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Renovated Law Library Reading Room – Pics of the Week

In Custodia Legis - 7 hours 58 min ago

To celebrate the opening of the renovated Law Library Reading Room (LLRR) we decided to provide some pictures of our new space.  First up is a view of the the new reference desk and patron area.

Panoramic view of the LLRR Entrance and Reference Desk / Photograph by Andrew Weber

Next, our new entrance – please note we have a new room number, LM242.

LM242 Entrance to Law Library Reading Room / Photograph by Andrew Weber

The renovated space now has 13 computer terminals for public patrons.

LLRR patron computer terminals / Photograph by Andrew Weber

We also wanted to take this opportunity to thank some of the behind-the-scenes staff who worked so hard to make sure our new space was ready to open.

First, the CALM staff who moved 35,000 volumes in seven days.

David Wright, Dennis Clark, Eduardo Perel, Rudolph Parker, Shah Pollydore, Dwayne Ouzts and LuQman Malik / Photograph by Andrew Weber

And our undying thanks goes to the Law Library Asset Management staff who labored without ceasing for three days to install the computers, the printers, the phones, the microfiche machines and the scanner.

Kevin Long, Trung Le, Latesha McCalip and George Wilkie / Photograph by Andrew Weber

We also want to include Patrick Ouellette and Charles Dove, director of Asset Management, in our thanks though they were not available for the photo session.

We hope to see you soon in our renovated space.

 

 

Categories: Research & Litigation

The Face Of Opioid Addiction: Vinnie, A ‘Regular’ Guy From Revere

CommonHealth (WBUR) - 9 hours 11 min ago

In this 2013 file photo, a recovering heroin addict holds a demonstration dose of the medication Suboxone. (M. Spencer Green/AP)

By Dr. Annie Brewster

Want a glimpse of what opioid addiction really looks like?

Meet Vinnie: a self-described “regular” guy from Revere, Mass., and a recovering drug addict.

Toothless, and 60, Vinnie was prescribed opioids — Oxycodone, Oxycontin, Dilaudid, among others — for a chronic pain condition. Though he says he never intended to abuse these medications, Vinnie became an addict, taking painkillers for 28 years as his doctors kept prescribing higher and higher doses to manage his pain. Listen to his story here:

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Vinnie stopped caring about anything except opioids, and finding his next dose of medication.

Vinnie, from Revere, is a recovering drug addict.

His marriage fell apart. He missed opportunities to spend time with his only daughter as she grew up. He became estranged from friends. He stopped taking care of his body and lost his teeth, gained 100 pounds, and developed diabetes, heart disease and arthritis. He fundamentally lost his will to live and contemplated suicide.

Ultimately, it was a pharmacist who put a stop to Vinnie’s opioid use by refusing to fill his prescription. After his initial panic, this abrupt end to the drugs led Vinnie to connect to a new doctor, an addiction specialist. His new regimen included a slow tapering of the narcotics and the initiation of Suboxone therapy.

The state and nation are in the midst of an escalating opioid crisis — it’s estimated that 100 Americans died each day from opioid overdoses in 2013, and the number of deaths from drug overdoses was three times that of the combined deaths from car accidents and homicides in that same year.

Just this week Massachusetts Gov. Charlie Baker enlisted medical schools to provide more addiction-related training to medical students. Against this backdrop, Vinnie’s story shows the harsh reality of addiction as well as a path to recovery.

How to fix it? It’s clear that a multifaceted approach is needed, as outlined in an extensive report put out by Gov. Baker’s Opioid Working Group in June.

One element, relevant to Vinnie, is consideration of one of several medications available to treat opioid addiction, including methadone, buprenorphine and naltrexone. Currently, these medications are underused, partly because they are controversial.

Access can be tough, as the majority of treatment centers don’t provide such medications, and many insurers don’t cover them or have strict rules on how and for how long they can be prescribed.

Recent Coverage Of The Opioid Addiction Crisis In Mass. Complete Coverage

Suboxone, the drug Vinnie takes, is a combination of buprenorphine and naltrexone, a partial opioid agonist to reduce drug cravings and an opioid antagonist added in small amounts in an effort to prevent abuse. This medicine is much easier to get than methadone (patients can take it home instead of having to go to a clinic every day), and it can be used both for medically supervised opioid withdrawal and for long-term maintenance therapy.

So, what’s the controversy? Some argue that use of Suboxone (and methadone) is just replacing one addiction for another. It is still an opiate-like compound, and one that is habit-forming.

In addition, Suboxone has street value. It has become increasingly popular among addicts as a means of curbing opiate withdrawal symptoms, bridging the gap until opioids can be obtained, and perhaps, because there is a market for it, providing an income source to allow for the purchase of more illicit drugs.

Does this mean we shouldn’t use the medication? Data clearly show that medications like Suboxone and methadone are saving lives, decreasing the spread of infectious diseases, decreasing criminal behavior and improving social functioning among addicts. And Vinnie’s story certainly argues in favor of Suboxone. As he says: It gave him back his life.

Dr. Annie Brewster, M.D., is founder and executive director of Health Story Collaborative, a nonprofit in Boston. She also produces stories for CommonHealth’s Listening to Patients series.

Categories: Health Care

HHS Unveils Civil Rights Protections For Transgender Patients’ Health Services

Kaiser Health News - Thu, 09/03/2015 - 4:03pm

The Obama administration issued a sweeping proposal Thursday to bolster civil rights protections in health care, barring medical providers and insurers from discriminating based on gender, whether in treatments or access to facilities or services.

The long-awaited rules from the Office of Civil Rights in the Department of Health and Human Services further define protections included in the Affordable Care Act, particularly broadening those for transgender Americans. The proposal also includes provisions requiring medical providers to bolster their communication efforts for people with disabilities or limited English proficiency.

“Sadly … there continues to be a persistent problem with discrimination in the health care industry and this rule provides valuable tools to appropriately address them,” said Jocelyn Samuels, director of the HHS Office for Civil Rights.

Advocates were generally encouraged by the proposal, which won’t be finalized until after a public comment period ends Nov. 6. The president’s signature health care law was the first federal law to definitively say that medical providers cannot discriminate on the basis of sex. The new regulations detail how the government will enforce the law’s protections.

“We are pleased to see the administration, finally, make real the promise of that first of its kind legal rule,” said Emily Martin, vice president and general counsel of the National Women’s Law Center.

Use Our Content This KHN story can be republished for free (details).

The proposal will have far-reaching effects because it covers any insurers who participate in the federal and state insurance marketplaces, as well as hospitals, doctors and other providers who receive federal funding, such as Medicare or Medicaid.

Once finalized, the proposal would bar insurers from categorically denying all health care services needed by people who are changing from one gender to another. The rules also say medical facilities cannot turn away transgender patients and need to give transgender patients access to facilities, such as bathrooms, consistent with the gender with which they identify.

“We are clearly not intending to ban single-sex bathrooms or hospital wards or locker rooms … but we anticipate that individuals will be provided access to those facilities consistent with their gender identity,” said Samuels.

The administration specifically asked for comments in two areas: How to handle issues of discrimination based on sexual orientation and whether there should be any specific exemptions for health providers based on religious beliefs.

“This rule has the potential to increase fairness and access in health care for many, many people and could be truly life saving for transgender people,” said Harper Jean Tobin, director of policy at the National Center for Transgender Equality. “Nineteen percent of transgender people surveyed said they have been outright turned away from a hospital, clinic or doctor’s office and that, obviously, is not OK if they are tasking federal funds of any kind.”

The new rules “seem strong in addressing benefit design problems that discriminate based on sex or gender identity,” said Martin at the women’s law group, which released a report in April showing 96 insurance plans in 12 states offered coverage that did not meet the health law’s non-discrimination standards.  Violations included sex discrimination, restrictions on coverage based on age, barring care for transgender patients or excluding coverage for chronic pain.

A spokeswoman for America’s Health Insurance Plans, the industry’s trade lobby, said the proposal was still being reviewed and did not have a specific comment.

Categories: Health Care

CDC: One-Third Of Children With ADHD Diagnosed With The Disorder Before Age 6

CommonHealth (WBUR) - Thu, 09/03/2015 - 2:16pm

(Vivian Chen/Flickr)

One-third of children diagnosed with ADHD were diagnosed young — before the age of 6 — according to a new national survey from the U.S. Centers for Disease Control and Prevention.

Earlier, the CDC found that based on parental reports, 1 in 10 school-aged children, or 6.4 million kids in the U.S., have received a diagnosis of ADHD, a condition marked by symptoms including difficulty staying focused and paying attention, out of control behavior and over-activity or impulsivity.

The percentage of children diagnosed with ADHD has increased steadily since the late 1990s and jumped 42 percent from 2003-2004 to 2011-2012, the CDC says. Last year, concerns flared when a report found that thousands of toddlers are being medicated for ADHD outside of established pediatric practice guidelines.

In the current analysis, also based on parental reporting, and using data drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, the CDC also found:

•The median age at which children with ADHD were first diagnosed with the disorder was 7 years old

•The majority of children (53.1%) were first diagnosed by a primary care physician

•Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist

•Children diagnosed at age 6 or older were more likely to have been diagnosed by a psychologist

•Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%)

•Someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%)

•For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment

What are we — parents, educators, doctors — to make of all this? In particular, what does it mean that so many very young kids are being diagnosed with an attention disorder? (Has anyone ever encountered a 4- or 5-year-old child who is not hyperactive, impulsive and inattentive??)

I asked two doctors — a pediatrician and a psychiatrist — for their impressions of the CDC report. Both agreed that we seem to have two problems when it comes to ADHD: over-diagnosing and under-diagnosing. Here, lightly edited, are their responses.

First, the pediatrician:

James M. Perrin, MD, is a professor of pediatrics at Harvard Medical School and associate chair of MassGeneral Hospital for Children. Dr. Perrin is also the immediate past president of the American Academy of Pediatrics and chaired the 1990s committee that wrote the first practice guidelines for ADHD (and he was on the committee for the 2011 revision).

RZ: How difficult is it to diagnose ADHD in children under 6 years old?

JP: In the pediatric community, we have worked over last 15 years to train general pediatricians to make diagnoses of ADHD reliably and follow very clear, specific guidelines on how to do so. In 2011, the AAP revised its practice guidelines for ADHD and included the opportunity to diagnose children ages 4 and 5 years old.

At the same time we recognize it’s very hard to do that well in that age group…because a lot of children are inattentive at 4 — you don’t expect them to work hard and read a Hardy boys book for an hour and half. Five is often impulsive, active, so it’s not unusual to have symptoms that children with ADHD would also have at age 4, 5. So, it’s not easy.

We did say [in the guidelines] pretty clearly that you shouldn’t make the diagnoses without significant impairment of normal behavior. What we mean by that is a child whose symptoms impair her ability to play with other children, or whose behavior is so out of control that it’s dangerous, for instance she runs out in front of cars, or has many accidents, that’s when the symptoms become impairing.

were aged 2–15 years in 2011–2012 and had a diagnosis of ADHD: United States, 2014 (Source: CDC)" href="//s3.amazonaws.com/media.wbur.org/wordpress/15/files/2015/09/Screen-shot-2015-09-03-at-2.39.33-PM.png">

Child’s age when parent was first told that child had ADHD, among children who
were aged 2–15 years in 2011–2012 and had a diagnosis of ADHD: United States, 2014 (Source: CDC)

The other thing is that we have worked for the past 15, 18 years on how pediatricians address ADHD — the diagnosis, the treatment and the followup. But insurers don’t pay for these time-consuming evaluations. If you are dealing with a 7-year-old, you want to get information from the school so it’s best to have  direct contact from a principal, a teacher, a nurse, if there is one. And that takes time to gather.

Ideally, you want much more than just information from the parents, in fact, the DSM requires that to diagnose both 4- and 5-year-olds, the child must exhibit symptoms in more than one place, not just at home, and that’s true for older children too.

But if you think about a 4-year-old, it’s not always easy to get input from another place in addition to a parent report. It’s harder to make the diagnosis in younger children and I’d be worried about cutting corners to make the diagnosis.

Does this also mean that increasingly, 4- and 5-year-olds exhibiting these symptoms are seeing psychiatrists and other mental health professionals?

I think its relatively unusual for [young children] to see a mental health person without going through a pediatrician…but increasingly, we are seeing young children being kicked out of daycare for behavior — fighting, biting, uncontrollable behavior. So there are kids, 3, 4, 5 years old referred to mental health. I’ve been looking at ADHD for 20-plus years and I’m not comfortable diagnosing ADHD in a 4-year-old without help.

Why not?

What we are dealing with in ADHD is a condition where there is no blood test, no X-ray test, no test that is diagnostic. It’s different from diabetes, or many other conditions. So what we [look out for] is when the symptoms are exaggerated so much, for instance, the child’s lack of attention is way out of the normal range. But that has to be determined, we are dealing with a spectrum here.

What about medication for children under 6?

Evidence on the use of medication for 4-, 5-year-olds isn’t great. The 2011 guidelines recommend behavior interventions as a first line treatment, involving parents in active parent training programs. For ages 6 and up, it’s a combination behavior and medication; the recommendation is starting a combination of both at the same time.

It’s hard not to read these statistics and wonder if we’re not pathologizing fairly normal kid behavior. After all, as you said, 4-year-olds simply aren’t terribly attentive.

There was an interesting study in China [presented at a scientific meeting but unpublished] where researchers studied diagnoses of ADHD in boys, and they found that children who started school younger had higher rates of diagnosis of ADHD. But once they aged, many of those diagnoses were inaccurate. The point is that maybe we are rushing children too far too soon, and some of these children may have what look like symptoms of ADHD but what they really have are symptoms of being immature. All of which makes it more complicated as to how you diagnose ADHD in 4- and 5-year-olds.

So it sounds like there’s both over-diagnosing and under-diagnosing going on?

The evidence indicates that some children who have the diagnosis of ADHD do not actually have the condition and that many children with ADHD are never diagnosed.

Now, the psychiatrist:

Ned Hallowell, MD, is a nationally recognized child and adult psychiatrist who specializes in ADHD. He is based in Sudbury, Mass and New York City.

RZ: What do you make of the CDC data?

NH: I think it’s good news and bad news. There’s greater awareness in the general public and among mental health professionals of ADHD. But the not-so-good news is we don’t have enough clinicians, particularly primary care, who have enough training to make the diagnoses…they are on the front lines. It’s very understandable that some kids, a number of kids under age 6, may look like like they have ADHD and they don’t.

What’s the problem?

In my view it’s the combination of electronic overstimulation, too much screen time, with not enough family connection — family dinners, going for a picnic, it’s the human moment, compared to the electronic moment. And that can look like symptoms that look like ADHD.

The hallmarks of ADHD are distractibility, impulsivity, impatience, trouble with organizing and planning, getting your stuff together, those also can be caused by having too much time in front of the screen and not enough time with a human being.

We have a social problem masquerading as a medical one. So many primary care providers have neither the time or the training to do the job they’d like to do. Child psychiatrists are as rare as hen’s teeth, but we we have the most training in diagnosing this condition.

So what’s the takeaway here?

To me the big point is this modern paradox, the over-connection to electronics and under-connection to people — as you get younger, 5, 4, 3, it’s usually social problems that can look like ADHD, stress in the family, conflict in the family, poverty, violence.

What is the key to diagnosing this disorder in very young kids?

There are several several factors in diagnosing ADHD in these younger children. It’s intensity — how much more distractible are they, for example.

And the teacher observations are so important, parents don’t have a big cohort to compare to, you need several sources of information. Does this kid stand out? Another key thing is, does it occur in multiple settings, is it just at home, or daycare too?

You also want to be sure to rule out medical causes, lead poisoning, fetal alcohol syndrome, you want to make sure you check the medical causes.

Do you think the actual number of kids with ADHD is rising, or is it simply greater awareness of the condition?

I think two things: It’s increasing awareness and training, more accurate diagnosis and inaccurate diagnosis. The solution is to have people really trained and to have information from multiple sources.

My personal thing that I keep trying to stress is the need for human connection. I like to say it’s a vitamin C deficiency — a vitamin connect deficiency, connection to friends, neighborhoods, pets, nature, to heroes and dreams. I think it produces what can look like ADD or even failure to thrive, it’s a lack of sparkle, zest. The good news is that connection is free…that’s why I prescribe dogs all the time.

Categories: Health Care

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