Tag Archives: treatment

How to Address Eating Disorders at Work

In America, 30 million people will struggle with an eating disorder at some point in their life. With statistics this high, it is likely that someone you know, or perhaps even you, has struggled with this mental health issue. Family members, friends and even coworkers can struggle with anorexia, bulimia and binge eating disorder. Despite their prevalence, eating disorders are treatable. It is important to know the signs and symptoms as well as what to do if someone you know is at risk—especially in the workplace.

Our workplaces are often a source of stress. Deadlines, long hours and strained relationships can leave us feeling tired and vulnerable. When we feel down, we can be more susceptible to mental illness, including eating disorders, and stressful times can exacerbate existing conditions. With eating disorders, as with most illnesses, early intervention is important.

Businesses are in an excellent position to help employees who may be struggling with an eating disorder. Wellness programs can help raise awareness and encourage treatment. And anonymous screening programs can be an effective way to assist employees.

Anonymous and confidential mental health screenings are designed to help individuals examine any thoughts or behaviors that may be associated with eating disorders. After completing the self-assessment, users are provided with helpful resources and treatment information, if necessary. Although the screenings are not diagnostic, they will determine if someone is exhibiting symptoms associated with an eating disorder and if that someone should seek help.

Some common eating disorder signs and symptoms include:

  • Frequent comments about feeling “fat” or overweight
  • In general, behaviors and attitudes indicating that weight loss, dieting and the control of food are becoming primary concerns
  • Skipping meals or taking small portions of food at regular meals
  • Hiding body with baggy clothes
  • Evidence of binge eating, including disappearance of large amounts of food in short periods or lots of wrappers and containers indicating consumption of large amounts of food
  • Maintaining an excessive, rigid exercise regimen—despite weather, fatigue, illness or injury—because of the need to “burn off” calories
  • Drinking excessive amounts of water or using excessive amounts of mouthwash, mints and gum

If you are concerned that a coworker may have an eating disorder, there are things you can do to help. Rather than focus on issues related to their physical appearance, let your coworker know you have noticed a change in their behavior. Perhaps the quality of their work has suffered or their mood has changed. Let them know that you care and offer helpful resources. If your workplace offers a wellness or screening program, share that information. Anonymous eating disorder screenings are always available at MyBodyScreening.org. Be sure to follow-up with the coworker to see how they are doing. Support systems are important as they work toward recovery.

The National Action Alliance for Suicide Prevention is a public-private partnership advancing the National Strategy for Suicide Prevention, put forward by the U.S. surgeon general. The alliance supports mental health and suicide prevention programs in the workplace and endorses mental health screenings as part of those programs. Screenings can make a difference in mental health and suicide prevention.

As millions of adults struggle with eating disorders, workplaces can make an impact by spreading awareness, offering screenings and encouraging treatment. It is in the best interest of an employer to help workers stay healthy and productive. Wellness and screening programs are a proven way to do this.

Why Healthcare Costs Soar (Part 2)

This is the second of a two-part series, by David Toomey and me, on why healthcare cost growth has historically been much higher that general inflation. 

In the last blog post, we outlined the complexity of the network negotiation process and the challenging dynamics among the insurance companies, the providers and the employers. The majority of employers have not seen financial data or interacted with providers enough to understand the quality and cost variation within a network. The big question looming is what to do around contract negotiations tied to network access, patient disruption and costs.

David invited a half-dozen large, self-insured employers in a market to delve deeper into the clinical care and cost variation analysis. The intent was to share performance data with the employers, so they could understand the positive financial impact that could come from channeling members to higher-value providers.

Reports showed that, within physician groups, there was wide variation in physician performance. But this took time for the employers to grasp because their businesses were focused on a consistent consumer experience—each cup of coffee made the same way with the same ingredients.

After a basic grounding in the data, the next step was to have the employers meet with the largest systems and physician groups, so the companies could get a sense of these suppliers’ value propositions beyond just claims-based performance reports. The employers felt they were ready for the first meetings with a major health system that we will call “the provider,” which outlined its capabilities and introduced its mission statement as well as its commitment to patients.

After the overview, the first employer question was, “Who is your customer?” The provider’s response: “The patient, of course.” Second employer question: “Who pays the bill?” The pr

Breaking the Silence on Mental Health

Shh, it’s time for another round of “let’s discuss depression or suicide in the workplace.” That’s right, shh. After all, we aren’t supposed to discuss these issues. If we do, someone else may try to commit suicide. If we hush up the problem, maybe it will go away.

So, help me to understand why we tolerate this silence with mental illness and not with any other medical condition. I think it is because mental health is a bit more mysterious and scarier than most other conditions.

But mental health does account for a large percentage of the costs related to lost productivity ($51 billion). It generates direct costs of treatment of $26 billion a year[1] — and “absence, disability and lost productivity related to mental illness cost employers more than four times the cost of employee medical treatment.”[2]

We need to get over our fear and get the discussions out in the open. Only then will we have a chance to break the cycle.

The goal of breaking the silence is already occurring on the high school level and is showing results. I realize that this is a different population, teen-agers, but talking about it really does matter in prevention. This most recently occurred in a high school in Crystal Lake, Ill., after two teen-age friends took their lives. The school and community leaders made a point of getting information to other students about the warning signs so that they could possibly identify those in danger and encouraged parents to talk with their teens about their grief. Leaders also provided grief counselors onsite and gave the students different options for grieving, which included holding vigils, providing groups and allowing for other forums of expression.

This is an excellent model that can be adapted for the workplace in partnership with your employee assistance program (EAP). Here are some things employers can do for their workplaces after a suicide:

  • Openly discuss suicide and offer grief groups to anyone directly or indirectly involved with the people who took their lives. Make it okay to talk about the suicide. For more information on steps employers might take, go to “A Manager’s Guide to Suicide Postvention in the Workplace.”
  • Provide information about the warning signs so that employees can help identify others who might be at risk. Make sure that employees and their family members get information about resources that they can access for themselves, their family members or other co-workers. And stress the confidential nature of these sources. A great first step is the National Suicide Prevention Lifeline (800-273-TALK (8255)).

The best defense, however, is a good offense. To encourage prevention, I suggest the following:

  • Create a “mental health/wellness” friendly workplace that involves openly discussing mental health and stress and making sure that employees know that there is confidential help available.
  • Provide employees and managers with training on signs of depression, anxiety, etc. and encourage them to seek help if they or a colleague is showing any of these signs.
  • Have your EAP visible through consistent promotional efforts using print, email and social media.
  • Make sure that the company’s benefits plans have good mental health coverage.

I have been lucky enough to have spent the last 36 years in the field helping individuals and organizations become more open to dealing with psychological issues that may interfere with their professional or personal growth. And I have been amazed at how successful treatment can be when the issue is confronted head-on.

As leaders in the insurance industry, those of you who subscribe to this blog are trusted advisers to the leadership and decision makers in organizations of all kinds. I therefore implore you to use these relationships to encourage them to face mental health in an open and forthright manner. Only when people are able to openly seek out help for mental health related concerns in the same manner that they seek out medical treatment for other issues will we be successful.

[1] Managed Care Magazine (2006, Spring) Depression in the Workplace Cost Employers Billions Each Year: Employers Take Lead in Fighting Depression.

[2] Partnership for Workplace Mental Health, A Mentally Healthy Workforce—It’s Good for Business, (2006), www.workplacementalhealth.org.

Screening: More Does NOT Equal Better

In an important op-ed piece in the New York Times, “An Epidemic of Thyroid Cancer?”, Dr. H. Gilbert Welch from Dartmouth University wrote that he and his team of researchers found that the rate of thyroid cancer in South Korea has increased 15-fold!

15X! How can this be?!

Were South Koreans exposed to massive amounts of radiation? Did South Koreans start using some dangerous skin product?

No. And no.

South Korean doctors and the South Korean government encouraged increased cancer screening. More screening must be better, right?

No. Not at all…

This is an important concept for employee benefits professionals to understand: More screening is not necessarily better.

What happened in South Korea is that the thyroid cancer had been there all along, just undetected. The most common type of thyroid cancer — papillary thyroid cancer — is usually very slow-growing, and people with this cancer never know it is there. It does not affect their health, and it does not kill them. According to the article, it is estimated that 1/3 of ALL ADULTS have thyroid cancer.

Thyroid cancer screening is performed by an ultrasound of the neck. It is an un-invasive, painless, fairly simple test. So what happened in South Korea was not an epidemic of thyroid cancer but, as the article puts it, “an epidemic of diagnosis.”

There is potential harm in treating a cancer that will likely not cause you any problems. Two out of every 1,000 thyroid surgeries result in death. Removal of the thyroid means a person will have to take thyroid replacement medication for the rest of her life. This medication can be hard to adjust, leading to problems with metabolism, such as weight gain or low energy.

In the U.S., there are many screenings that the U.S. Preventive Services Task Force has deemed “unproven” for application across entire populations of asymptomatic individuals. For example:

  • Screening the skin for skin cancer
  • Screening the carotid arteries (neck blood vessels) for narrowing

It is important to address the converse. Increased screening that has been shown to reduce morbidity and mortality is a good thing. Screening for high blood pressure is a good thing. Screening for diabetes is a good thing. Screening for certain types of cancers is a good thing.

What does this mean for the employee benefits professionals and the healthcare consumer?

  • Beware of “blanket” statements that more screening is better or of companies that are offering screenings that are not vetted.
  • Know that screening can actually cause harm because of side effects or complications of treatment for a “disease” that is really not a problem.
  • As you set up prevention programs for your employees, ensure that those programs are based on scientific evidence.

When Is It Right to Prescribe Opioids?

Opioids have been used for thousands of years in the treatment of pain and mental illness. Essentially everyone believes that opioids are powerful pain relievers. However, recent studies have shown that taking acetaminophen and ibuprofen together is actually more effective in treating pain. Because of this, it is helpful for medical professionals and patients to understand the history of these opioid medications and the potential benefits of using nonsteroidal anti-inflammatory drugs (NSAIDs) instead.

Extracted from the seedpod of the poppy plant, opium was the first opioid compound used for medicinal purposes. The active ingredients of opium are primarily morphine, codeine and thebaine. Opium and its derivatives have had more impact on human society than any other medication. Wars have been fought and countless lives have been lost to the misuse, abuse and overdose of opioids. It is also clear, however, that many received comfort from pain when there was no other alternative. For thousands of years, opium products provided the only effective treatment of pain and were also used to treat anxiety and depression. Tolerance, dependence and addiction were identified early as a problem with opioids.

In 1899, Bayer produced and introduced aspirin for wide distribution. It became the first significant alternative to opioids for treating pain. Aspirin not only relieves pain but also reduces inflammation and is in the class of NSAID medications. Aspirin was commonly used for mild pain such as headache and backache. Other NSAID medications followed with the development of ibuprofen in 1961, indomethacin in 1963 and many others over the next 20 years. While these drugs are not addictive or habit-forming, their use and effectiveness were limited by side effects and toxicity. All NSAID medications share some of the same side effects of aspirin, primarily the risk of gastrointestinal irritation and ulcer. These medications can also harm renal function.

Acetaminophen was created in 1951 but not widely distributed until 1955 under the trade name Tylenol. Acetaminophen is neither an opioid nor an NSAID. Tylenol soon became another medication that was useful in the treatment of pain, offering an alternative to the opioid medications and to aspirin. Acetaminophen avoids many of the side effects of opioids and NSAIDs b­ut carries its own risk with liver toxicity.

Efficacy in acute pain

Since the development of acetaminophen, medical professionals have had the choice of three different classes of medications when treating pain. Those decisions are usually made by considering the perceived effectiveness of each medicine and its side effects along with the physical status of the patient. For example, acetaminophen should not be taken by someone with advanced liver damage; NSAIDs should not be given to an individual with advanced kidney disease or stomach ulcers; and opioids pose a potential risk to anyone with a personal or family history of addiction.

Although many have long been believed that opioids are the strongest pain medications and should be used for more severe pain, scientific literature does not support that belief. There are many other treatments that should be utilized for treating pain. Studies have shown NSAIDs are just as strong as the opioids.

Number needed to treat

When considering the effectiveness or the strength of pain medications, it is important to understand one of the statistical measures used in clinical studies: the number needed to treat (NNT). NNT is the number of people who must be treated by a specific intervention for one person to receive a certain effect. For example, when testing pain medications, the intervention is the dose of pain medication, and the effect is usually 50% pain relief. That is considered effective treatment, allowing people increased functional abilities and an improved quality of life (Cochrane. org, 2014). So the question becomes, how many people must be treated with a certain dose of a medication for one person to receive 50% pain relief (effective relief)?

A lower NNT means the medicine is more effective. A product with an NNT of 1 means that the medicine is 100% effective at reducing pain by 50% — everyone who takes the medicine has effective pain relief. A medicine with an NNT of 2 means two people must be treated for one to receive effective relief. Or, alternatively, one out of two, or 50%, of people who take the medicine get effective pain relief. An example of a medicine that would not be a good pain reliever would be one with a NNT equal to 10. In such a case, you would have to treat 10 people for one to receive effective pain relief. Basically, the medication with the lowest NNT will be the most effective. For oral pain medications, an NNT of 1.5 is very good, and an NNT of 2.5 would be considered good.

Treating chronic pain

Despite the widespread use of opioid medications to treat chronic pain, there is no significant evidence to support this practice. A recent article reviewing the evidence regarding the use of opioids to treat chronic non-cancer pain concluded, “There is no high-quality evidence on the efficacy of long-term opioid treatment of chronic nonmalignant pain.” (Kissin, 2013, p. 519) A recent Cochrane review comparing opioids with placebo in the treatment of low back pain came to a similar conclusion. This review said that there may be some benefit over placebo when used for short-term treatment, but no evidence shows that opioids are helpful when used for longer than four months. There is no evidence of benefit over non-opioid medications when used for less than four months. (Chaparro et al., 2014)

Several other reviews have also concluded that no evidence exists to support long-term use – longer than four months – of opioids to treat chronic pain. (Kissin, 2013; Martell et al., 2007; McNicol, Midbari, & Eisenberg, 2013; Noble et al., 2010)

Epidemiologic studies have also failed to confirm the efficacy of chronic opioid therapy (COT) for chronic non-cancer pain. A large study from Denmark showed that those with chronic pain who were on COT had higher levels of pain, had poorer quality of life and were less functional than those with chronic pain who were not on COT. (Eriksen, Sj.gren, Bruera, Ekholm, & Rasmussen, 2006)

In the last 20 years in the U.S., we have increased our consumption of opioids by more than 600%. (Paulozzi & Baldwin, 2012) Despite this increase, we have not decreased our suffering from pain. The Burden of Disease study in the Journal of the American Medical Association (JAMA) showed that Americans suffered as much disability from back and neck pain in 2010 as they did in 1990 before the escalation in the prescribing of opioids. (Murray, 2013) A study in JAMA in 2008 found, “Despite rapidly increasing medical expenditures from 1997 to 2005, there was no improvement over this period in self-assessed health status, functional disability, work limitations or social functioning among respondents with spine problems.” (Martin et al., 2008, p. 661)

It is currently estimated that more than 9 million Americans use COT for the treatment of chronic nonmalignant pain (Boudreau et al., 2009). When we consider the proven benefits of this treatment along with the known risks, we must ask ourselves how we can ethically continue this treatment.

The reality is we really don’t know if COT is effective. Anecdotal evidence and expert opinion suggest it may be beneficial in a few, select people. However, epidemiologic studies suggest that it may be doing more harm than good.

Terminal care

The treatment of incurable cancer, end-stage lung disease and other end-of-life situations are notable examples where opioid medications are absolutely indicated. Although opioid painkillers are not very good medications for the treatment of pain, they are very strong psychotherapeutic agents. They are excellent at relieving anxiety and treating depression for a limited time. Opioids cause beneficial changes to brain serotonin, epinephrine, norepinephrine, dopamine and endorphins. For short-term, end-of-life situations, these neuropsychiatric effects are likely beneficial. For terminal care, opioids are the medications of choice.

Conclusion

The opioid medications are often referred to as “powerful painkillers.” In fact, the evidence shows that they are mild to moderate painkillers and less effective than over-the-counter ibuprofen. They have, however, powerful side effects that harm hundreds of thousands of individuals every year in the U.S. Even if one disregards the public health problems created by the use of opioid painkillers, these medications still are not a good choice for the treatment of acute pain — regardless of the severity. In some situations, limited use is appropriate. But in the majority of situations in which opioid painkillers are used today, they are not appropriate.

The standard of care in the practice of medicine today is to provide the best treatment that causes the least harm. When there is a treatment that is proven to be both more effective and safer, it is the treatment of choice. The implication of this data for policymakers is critical. By implementing policy that puts restrictions on opioid prescribing to protect public health, policymakers will also improve the treatment of pain by guiding prescribers to use medications that are more effective. It is also important for the medical and dental communities to address this inadequate and unsafe treatment of pain and change practice standards to guide care that is more appropriate for what our patients need and deserve.

This is an excerpt from a paper that can be downloaded in its entirety from the National Safety Council.