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Why Patients Aren’t Getting the Shingles Vaccine

Four years ago at age 78, R., a retired professional known as much for her small-town Minnesotan resilience as her commitment to public service, developed a fleeting rash over her left chest. The rash, which turned out to be shingles, or herpes zoster, was hardly noticeable.

But the complications were unforgettable.

For close to a year afterward, R. wrestled with the searing and relentless pain in the area where the rash had been. “It was ghastly, the worst possible pain anyone could have,” R. said recently, recalling the sleepless nights and fruitless search for relief. “I’ve had babies and that hurts a lot, but at least it goes away. This pain never let up. I felt like I was losing my mind for just a few minutes of peace.”

Shingles and its painful complication, called postherpetic neuralgia, result from reactivation of the chicken pox virus, which remains in the body after a childhood bout and is usually dormant in the adult. Up to a third of all adults who have had chicken pox will eventually develop one or both of these conditions, becoming debilitated for anywhere from a week to several years. That percentage translates into about one million Americans affected each year, with older adults, whose immune systems are less robust, being most vulnerable. Once the rash and its painful sequel appear, treatment options are limited at best and carry their own set of complications.

While the search for relief costs Americans over $500 million each year, the worst news until recently has been that shingles and its painful complication could happen to any one of us. There were no preventive measures available.

But in 2006, the Food and Drug Administration approved a new vaccine against shingles. Clinical trials on the vaccine revealed that it could, with relatively few side effects, reduce the risk of developing shingles by more than half and the risk of post-herpetic neuralgia by over two-thirds. In 2008, a national panel of experts on immunizations at the Centers for Disease Control and Prevention went on to recommend the vaccine to all adults age 60 and older.

At the time, the shingles vaccine seemed to embody the best of medicine, both old school and new. Its advent was contemporary medicine’s elegant response to a once intractable, age-old problem. It didn’t necessarily put an end to the spread of disease, in this case chicken pox; but it dramatically reduced the burden of illness for the affected individual. And, most notably, its utter simplicity was a metaphoric shot-in-the-arm for old-fashioned doctoring values. Among the increasingly complex and convoluted suggestions for health care reform that were brewing at that moment, here was a powerful intervention that relied on only three things: a needle, a syringe and a patient-doctor relationship rooted in promoting wellness.

Not.

In the two years since the vaccine became available, fewer than 10 percent of all eligible patients have received it. Despite the best intentions of patients and doctors (and no shortage of needles and syringes), the shingles vaccine has failed to take hold, in large part because of the most modern of obstacles. What should have been a widely successful and simple wellness intervention between doctors and their patients became a 21st century Rube Goldberg-esque nightmare.

Last month in The Annals of Internal Medicine, researchers from the University of Colorado in Denver and the C.D.C. surveyed almost 600 primary care physicians and found that fewer than half strongly recommended the shingles vaccine. Doctors were not worried about safety — a report in the same issue of the journal confirmed that the vaccine has few side effects; rather, they were concerned about patient cost.

Although only one dose is required, the vaccination costs $160 to $195 per dose, 10 times more than other commonly prescribed adult vaccines; and insurance carriers vary in the amount they will cover. Thus, while the overwhelming majority of doctors in the study did not hesitate to strongly recommend immunizations against influenza and pneumonia, they could not do the same with the shingles vaccine.

“It’s just a shot, not a pap smear or a colonoscopy,” said Dr. Laura P. Hurley, lead author and assistant professor of medicine at the University of Colorado in Denver. “But the fact is that it is an expensive burden for all patients, even those with private insurance and Medicare because it is not always fully reimbursed.”

Moreover, many private insurers require patients to pay out of pocket first and apply for reimbursement afterward. And because the shingles vaccine is the only vaccine more commonly given to seniors that has been treated as a prescription drug, eligible Medicare patients must also first pay out of pocket then submit the necessary paperwork in order to receive the vaccine in their doctor’s office. It’s a complicated reimbursement process that stands in stark contrast to the automatic, seamless and fully covered one that Medicare has for flu and pneumonia vaccines.

Despite this payment maze, some physicians have tried to stock and administer the vaccine in their offices; many, however, eventually stop because they can no longer afford to provide the immunizations. “If you have one out of 10 people who doesn’t pay for the vaccine, your office loses money,” said Dr. Allan Crimm, the managing partner of Ninth Street Internal Medicine, a primary care practice in Philadelphia. Over time, Dr. Crimm’s practice lost thousands of dollars on the shingles vaccine. “It’s indicative of how there are perverse incentives that make it difficult to accomplish what everybody agrees should happen.”

Even bypassing direct reimbursement is fraught with complications for doctors and patients. A third of the physicians surveyed in the University of Colorado study resorted to “brown bagging,” a term more frequently used to describe insurers who have patients carry chemotherapy drugs from a cheaper supplier to their oncologists’ offices. In the case of the shingles vaccine, the study doctors began writing prescriptions for patients to pick up the vaccine at the pharmacy and then return to have it administered in their offices. However, the shingles vaccine must be frozen until a few minutes before administration, and a transit time greater than 30 minutes between office and pharmacy can diminish the vaccine’s effectiveness.

Dr. Crimm and the physicians in his office finally resorted to what another third of the physicians in the study did: they gave patients prescriptions to have the vaccine administered at pharmacies that offered immunization clinics. But when faced with the added hassles of taking additional time off from work and making a separate trip to the pharmacy, not all patients followed through. “Probably about 60 percent of our patients finally did get the vaccine at the pharmacy,” Dr. Crimm estimated. “This is as opposed to 98 percent of our patients getting the pneumonia and influenza vaccines, immunizations where they just have to go down the hall because we stock it, roll up their sleeves then walk out the door.”

With all of these barriers, it comes as no surprise that in the end only 2 percent to 7 percent of patients are immunized against shingles. “There’s just so much that primary care practices must take care of with chronic diseases like obesity and diabetes and heart disease,” Dr. Hurley noted. “If a treatment isn’t easy to administer, then sometimes it just falls to the bottom of the list of things for people to do.”

“Shingles vaccination has become a disparity issue,” Dr. Hurley added. “It’s great that this vaccine was developed and could potentially prevent a very severe disease. But we have to have a reimbursement process that coincides with these interventions. Just making these vaccines doesn’t mean that they will have a public health impact.”

Human Bodies Make Their Own Morphine

A laboratory morphine vial from the 1880s.

Our bodies produce a small but steady amount of natural morphine, a new study suggests.

Traces of the chemical are often found in mouse and human urine, leading scientists to wonder whether the drug is being made naturally or being delivered by something the subjects consumed.

The new research shows that mice produce the “incredible painkiller”—and that humans and other mammals possess the same chemical road map for making it, said study co-author Meinhart Zenk, who studies plant-based pharmaceuticals at the Donald Danforth Plant Science Center in St. Louis, Missouri.

In the study, researchers injected mice with an extra dose of a natural brain chemical called tetrahydropapaveroline (THP), which humans and mice are known to produce.

Using a tool called a mass spectrometer to analyze the mouse urine, the team was able to tell that THP underwent chemical changes in the body that created morphine, according to the study, published this week in the journal Proceedings of the National Academy of Sciences.

What’s more, the study found that mouse morphine is produced in nearly the same way as the morphine in poppies—the only morphine-making plants known to science.

Morphine a Defense Mechanism?

But “the big question is, What is it for?” Zenk said of the mammal-made morphine.

THP must undergo a complicated, 17-step process in the body to create morphine. Even so, the chemical has evolved twice—in poppies and in mammals—suggesting it’s somehow valuable for survival.

In the well-studied poppy plant, scientists suspect morphine acts as a defense against predators. For instance, a rabbit eating—and thus killing—a morphine-laced poppy may become sluggish, making itself easy prey for a passing hawk.

Likewise, Zenk noted, if an animal attacks a person, even background levels of morphine may block out enough pain to allow the person to escape. (Explore the human body.)

For now, however, this is “absolute speculation,” Zenk said. Next he plans to test the urine of people who have endured horrible pain—such as traffic-accident victims—to see if their bodies spiked morphine levels.

It’s also difficult to say whether the discovery will yield any new treatments, Zenk added. (Related: “Toxic Snail Venoms Yielding New Painkillers, Drugs.”)

But it’s possible that scientists could someday induce a person’s body to create a natural jolt of morphine that might prove less damaging than injecting the substance into the body. Morphine shots can carry many side effects, he said—especially constipation.

Over 65? Take lots of vitamin D to prevent a fall

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Over 65? Take lots of vitamin D to prevent a fall

Important news for seniors: A daily dose of vitamin D cuts your risk of falling substantially, researchers reported today.

But not just any dose will do. “It takes 700 to 1000 international units (IU) of vitamin D per day and nothing less will work,” Dr. Heike A. Bischoff-Ferrari, who directs the Center on Aging and Mobility at the University of Zurich, Switzerland, noted in an email to Reuters Health.

Those recommendations – which are higher than those by the U.S. Institute of Medicine — are based on the results of eight studies that looked at vitamin D supplements for fall prevention among more than 2,400 adults aged 65 and older. Falls were not notably reduced with daily doses of vitamin D lower than 700 IU.

An analysis of all eight studies, posted online today in the British Medical Journal, add weight to several others which have shown that vitamin D improves strength and balance, and bone health in the elderly, the researchers note.

Each year, 1 in 3 people aged 65 and older, and 1 in 2 aged 50 and older, fall at least once. Nine percent of these mishaps require a trip to the emergency room and around 6 percent result in a fracture. Many elderly people who fall end up in nursing homes.

“Falls are important events to prevent,” Bischoff-Ferrari said, “and 700 to 1000 IU of vitamin D per day is safe and inexpensive,” but it’s higher than the currently recommended by the Institute of Medicine for older adults. (The Institute recommends 400 IU per day for adults between age 51 and 70, and 600 IU per day for those aged 70 years and over.)

The current findings, Bischoff-Ferrari said, provide an argument to revise the recommendations. They looked at two forms of the vitamin: Vitamin D3, or cholecalciferol, which is more readily absorbed by the body and more potent than vitamin D2, or ergocalciferol, the form often found in multivitamins.

“At the higher dose of 700 to 1000 IU vitamin D, the benefit on fall prevention is significant — at least 19 percent, 26 percent with vitamin D3,” Bischoff-Ferrari said.

While vitamin D3 seemed more potent than D2, forms of vitamin D marketed as “active,” such as calcitriol, did not seem to be more effective than standard vitamin D supplements, the researchers found. Such active forms are more expensive and carry a higher risk of elevated calcium levels, which have been linked to hormone problems and cancer.

Moreover, the effect of 700 to 1000 IU vitamin D daily is kicks in “in a few months and is sustained over years, and the benefit is independent of age and present in those living at home and those living in nursing homes,” Bischoff-Ferrari noted.

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