stealth in March 2021, led by Livongo vet Glen Tullman. The startup announced a $58 million Series B raise in June that year, and a $200 million Series C early in 2022. 

It’s also been adding new offerings this year. In April, the company revealed Transcarent Oncology Care, aimed at helping members find cancer care institutes, oncology providers and appropriate clinical trials. It also launched a behavioral health program earlier this spring that helps patients find in-person or virtual therapy.

Sept. 19, 2022 — Imagine this: You think you might have COVID. You speak a couple of sentences into your phone. Then an app gives you reliable results in under a minute.

“You sound sick” is what we humans might tell a friend. Artificial intelligence, or AI, could take that to new frontiers by analyzing your voice to detect a COVID infection.

An inexpensive and simple app could be used in low-income countries or to screen crowds at concerts and other large gatherings, researchers say.

It’s just the latest example in a rising trend exploring voice as a diagnostic tool to detect or predict diseases.

Over the past decade, AI speech analysis has been shown to help detect Parkinson’s disease, posttraumatic stress disorder, dementia, and heart disease. Research has been so promising that the National Institutes of Health just launched a new initiative to develop AI to use voice to diagnose a wide array of conditions. These range from such respiratory maladies as pneumonia and COPD to laryngeal cancer and even stroke, ALS, and psychiatric disorders like depression and schizophrenia. Software can detect nuances that the human ear can’t, researchers say.

At least half a dozen studies have taken this approach to COVID detection. In the most recent advancement, researchers from Maastricht University in the Netherlands are reporting their AI model was accurate 89% of the time, compared with an average of 56% for various lateral flow tests. The voice test also was more accurate at detecting infection in people not showing symptoms.

One hitch: Lateral flow tests show false positives less than 1% of the time, compared with 17% for the voice test. Still, since the test is “virtually free,” it would still be practical to just have those who test positive take further tests, said researcher Wafaa Aljbawi, who presented the preliminary findings at the European Respiratory Society’s International Congress in Barcelona, Spain.

“I am personally excited for the possible medical implications,” says Visara Urovi, PhD, a researcher on the project and an associate professor at the Institute of Data Science at Maastricht University. “If we better understand how voice changes with different conditions, we could potentially know when we are about to get sick or when to seek more tests and/or treatment.”

Developing the AI

A COVID infection can change your voice. It affects the respiratory tract, “resulting in a lack of speech energy and a loss of voice due to shortness of breath and upper airway congestion,” says the preprint paper, which hasn’t been peer reviewed yet. A COVID patient’s typical dry cough also causes changes in the vocal cords. And previous research found that lung and larynx dysfunction from COVID changes a voice’s acoustic characteristics.

Part of what makes the latest research notable is the size of the dataset. The researchers used a crowd-sourced database from the University of Cambridge that contained 893 audio samples from 4,352 people, of whom 308 tested positive for COVID.

You can contribute to this database – it’s all anonymous — via Cambridge’s COVID-19 Sounds App, which asks you to cough three times, breathe deeply through the mouth three to five times, and read a short sentence three times.

For their study, Maastricht University researchers “only focused on the spoken sentences,” explains Urovi. The “signal parameters” of the audio “provide some information on the energy of speech,” she says. “It is those numbers that are used in the algorithm to make a decision.”

Audiophiles may find it interesting that the researchers used mel spectrogram analysis to identify characteristics of the sound wave (or timbre). Artificial intelligence enthusiasts will note that the study found that long short-term memory (LSTM) was the type of AI model that worked best. It’s based on neural networks that mimic the human brain and is especially good at modeling signals collected over time.

For laypeople, it’s enough to know that advancements in the field may lead to “reliable, efficient, affordable, convenient, and simple-to-use” technologies for detection and prediction of disease, the paper said.

What’s Next?

Building this research into a meaningful app will require a successful validation phase, says Urovi. Such “external validation” — testing how the model works with another dataset of sounds — can be a slow process.

“A validation phase can take years before the app can be made available to the broader public,” Urovi says.

Urovi stresses that even with the large Cambridge dataset, “it is hard to predict how well this model might work in the general population.” If speech testing is shown to work better than a rapid antigen test, “people might prefer the cheap non-invasive option.”

“But more research is needed exploring which voice features are most useful in picking out COVID cases, and to make sure models can tell the difference between COVID and other respiratory conditions,” the paper says.

So are pre-concert app tests in our future? That’ll depend on cost-benefit analyses and many other considerations, Urovi says.

Nevertheless, “It may still bring benefits if the test is used in support or in addition to other well-established screening tools such as a PCR test.”

By Denise Mann
HealthDay Reporter

MONDAY, Sept. 19, 2022 (HealthDay News) — Weeks after a stay in the hospital, your bill arrives and you can barely believe the amount due. How is this even possible if you have good health insurance and, more importantly, how will you pay it?

Unfortunately, you’re not alone. More than one in 10 American adults and nearly one in five U.S. households have medical debt, a new study finds. Making matters worse, incurring medical debt more than doubles your chances of not being able to afford food, rent, mortgage or utilities, and losing your home.

“Medical debt is incredibly common and it is toxic,” said study author Dr. Steffie Woolhandler. She is a primary care doctor and distinguished professor at Hunter College in New York City.

It’s a vicious cycle, said Woolhandler, also a lecturer in medicine at Harvard Medical School in Boston and a research associate for Public Citizen’s Health Research Group, a nonprofit consumer advocacy organization.

“People get sick and they go into medical debt, and this causes food insecurity and housing insecurities, which makes them even sicker, so then they need more medical care and incur even more medical debt,” she said.

The bottom line? “They get sicker and poorer and sicker and poorer,” Woolhandler explained.

For the study, researchers crunched data from the U.S. Census Bureau’s 2018, 2019 and 2020 Surveys of Income and Program Participation for a group of people who had participated for all three years. They used this data to isolate the effects of medical debts.

The average amount of medical debt was about $2,000 for an adult and about $4,600 per U.S. household, the study showed.

Medical debt was common even among folks with insurance.

“There have been other reports about medical debt, but this is the first time that we have actually been able to link it to consequences like going without food and losing housing,” Woolhandler said.

Middle-class Americans were just as likely as people with low incomes to have medical debt. People with military health insurance had the lowest rate of medical debt at just under 7%, the study found.

People at highest risk for new medical debts were those who became newly disabled, were hospitalized or lost their health insurance, the researchers reported.

It’s time to fix this mess, and it’s possible, Woolhandler said.

“Polls show that the majority of Americans would support a system where the government pays all medical bills,” she said.

The recent No Surprises Act helped make things a little better. This bill went into effect in January and protects people with insurance from receiving surprise medical bills from unexpected, out-of-network coverage for medical care.

There are other things you can do to lower your risk of incurring crippling medical debt, she said. “If you go into the hospital and get a bill that you can’t pay, try to negotiate,” she said. “You are in much better shape talking to the hospital than a collection agency.”

Many hospitals do have financial assistance programs as well, she said. Always go over any medical bills and make sure they are accurate, she suggested.

The findings were published online Sept. 16 in JAMA Network Open .

Allison Sesso is the president and CEO of RIP Medical Debt, a Long Island City, N.Y.-based national nonprofit that seeks to help people get out of medical debt.

“Medical debt isn’t just a mark on one’s credit score. We know it prevents patients from seeking further care or they’re denied care,” said Sesso, who has no ties to the new study.

“Medical debt does not just affect the uninsured: People with health insurance are at risk of medical debt due to high out-of-pocket costs,” she added.

Why? The average annual deductible for employer-sponsored insurance has grown steadily. “Ensuring that people have access to affordable, robust and low-deductible health insurance plans is the best way to close the health insurance gap,” Sesso said.

Implementing Medicaid expansion — which would cover more low-income Americans — in holdout states is an immediate way to help millions of people avoid medical debt, she added. And financial aid needs to be extremely accessible when people see a doctor or go to a hospital.

“We’d like to see a ban on extraordinary collection practices like lawsuits, wage garnishments, and liens on homes for individuals who simply cannot pay an astronomical medical debt,” Sesso said.

More information

RIP Medical Debt offers tips on how to avoid medical debt.

SOURCES: Steffie Woolhandler, MD, MPH, primary care doctor, distinguished professor, CUNY’s Hunter College, New York City, lecturer, medicine, Harvard Medical School, Boston, research associate, Public Citizen Health Research Group; Allison Sesso, President and CEO, RIP Medical Debt, Long Island City, N.Y.; JAMA Network Open, Sept. 16, 2022, online

What time is it? Your body knows, based on a carefully calibrated internal clock that turns certain genes off and on throughout the day. And humans have long known that certain medicines are best used at different times of day: caffeine in the morning, to name one.

What if cancer medications, provided at specifically tuned times for individual patients, could work better and reduce side effects?

That’s the hope of scientists working on “chronochemotherapy.” But researchers say that both scientific and practical issues mean the approach isn’t ready for prime time.

“We’re still kind of in the learning curve,” says Jian Campian, MD, a neuro-oncologist at the Mayo Clinic in Rochester, MN.

Time Trials

The challenge with cancer medications is to maximize the killing of cancer cells while leaving healthy ones alive. The body’s natural internal clock could help limit toxicity, says Francis Lévi, MD, an oncologist and researcher at Paris-Saclay University. The trick would be to find a time when healthy cells are protected against the drugs or are able to break them down into something that doesn’t harm them – but while cancer cells can’t do that. Tumor cells often have dysfunctional internal clocks, so they’re likely to be more susceptible to treatment at times when healthy cells are protected, says Lévi.

One cancer treatment where timing seems to make a difference is with the combination of 6-mercaptopurine and methotrexate for certain types of leukemia in children. For example, one study in 1985 found that the 36 children who took the drugs in the morning were 4.6 times more likely to relapse than the 82 kids who took it in the evening. Based on this and other studies, doctors usually recommend taking this pair of meds in the evening.

But for most cancer meds, evidence for an effect of time of day is thin or nonexistent.

Campian and colleagues recently asked whether timing made a difference for the drug temozolomide in people with the brain cancer glioblastoma. They already had data on people who took the drug in the morning or the evening. That’s because Campian was trained to tell patients to take it in the evening, so they could sleep through unpleasant side effects like nausea, but other doctors she worked with suggested taking it in the morning.

When the researchers looked back at 166 of their patients, they saw that the people who took temozolomide in the morning survived longer. That suggests the timing makes a difference, but a looking-back study like this is hardly proof of an effect.

Next, the team started a new study, asking whether it would even be feasible for patients to take their meds on a specific time schedule, and if the drug would work better in the morning. In this small study, among 35 adults with brain tumors, participants recorded when they took meds in a diary, which showed they hit the right time of day more than 90% of the time. The results differed from the previous study, in that people who took the drug in the morning didn’t survive any longer than those who took it in the evening.

With conflicting results from two small studies, it’s an open question as to whether timing temozolomide makes a difference. The next step is to go back into the laboratory to understand better how temozolomide efficacy might vary with circadian rhythms, says collaborator Erik Herzog, PhD, a biologist at Washington University in St. Louis. A much larger study would be necessary to test whether this type of chronotherapy does indeed work in people, and how much of a difference it makes.

Lévi has already tested chronochemotherapy in hundreds of people with colorectal cancer. Half of the 564 people in his trial received the standard treatment, including three medications. The others received the same drugs, but with their IVs timed so two meds would peak early in the morning and one would be at maximum in the afternoon.

The results were mixed. On the positive side, men’s risk of death dropped by 25% on the timed treatment. But among women, the chronochemotherapy increased the risk of earlier death by 38%.

Lévi says the difference may be because circadian rhythms control genes differently in men and women, leading to a 5- to 6-hour difference in response to medications.

Not So Fast

Lévi’s results illustrate a key challenge in chronochemotherapy: How do you know when each person should get their meds? Must the dosing schedule be personalized for each patient?

Sex isn’t the only issue. Some people are morning larks. Others are night owls. Researchers envision using activity monitors on patients’ wrists to figure out their unique schedules before prescribing chronochemotherapy.

Meanwhile, some cancers disrupt the body’s internal clock, which could make a chronochemotherapy approach moot.

There are also practical challenges in providing tightly timed medicine.

You could take oral medications like temozolomide any time you’re awake. But what about drugs that require IVs? It could be possible for hospital inpatients to receive tightly timed therapies at any hour, says Belinda Mandrell, PhD, director of nursing research at St. Jude Children’s Research Hospital in Memphis. Lévi prefers programmable drug pumps that can meter out meds at home.

The bigger challenge, though, is to figure out if chronochemotherapy works at all. Aziz Sancar, MD, PhD, a biochemist at the University of North Carolina in Chapel Hill, has doubts. He says more work in cells and mice should be done before clinical trials in people are appropriate.

“I don’t say it’ll never work,” he says. “I think chronotherapy is not there yet, and I don’t know if it’ll ever be there.”