Perianal Disease: Not Everything is a Hemorrhoid (Cortez, 11/20/2024)

 https://youtu.be/Eh-q0sfjm5k

Vaping: Medicine or Menace (Ling, 11/13/2024)

 A recording of this presentation is available HERE.

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This was a mind-blowing and practice-changing Grand Rounds this week -- so much to learn and understand about vaping (aka e-cigarettes) as primary care providers. The speaker, Dr. Pamela Ling, is the Director of the UCSF Center for Tobacco Research and Education, and she shared so much valuable data and on-the-ground information about the current state of vaping. The title of her talk was Vaping: Medicine or Menace?

Here's what I learned:

First off, the vaping industry is rapidly evolving. Unfortunately, the science, while forthcoming, lags behind an agile and sneaky industry. The first e-cigarettes came on the market in 2009 and looked like little "fake cigarettes" (they even featured a puff of smoke). Now, vapes come in a shapes and sizes and with increasingly concentrated (and flavored) solutions and changing delivery devices. 

E-cigarettes create an aerosol by using a battery to heat up liquid that usually contains nicotine, flavoring, and other additives. Users inhale this aerosol into their lungs. E-cigs can also be used to deliver cannabinoids, such as marijuana and other drugs. 

OMG check this out! These are vaping products confiscated from high schools in California and North Carolina (1000 products from 25 high schools) from an MMWR publication.

While cigarette smoking levels are down in California (and SoCO), vaping is on the rise, and the youngest have the highest rates.

In fact, SoCo teens seem to have higher rates of vaping than California teens overall.

And, unsurprisingly for those of us who care for marginalized populations, more vulnerable kids (based on gender identity, race, etc) have even higher rates of e-cigarette use

Note that while Sonoma County average of e-cigarette use is 12%, certain groups have MUCH higher rates, namely: SoCo gender questioning kids and kids who identify as black/African American, and Native American.

In addition to vaping nicotine, cannabis is increasingly popular; almost as many people use cannabis as tobacco now in the US. And while smoking is still the most common way to consume cannabis, edibles and vaping are both increasing.

Of note, older generation vapes contained far LESS nicotine. Newer vapes include chemicals that make higher concentrations more palatable and more appealing. As you can see in the image below, whereas older versions (The JUUL) contained the equivalent of about 1 pack of cigarettes, newer versions (e.g. Flum pebble) now contain up to 30 packs of cigarettes. This leads to increased nicotine consumption and dependence. And because of price controls and taxation cigarettes, vaping can save money, which certainly also influence habits and behaviors. Whereas a carton of cigarettes may cost upward of $50-85, a single vape (the equivalent of 3 cartons) costs less than $20 online. 

The same is true for rising THC concentrations in cannabis vapes. 

Do E-cigarettes help people quit smoking?

It is important to understand that there is SOME evidence of the use of e-cigarettes to promote smoking cessation, though the evidence is weak at best. E cigarettes are not approved by the FDA for smoking cessation, though they are recommended by the UK NHS due to this evidence. Under RCT conditions, earlier generations of vape products have been shown to be more effective than nicotine replacement therapy. You can see this data below summarized in the Cochrane review below. 

This has not borne out in population level observational studies-- in other words, when used as a consumer product, e-cigarettes do not help with cessation. Also important to note that the e-cig market is evolving extremely rapidly and the products are increasingly appealing to young people (this is not a coincidence).

Isn't vaping better for us than smoking?

Stella Tomassi and colleagues published a study of young adult vapers who never smoked compared to smokers using quantitative PCR to detect DNA damage (as a marker for future cancer).  They found a dose-dependent formation of DNA damage in oral cells of vapers who had never smoked tobacco cigarettes as well as exclusive cigarette smokers. They also found more damage seen in heavier users, users of pod vapes and sweet flavors) independent of nicotine levels.  

Recent studies of the epigenetic effects of tobacco smoking and e-cigarette use found similar changes in DNA methylation among people using cigarettes and people using e-cigarettes, changes that were associated with lung carcinogenesis.

While we do not have direct human data on vaping and lung cancer outcomes, these newer biomarkers of DNA damage and epigenetic changes are likely to be informative for lung cancer risk.

When people switch completely from cigarettes to e-cigs, there is definitely a decline in those biomarkers. So maybe vaping IS better than cigarette smoking. Unfortunately, many people try to convert to vaping but then continue intermittently also smoking cigarettes. Interestingly, the evidence shows that these "dual users" do not reduce their exposures to carcinogens.  

In terms of cardiovascular disease: a recent study published in NEJM 2024 found that CV disease risk from vaping was NO different than CV disease risk from smoking. So for CV risk the answer is NO.

But here's perhaps one of the most important take home points: dual use (using BOTH vapes and cigarettes) is definitely the worst for patients. Check out this summary table below showing the risk of disease appears higher for dual users. . .

Dr. Ling's closing advice to clinicians:

• Ask about vaping to engage in a cessation conversation
• Ask about both nicotine and cannabis vaping
• Encourage to treat nicotine vapes like any tobacco product
• Encourage complete switching not dual use
• Longer term transition off vaping products (using nicotine-replacement)

Ariel Thomas-Urlik, MPH from the Sonoma County Department of Public Health, who helped make this presentation possible, also shared some local information about local laws aimed at preventing widespread sales of nicotine products to children and adults.  

Did you know that SoCo has a minimum price of $10/pack for cigarettes? No coupons or discounts are allowed to be applied. 

Also California law currently prevents flavored tobacco products from being sold in physical retail stores, and a new law going into effect this week prohibits County of Sonoma do NOT ALL e-cigarette sales in physical retailers that sell tobacco (cannabis dispensary do not apply). While retailers continue to sell, DPH is using volunteer decoys to catch retailers who are violating this law. There is less access in SoCo, and we know that when access goes down, people become more interested in quitting. 

A new state law CA AB3218 which goes into effect on January 1, 2025 makes online purchase of vapes illegal in the state of California!

Methadone in Hospitalized Patients (Bowen & Aguilar 11/6/2025)

 A recording of this presentation is available HERE. 

Deep gratitude for our two Addiction Medicine Fellows, Drs. Bianka Aguilar and Anna Bowen, for an important and concrete presentation this week on Methadone in Hospitalized patients. They will be back in the spring with another Addiction Medicine presentation!

Here are my favorite pearls:

1) Starting methadone in the hospital decreases self-directed (AMA) discharges (30% vs. 59.6%), reduces all-cause readmission rates (27% vs. 41%), and decreases risk of endocarditis, osteomyelitis, and septic arthritis. I was taught that we should be "cautious" in the hospital about starting methadone if there wasn't a long-term plan for follow-up, but this is no longer true. If a patient is motivated to start methadone and it is indicated, we should do it. There are many new algorithms that can cross taper people easily from methadone to buprenorphine IF they are unable to get methadone through an outpatient treatment center.

2) Fentanyl in our drug supply has changed the treatment of opioid use disorder (OUD).  Recent studies are showing the methadone may be superior to buprenorphine in terms of treating OUD in fentanyl users. Methadone for OUD also appears to have higher retention rates. 

3) Traditional methadone induction involved weeks of up titrating doses until methadone was at therapeutic levels; newer studies, particularly in the fentanyl era, have found that quick starts--  higher starting doses, 30-40mg on D#1, and quicker up-titrating, increasing by 10-15mg, per day is safe and effective.

4) While methadone is known to lengthen the QT interval, not everyone on methadone needs serial or even baseline EKG monitoring. Most guidelines recommend an EKG at initiation of methadone only for patients with other cardiac risk factors (e.g. known prolonged QT, CAD, CHF, etc.)  AND once methadone doses near 100mg daily. This is a dose response side effect. We should remember to look at other medications that can also prolong QTc to see if those can be altered/discontinued. A QTc of >500 is not an absolute contraindication to treating with methadone, but the clinical scenario merits review (e.g. medication review)

4) Some people are "rapid metabolizers", meaning that single daily dose of methadone may be insufficient to help with cravings and treat their opiate use disorder. This is known to be true in pregnancy, but can also occur in some patients. Rapid metabolizing most often manifest as someone who appears appropriately treated by a certain methadone dose by 2-4 hours after their dose (maybe even a little sedated), but then 12 hours later is experiencing s/sx of withdrawal or cravings. We can potentially help their case to receive methadone BID by checking "peak" (2-4 hours after the dose) and "trough" (right BEFORE their dose) serum level of methadone.

Practical tips for methadone in hospitalized patients:

• Consult the addiction medicine fellows (on call schedule on Epic)
• Document a 1 year history of OUD
• Use the COWS score to monitor s/sx of withdrawal
• We have 2 Methadone clinics in Santa Rosa: DAAC and SRTP. When initiating methadone, contact one of these clinics ASAP to arrange intake.
• There is a federal 3 day exception for patients being discharged from the hospital, to whom we can prescribe methadone. Current local help is available via Creekside Pharmacy vs. SSRRH ER.
• Offer all patients naloxone on discharge. 
• Use the California Bridge website for help, including guidelines and algorithms.
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• Keep your eye out for newer studies showing quick start algorithms

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  Toronto Perinatal Addiction Medicine Team
  
  

  
  
  

Integrative Approach to Anxiety and Depression (Brown, 10/30/2024)

A recording of this presentation is available HERE.

Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this week on Integrative Approach to Anxiety and Depression. Anyone in primary care knows that we do a lot of management of psychiatric disorders in the primary care setting, often with very little specialty support. Many patients are interested in pursuing not just standard medical therapy (SSRI + cognitive behavioral therapy), but also integrative modalities.

Dr. Brown laid out the evidence for a wide range of non-pharmaceutical and non-psychotherapy treatments for anxiety and depression. The bottom line is that there are many, many, many integrative options with a range of small to moderate to strong evidence for the management of anxiety/depression. Put your seatbelts on. And don't use too many at once!

Integrative modalities, for the purpose of this talk include 

• lifestyle/behavioral 
• nutrition 
• supplements and 
• physical practices

Lifestyle/behavioral

Exercise works! The USPSTF recommends 2.5 hours/week of aerobic exercise for overall improved health. And good news, exercise can improved depression!  Some exercise modalities may be better than others, including: include walking/jogging/yoga/strength training. The more "intense" the better. However, in a 2023 review article, ANY regular exercise, regardless of type, setting, or supervision decreased depression scores by 5-7 points. 

There is not much evidence for exercise in anxiety, with a different review paper finding a benefit of exercise for anxiety in 7 of 25 studies and no benefit in the remaining 18.

It should come as no surprise that substance use and substance use disorders are frequent comorbidities with anxiety and depression. Note in the chart below:

• 16% of people with anxiety disorder also have SUD
• 16% of people with an adjustment disorder also have SUD
• 16% of people with depression also have SUD

Nicotine and tobacco, alcohol, and yes, even marijuana>>worsen anxiety

Sleep and anxiety/depression, as we know, have a bidirectional relationship. Treating the underlying cause of sleep helps (e.g. sleep disordered breathing). If you target insomnia, you improve mental health.

Social support helps too. Social support and connectedness -- perhaps even via online platforms-- helps depression and anxiety, even in people with a diagnosed social anxiety disorder!

Time spent in the natural world, including activities like "forest bathing", nature-based treatment, gardening, wilderness time, outdoor adventuring all have a positive effect on mood and anxiety. Many of the studies looking at time in nature are Korean studies, and plenty show positive effect, which is durable (at least up to 12 weeks after the outdoor time). One study even found that LOOKING at images of nature had a positive impact on mood. 

Nutrition 

Eating a healthy diet improves depression and anxiety! And there are plenty of different healthy diets that have been shown to improve mood in a 2021 Systematic Review: a diet high in fruits/veggies, a diet with less calories, a diet high in omega-3 fatty acids, probiotics, a diet rich in dietary minerals, and a ketogenic diet. Even eating breakfast works!

What doesn't work? An unhealthy diet: insufficient protein, high fat, lots of carbs/sugars, and a diet low in tryptophan (which is found in protein-rich foods, not just turkey).

Supplements

Many many botanicals are used to treat symptoms of depression anxiety. Four that Dr. Brown highlighted with moderate/strong evidence for positive effect are:

• Kava Kava (Piper methysticum): 50-70mg TID, mixed evidence, some concern for hepatoxicity
• St. John's Wort (Hypericum perforatum): strong evidence in depression, 500-1800mg/day. A 2017 Meta-analysis found it to be equivalent to SSRIs (of note, not safe to take at same time as SSRIs)
• Saffron (Crocus sativus): 30-200mg/day, strong evidence for depression and anxiety, $$ cost can be an issue, also concerns regarding first trimester SAB in early pregnancy
• Lavender (Lavandula angustifolia): "a few drops", moderate evidence, compared to lorazepam in a trial of preoperative patients was found to be "equivalent". SE: gynecomastia
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Probiotics: studies show a small but consistent positive effect in depression/anxiety (not enough to be used as monotherapy, but consider for adjunct)

Vitamin Supplements

Dr. Brown highlighted five vitamins with some efficacy in depression/anxiety:

• Vitamin D: stronger evidence in depression (than anxiety)
• B Complex, found in dark/green/leafy veggies, may be good adjunct
• Zinc: dose response benefit in depression and anxiety
• Magnesium: strong evidence as either monotherapy OR adjunct, depression more than anxiety, change of 4 points on GAD7 or PHQ9, so may be good choice for mild-mod depression/anxiety

Physical Practices

Dr. Brown finished up his presentation talking about a range of physical practices that, again, have some evidence for treatment of depression and/or anxiety, specifically:

• Acupuncture: 2024 Meta-analysis found that acupuncture was BETTER than SSRIs for depression, particularly if electro-acupuncture techniques are used. Most studies indicate that a combination of SSRI and acupuncture decreases rates of remission. There is less evidence for acupuncture in anxiety.
• Acupressure: no evidence for durable benefit, but may be good for episodic symptoms (and can be self-done)
• Progressive Muscle Relaxation: strong evidence in pre-procedural anxiety and symptoms report for patients. There are a wide range of muscle relaxation techniques, many can be taught in just a few minutes in the office setting
• Breathwork: Once again, there are many different breath practices. Two easy ones to teach in the office are: Box, 4-7-8 (see images below). Both have been shown to help with symptom management

Finally, do Apps work? Apps tend to be cheap and easy for patients to get, particularly in a low resource. According to Dr. Brown. There have been 50+ studies, including an RCT, looking at apps for physical practice changers, and they have shown a significant but small/moderate effect on depression/anxiety. So consider apps an option too!

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• Wang R, Xu F, Xia X, Xiong A, Dai D, Ling Y, Sun R, Qiu L, Ding Y, Xie Z. The effect of vitamin D supplementation on primary depression: A meta-analysis. J Affect Disord. 2024 Jan 1;344:653-661. doi: 10.1016/j.jad.2023.10.021. Epub 2023 Oct 16. PMID: 37852593.

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Hospital Medicine Update 2024 (Jordan, 10/23/24)

 A recording of this presentation is available HERE. 

Check back for a written summary!

Farmworkers’ experiences working during wildfires and impacts on health (Hyland and Gordon, 10/16/24)

This week, in commemoration of the 2017 Tubbs Fire, which destroyed over 5,000 homes in Santa Rosa, we had a really special presentation by two researchers from the Berkeley School of Public Health and Berkeley Law School on the impact of the Ag Pass program and wildfire smoke on Sonoma County farm worker health.  

If you can, please watch their presentation. A recording is available HERE.

It was both fascinating and disturbing to hear two researchers talk about the place we live and practice medicine-- and where thousands of vulnerable farm workers face dangers from our local policies during fire season.

• AB1103: California law that established a "Livestock pass" in 2021, work authorization program, allowing workers back into evacuation zones during natural disasters
• Counties have interpreted this law as permitting them to allow workers into evacuation zones
• Unfortunately, no occupational health analysis (by Cal-OSHA) was done in the passing of this law
• From 2017-2022, such passes were handed out in an Ad-Hoc manner by the Ag Commissioner, often based on personal contacts and phone calls

In 2022, the Sonoma County Board of Supervisors (BOS) passed their own version of the Ag Pass, which allows farmworkers back into an evacuation zones for "critical activities". The SoCo Sheriff decides when Ag Pass is activated.

In 2023, the local law was amended to include "grape harvest" as a "critical activity"

SoCo Ag Pass has three components:

1) Fire safety training (4 hours, no smoke or other exposure training required)

2) Apply through the SoCo Ag Commissioner

3) Go to the SoCo Sheriff's office to obtain the Ag Pass card

(this requires photo identification, address, phone number)

***

We have data from Sonoma County on the health impacts of wildfires on local health: 

• 25% increase in ED visits for respiratory symptoms
• 33% increase in hospitalizations for respiratory illnesses
• 18.7% increase in asthma prescriptions
• Disparities based on race and SES

This project was a collaboration between the Human Rights Center and Berkeley Public Health. Goal to examine health, physical safety, economic security, and data privacy

Law and policy analysis, health survey with overall goals to provide recommendations to Sonoma County and the State of California to improve health and safety of farm workers working in fire evacuation zones. 

Recruited local farm workers and trusted figures

Recruited farm workers: gain understanding of AgPass, their experience working previously in fire conditions (and symptoms), what information they need if they are working in wildfire conditions again, economic concerns related to wildfires.

1000+ workers from all over the county, 60% male, ~41 median age, 13 years on average experience working in agriculture

Experiences working during wildfires:

• 75% reported having worked during wildfire
• 64% received some protective equipment from employer
• many had to reuse
• many given surgical mask (rather than N95)
• 70% reported short term health impacts
• 36% who had health impacts indicated they lingered over time
• Mental health impacts

Barriers to accessing health care

• >50% reported no health insurance
• 39% difficult to get appointment at clinic (hours, days open, etc)

Gaps seen in the Ag Pass program as it relates specifically to health: 1) No consideration of short or long-term health effects to workers when Sheriff activates Ag Pass 2) Lack of criteria when Ag Pass can be activated (e.g. AQI level) 3) No health monitoring during/after wildfire events

Very real tension in this population between health and economic security. At baseline 75% are spending 50-75% of monthly income on rent (recommendation is 33%). If there is fire/flood/extreme heat, and farm workers cannot work and do not get paid, they cannot make their basic needs. Even though people are worried about health impacts of wildfire, even more are worried about financial impacts. 58% continued to work despite feeling sick because they needed income and were worried to lose the job. 

Most farm workers are most worried about paying for rent, groceries, gas, medicine/healthcare

Physical Safety Results

• There is no process to communicate with individuals who are reentering an evacuation zone.
• Currently employers are responsible to ensure workers leave in time
• The sheriff could request the information but no system at the county level to ensure this happens safely for workers. 
• No method for county agencies to communicate directly with pass holders. All communication is via employers.

The research team is holding local forums and events to disseminate these results directly to farm workers, two forums open to the public.

Recommendations:

• Recommending consolidating the AgPass application under one department (e.g. under Ag Commissioner) to make process more clear, streamlined, address concerns identified with signing up via the Sheriff's office (considering largely undocumented workforce)
• Support additional research: survey H2A workers inside evacuation zones, specific needs of indigenous language speakers in the county (current offerings only available in Eng/Spanish), understanding air pollutant exposures (increased monitoring), financial literacy needs (long-term planning in changing climate and extreme weather, likelihood this will only get worse)
• Health focused recommendations to SoCo BOS:
• Public Health and Health officials should be included in decisions to activate the Ag Pass, specifically tracking air quality and heat levels inside evacuation zones
• Increased air monitors across the county (hyper-local info needed in rural areas)
  
• Increase collaboration and support with Sonoma County Community Organizations Active in Disaster (COAD), 80 organizations across the county who have infrastructure to provider training and information to farm workers
• $$ support for health and safety training
• PPE to COAD that could be distributed BEFORE fire season in places that are comfortable
• Safety kids: N95, info about wildfire smoke, Cal-OSHA
• Training for employers and how to protect self and 
• Require sufficient stockpile of N95 for workers
• Increase hours of FQHCs across the county, expanded mobile health services, expanded monitoring 
• FQHC collecting farmworker employment
• Health focus recommendations for State of CA
• Update Cal-OSHA smoke standards (AQI >150, PPE needs to be available but not mandatory until AQI >500, no level which is considered unsafe to work)
• Need more monitoring of AQI levels during fire event
• Need requirements employers to communicate AQI levels
• Decrease barriers to reporting concerns to Cal OSHA
• Recommendation for Safety
• Use current active SoCo Alert system, require Ag Pass holders to sign up for these alerts, sign up all farm workers for these alerts
• Develop new alerts: e.g. Ag Pass activated, Deactivated, AQI levels
• Recommendations for economic improvements
• Interconnection of health/economic security
• Comprehensive disaster pay program; create meaningful choice for workers (e.g. hazard pay, disaster insurance, unemployment, paid sick leave)
• Enforcement of retaliation protection so workers don't lose job after choosing not to work for health and safety reasons

It is our duty as family physicians, particularly those of us working in the safety net, to pay attention to local policy and politic and to advocate for safer working conditions for our most vulnerable patients. Please help out where you can!