Opioid epidemic and the need for urgent measures

Addressing Problematic Opioid Use in OECD Countries

Some months ago I explained my concerns about opioid epidemic. I said that the problem is closer than most people think. In the last five years, there has been a 45% growth in publicly funded opioid prescription  in our country. Now OCDE presents the current situation in a report that highlights where we are and what can be done. The key messages are these ones:

• Better Prescribing: Doctors can improve their prescribing practices, for instance, through evidence-based clinical guidelines (e.g. for opioid prescription, for adequate medication-assisted therapy for OUD patients), prescribers training, surveillance of opioid prescriptions, and regulation of marketing and financial relationships with opioid manufacturers. In addition, patients and the general public can also benefit from clear educational materials and awareness interventions to enhance their opioid-related literacy and reduce stigma.
• Better care: Including the expansion of coverage for long-term medication-assisted therapy (e.g. methadone, buprenorphine, naltrexone) coupled with specialised services for infectious diseases management (e.g. HIV, hepatitis) and psychosocial interventions. Some countries have implemented interventions such as the availability of overdose reversal medications for all first responders, needle and syringe programmes, and medically supervised consumption centres.Quality of care must be improved and measured. 
• Better approach: There can be better coordination across the health, social and criminal justice systems. Governments can consider setting up of coordinated networks among the three sectors aiming to facilitate access to integrated services for people with OUD. In addition to health services, social interventions around housing and employment support, and law enforcement uptake of a public health approach are central.
• Better knowledge and research: Including the use of big data and impact evaluations to generate new information from different sources along with the application of advanced analytics. In addition, quality of care measurement should be enhanced in areas such as opioid prescription, OUD health care services, and patient reported indicators (e.g. PROMs, PREMs). Research and development is needed in key areas such as new pain management modalities and OUD treatments.

Genome editing: the game of biology is about to change

Hacking the Code of Life: How gene editing will rewrite our futures

The foundations of gene editing came about because a scientist in Alacant, Dr. Mojica started to find weird DNA sequences in some bacteria he was studying. After that Profs. Doudna and Charpentier and later Prof. Zhang translated initial findings into practice. Therefore it all started when a microbiologist studied the arms race between bacteria and viruses.
You'll find all these details in a book by Nessa Carey. If you want to understand in plain words what CRISPR is and what may represent for biology, then you have to read it.

The gene editing revolution is creating a technological toolkit that almost any half-decent scientist can lean into and find something useful. On the one hand, that should make us very excited. We can both solve problems and simply indulge our curiosity. But should it also make us worried? Using chisels and a mallet, Michelangelo created some of the most exquisite sculptures we have ever seen. But give the same heavy, sharp tools to someone else, and we can get a very different and much bloodier outcome.

But the same technology can also be used to alleviate human suffering, and if we are smart enough, lessen the impact that our heavy-footed species has on the only planet we know of in the entire universe that supports complex life. We cannot un-invent this technology, we probably can’t even control its spread. So what choice do we really have but to embrace it and use it well, to create a safer, more equal world for all?

Decentralisation in health services, is it worth it?

Decentralisation and performance measurement systems in health care

The main trends from the OECD survey results are:

• Decision-making in health care tends to rest largely with the central government, which has considerable power across many aspects of the delivery of health services. More specifically, central governments are more likely to be responsible for decisions regarding the policy aspects of health care, but have less control over decisions regarding the inputs, outputs and monitoring of health care services. In most countries, sub-national governments have large responsibility for input-related matters, such as determining the outsourcing of services and deciding on the contractual status of staff. On average, local governments have little decision-making power in the health sector, but have the most responsibility with regard to decisions about health care inputs.
• The role of the central governments in health care does not vary markedly between federal and unitary countries. However, sub-national government decision-making power tends to be higher in federal than in unitary countries. 
• The majority of OECD countries tends to rely on centralised performance measurement systems, especially to monitor the performance of hospital providers. Systems vary markedly between countries, although some trends across countries exist, including the observation that health performance systems are generally more geared towards improving performance rather than reducing service costs. 
• Less likely to be monitored under a specific performance framework are providers of ancillary services, retailers and other providers of medical goods, and providers of preventive care. Common reasons for the non-establishment of performance systems in these sectors, and in general, include a lack of capacity at the national level, a lack of available data and challenges to co-ordinate actors.

It is a great report, a must read. Impossible ot summarise in few words.

How much would you pay for a gene therapy?

Perspectives on Gene Therapy: Defining and Demonstrating Value to Payers

Kymriah has been included in the NHS and nobody but the regulator knows the price. Therefore, in Spain the answer to the question about the willingness to pay for gene therapy depends absolutely on a few officials in the Ministry, not so many, and they decide in a closed meeting without any transparency and outside of any legal procedure for public budgets. And nothing happens, that's great!. Unbelievably, that's it, the price is confidential and rule of law is useless in a failed state.

PS. Therefore, take note. There is no role for health economics evaluation, forget it forever.

Philip Stanton

Do sin taxes work?

The Use of Excise Taxes to Reduce Tobacco, Alcohol, and Sugary Beverage Consumption

The summary:

Of the 188 countries that reported 2016 tobacco tax and price data to the WHO, 173 levied an excise tax on manufactured cigarettes (61). Tobacco taxes have increased in many countries since the 2005 entry into force of theWHO’s Framework Convention on Tobacco Control. The treaty emphasizes the effectiveness of tax and price increases in reducing tobacco use, particularly among young people.On average, cigarette excise taxes account for 32% of the price in LMICs and 48% in HICs. Many, but not all, countries tax some or all other tobacco products, generally at rates well below the rate imposed on manufactured cigarettes. 

Nearly all governments levy excise taxes on at least some alcoholic beverages. Of the
192 countries that provided data to the WHO in 2012, 155 levied an excise tax on beer, 138 on wine, and 151 on distilled spirits; alcohol sales were banned in some of the nontaxing countries (52, 62). Alcoholic beverage excise taxes appear to be relatively low, according to the limited information provided.  As with cigarette taxes, alcohol excise taxes account for a lower share of price in LMICs than in HICs (both lower, in general, than for cigarettes). Among 74 reporting countries, excise taxes as a share of retail prices ranged from a low of 0.3% in Kyrgyzstan to a high of 44.9% in Norway, with an average of 17.3%. Taxes as a percentage of price are, generally, lowest on beer and highest on distilled spirits.

In 2014,Mexico became the first country in the Americas to adopt a significant tax specifically on SSBs, a one-peso-per-liter tax that raised taxed beverage prices by about 10% (13). Since then, other countries have adopted more significant taxes to reduce SSB consumption and promote health, including several US localities, South Africa, the United Kingdom, Ireland, Portugal, Saudi Arabia, the United Arab Emirates (UAE),Dominica, and Barbados.Most aim to raise retail prices by at least 10%, with a few resulting in more significant increases

Well, unfortunately the article explains the current status (and it helps) though the impact is much more difficult to measure.

Succesful populists: the age of elected despots

These are selected paragraphs from Martin Wolf excellent op-ed Elected despots feed off our fear and rage:

To be successful, a populist demagogue has to project belief in himself as a man of destiny. Self-obsession and even megalomania help; they may well be essential. In a compelling book, Disordered Minds, the Irish writer Ian Hughes suggests such men are narcissists or psychopaths. To a non-expert eye, they do appear deranged. How else can one sell the idea that “I alone am the people’s salvation” to oneself?

If such a leader wishes to subvert democracy, it is, alas, not that hard to do, as Harvard’s Steven Levitsky and Daniel Ziblatt argue in How Democracies Die. First, capture the referees (the judiciary, tax authorities, intelligence agencies and law enforcement). Second, sideline or eliminate political opponents and, above all, the media. Third, subvert the electoral rules. Supporting these assaults will be a fierce insistence on the illegitimacy of the opposition and the “fakeness” of information that does not align with whatever the leader finds useful to state.

People will want to trust such a leader whenever they desperately wish to believe that someone powerful is on their side in an unjust world. That is what happens when trust in the institutions and norms of a complex democracy falters. When faith in sober policymaking disappears, the charismatic figure emerges as the oldest kind of leader of all: the tribal chieftain. When things become this elementary, the difference between developing and so-called advanced democracies can well melt away. True, the latter have stronger institutions and norms and a more educated electorate. In normal circumstances, that may be enough to resist. Some argue it will remain enough. Yet, we are human. Humans adore charismatic despots; they always have.

Theranos details explained: the "inventor" that fooled so many smart people

The Inventor: Out for Blood in Silicon Valley (2019)

Former posts have explained the story, now a 2h. HBO documentary adds details:

On the effectiveness of digital health technologies

EVIDENCE STANDARDS FRAMEWORK FOR DIGITAL HEALTH TECHNOLOGIES

Every other day we here about a new health app, and new digital advances in healthcare. Too often, any innovation is considered effective without any deep analysis. Now, NICE provides a guide for this specific issue.

The economic impact of a DHT can be assessed using an appropriate analysis of the economic information collected. The type of economic analysis done should be determined by the financial consequences of adopting and implementing the DHT from a payer or commissioner perspective. The appropriate level of economic analysis depends on the type of decision needed and likely financial commitment. To reflect the range of commissioning decisions associated with DHTs, we have proposed 3 levels of economic analysis (see table 8).
Many DHTs will start at a basic economic analysis level but, with additional information and data about the technology and its comparators, a more robust economic analysis can be undertaken. The higher levels of economic analysis needed depends on the financial commitment required including, for example, the level of upfront investment, the likelihood of opportunity costs and the certainty of the realisation of the benefits.

Foto Colectania

AI in Global Health, a framework

Artificial Intelligence in Global Health

AI in healthcare, a podcast

How A.I. Is Humanizing Healthcare with Dr. Eric Topol


Can A.I. and machine learning make healthcare more humane, loving, and passionate?

Dr. Eric Topol thinks so.

Dr. Topol (Website | Twitter) is a geneticist, medical researcher, and author of Deep Medicine. He has written over 1100 peer-reviewed articles and is one of the top most-cited medical researchers in the world.

In this episode, Chad sits down with Dr. Topol to talk about how A.I. and machine learning are putting the patient experience back at the forefront of healthcare. Dr. Topol also explains why you don’t actually own your own medical data and what steps we need to take to get it back.

A lifetime fair drug pricing system

When Is The Price Of A Drug Unjust? The Average Lifetime Earnings Standard

Is there any measure for unfair pricing in drugs?. According to Ezequiel Emanuel prices should not

"exceed 11 percent of the average American’s disposable income. This suggests that current prices for many drugs are excessive and unjust."

Why?.

Currently, average lifetime costs for health care are estimated at 31 percent of disposable income. Drugs account for 17 percent of health care expenses. A threshold for medical care as a share of disposable income that is set 10 percentage points higher than the current average amount spent on medical care (at 41 percent, or $261,907) is generous, as is a threshold for drug costs as a share of medical costs set 10 percentage points higher (at 27 percent, or $70,715) than the current share. Using these standards, the costs for all of the drugs a person takes in a lifetime should not consume more than 27 percent of medical costs, or $70,715. This constitutes 11 percent of lifetime disposable income.

He achieves this conclusion after applying these principles:

1. Complete life. The unit of analysis should not be a year or other limited time frame, but rather the impact over a whole lifetime
2. Limited resources. The just price of a drug should reserve enough resources for people to pursue valuable life activities
3. Value. There should exist a close relationship between the actual benefits of an intervention and its price
4.  Comprehensiveness. Life activities other than health matter; in considering the benefits of a treatment, we should also consider how it affects education, employment, and other valuable life activities

This article represents a deep change of perspective on drug pricing. Cost-effectiveness of individual drugs are not enough, a lifetime and societal perspective is necessary. I agree in this part, however methodological implications are huge and uncertain.

Bonnard at Tate modern right now

Personal Health Data Cooperatives

Personal Data Cooperatives – A New Data Governance Framework for Data Donation and Precision Health
The Ethics of Medical Data Donation

Given that personal data can be copied, individuals are entitled to copies of their data and individuals are the ultimate aggregators of all their personal data, citizens are elevated to new roles at the center of health research and a novel personal data economy. There, citizens, not some multinational company, control the use of and benefit from the intellectual and economic value of these data.

In a chapter of the book you'll find a description of MIDATA cooperative, a swiss case. My impression is that this is the appropriate approach. A closer initiative is SalusCoop. However, as happens in any public good, its governance is always the foremost issue.

Biotech boom 2018

Top drugs and companies

From NRD

From Nature NRD

Bioethics landscape