Staff Scientist Meleah Boyle, PhD MPH, co-senior author of the study, said addressing period poverty, as the issue has been called, is a growing area of research in the United States

“Our study highlights the widespread nature of period poverty and the need for broad actions – both locally and nationally – to increase the affordability and accessibility of these products for youth,” Boyle said.

Menstrual equity means that every person who menstruates should have equal access to affordable and quality menstrual products. Unfortunately, many people do not have access to these necessary products. In the study, researchers found that 30% of adolescents do not have the products they need with no differences based on measures of socioeconomic status, such as insurance and community opportunity, or individual differences, such as race and ethnicity.

Prior research estimates that of those who menstruate, 11.9 million struggle to find access to menstrual products. This lack of access can lead to absences from school and/or work as well as negative health outcomes such as urinary tract infections and bacterial vaginosis.

Boyle said the research highlights the need for public health programs and policy changes to ensure youth have access to the products they need to avoid negative impacts on their health and engagement.

“Ensuring access to healthy and appropriate menstrual health products should be a public health priority,” Boyle said.

Study co-author Riya Metha is scheduled to present the research from 5:15-6:15 pm ET Saturday, Sept. 28

In addition, Monika Goyal, MD, MSCE, co-senior author, will be among highlighted abstract authors who will give brief presentations and be available for interviews during a press conference from noon-1:30 pm ET Saturday, Sept. 28 in the National Conference Press Room, W208 AB. During the meeting, you may reach AAP media relations staff at 407-685-5401.

Please note: only the abstract is being presented at the meeting. In some cases, the researcher may have more data available to share with media, or may be preparing a longer article for submission to a journal.

ABSTRACT

Program Name: 2024 AAP National Conference-Abstracts

Submission Type: Council on Adolescents and Young Adults

Abstract Title: Prevalence of Period Poverty in a Pediatric Emergency Department

# of Newsworthy Nominations: 2

Gia Badolato

Washington DC, DC, United States

The abstract, “Overprescription of Opioids in White Children from Higher Socioeconomic Backgrounds: Disparities in Opioid Utilization for Pediatric Supracondylar Humerus Fractures,” looked at the rates in opioid prescriptions following childhood broken elbow diagnoses from 2012 to 2021.

Apurva Shah, MD, MBA, Attending Surgeon, Orthopaedic Surgery at the Children’s Hospital of Philadelphia, who authored the abstract, also pointed to results that showed a third of patients in the abstract received at least one opioid dose during their visit.

“As orthopaedic surgeons, we clearly need improved opioid use stewardship to improve healthcare outcomes for our patients,” Dr. Shah said.

Results found disparities in patient racial backgrounds, with Black children 27% less likely to receive an opioid prescription compared to other patients. By comparison, white patients were also shown to be 10% more likely to be given opioids.

Other factors that impacted patients’ likelihood of being given opioids included age and where they live, according to Dr. Shah.

“Non-opioid pain management has proven sufficient for pain management,” Dr. Shah said. “Knowing this, along with this abstract, pediatricians must consider the potential harm these drugs can have on populations with disproportionately easier access to healthcare.”

This research was funded by Children’s Hospital of Philadelphia, Division of Orthopaedics.

Scott Mahon is scheduled to present the research, which is below, at 8:51 – 8:55  a.m. on Sunday, Sept. 29 during the Section on Orthopaedics program at Orange County Convention Center, West Building, W311H. To request an interview with the authors, contact Ashley Moore at moorea1@chop.edu.

The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults. For more information, visit www.aap.org. Reporters can access the meeting program and other relevant meeting information through the AAP meeting website at http://www.aapexperience.org/ 

ABSTRACT

Program Name: 2024 AAP National Conference-Abstracts

Submission Type: Section on Orthopaedics

Abstract Title: Overprescription of Opioids in White Children from Higher Socioeconomic Backgrounds: Disparities in Opioid Utilization for Pediatric Supracondylar Humerus Fractures

Apurva Shah

Philadelphia, PA, United States

Their study recently published in the journal JAMA Health Forum shows that policies requiring coverage of a 12-month supply of short-acting hormonal contraception — most commonly the birth control pill — have not been fully implemented, resulting in no substantial increases nationally in year-long prescription orders. This leaves many patients at an increased risk for unintended pregnancy.

A common cause for decreased effectiveness with the pill is breaks in use, often due to running out of a prescription or a lapse in obtaining a refill. However, dispensing a longer-term supply of contraception — six or 12 months — is linked to improved continuous use, fewer breaks in coverage and health system savings.

“The decision of when or if to become pregnant is deeply personal,” said Maria Rodriguez, M.D., M.P.H., professor of obstetrics and gynecology in the OHSU School of Medicine and director of the OHSU Center for Reproductive Health Equity. “It shouldn’t be impacted by a delay in getting to your pharmacy for a refill, or a pill package running out while on vacation.”

To address this barrier, policymakers in 19 states have enacted 12-month contraceptive supply policies, which require insurers to cover the cost of dispensing a full year of coverage at once per prescription. However, OHSU researchers found that these policies have not been fully implemented and have failed to change current prescribing practices.

Using a difference-in-difference model, which compares changes in outcomes over time between populations, researchers looked at oral pill, patch and ring contraception prescriptions among nearly 4.8 million female Medicaid enrollees ages 18 to 44 in 36 states — 11 states with the 12-month supply policy, and 25 without. Researchers found that in 10 of the 11 states with the policy, an increase in the proportion of contraception dispensed was smaller than one percentage point — meaning just a nominal improvement in year-long prescription orders.

“Our findings suggest a significant gap in knowledge both for patients and prescribers, and we hope this serves as a call to action to make 12-month supplies the standard prescribing practice,” Rodriguez said. “This is low-hanging fruit for improving birth control access, especially for people who live in states with more restrictions on reproductive health care.”

For coverage policies to be effective, insurance companies must comply with and be held accountable for following the revised coverage guidelines, Rodriguez said. Similarly, clinicians would need to change their standard prescribing patterns to write for an extended supply of contraception, and pharmacists would need to dispense the full supply.

The research team says full implementation of these policies will require outreach to contraceptive users, prescribers, pharmacists and payers, as well as enforcement from state governments. A federal policy mandating coverage of a 12-month supply is another strategy to support access, as it would require all insurers, including private payers, to cover 12-month contraception supplies.

Rodriguez encourages patients to feel empowered to ask about their contraceptive options and advocate for choices that are the best fit their personal preferences, lifestyle and family planning goals.

“In our current health care landscape, where reproductive rights are constantly under attack, it’s critical to remove barriers and ensure broad access to contraception,” Rodriguez said. “We need providers to be following this prescribing practice as their default and patients to know that it’s their right to ask for it.”

A new study from King’s College London published in Nature Medicine reveals a new relationship between lipids and diseases impacting  metabolism in children, which could serve as an early warning system for conditions like liver disease.

Using machines that test blood plasma in babies that already exist in hospitals, the researchers suggest this could help doctors spot early signs of disease in children quicker and help them access the right treatment.

The findings also contest the common idea that cholesterol is a leading cause of complications around obesity in children, identifying new lipid molecules which contribute to health risks like blood pressure but are not only correlated with a child’s weight.

Lipids have traditionally been thought to be fatty acids in the body, either good or bad types of cholesterol or triglycerides, fats found in the bloodstream that is the most common in the human body. Recent studies from the same group of scientists have suggested that the picture is more complex.

Using a technique associated with chemistry called mass spectrometry, current evidence puts the types of different lipid present in the body in the thousands, each with separate functions.

Taking a control sample of 1,300 children with obesity, the team assessed their lipids in blood. Afterwards 200 of them were put on the HOLBAEK-model for a year, a lifestyle intervention for people with obesity popular in Denmark.

Subsequent readings showed that amongst the intervention group, counts of lipids tied to diabetes risk, insulin resistance and blood pressure decreased, despite limited improvements in some children’s BMI.

Dr Cristina Legido-Quigley, a group leader in Systems Medicine at King’s College London, Head of Systems Medicine at the Steno Diabetes Centre Copenhagen (SDCC) and principal author, said: “For decades, scientists have relied on a classification system for lipids that have split them into good and bad cholesterol, but now with a simple blood test we can assess a much broader range of lipid molecules that could serve as vital early warning signs for illness. In the future, this has the potential to be an entirely new way to evaluate someone’s personal risk of disease and by studying how to change lipid molecules in the body, we could even prevent metabolic diseases like diabetes altogether.”

Obesity continues to be a risk factor for conditions like fatty liver disease, but the team hope that doctors can use these measurements to treat children when they are at risk and not just a little larger than their peers.

Dr Karolina Sulek, who was part of the study and performed analysis at the SDCC, said: “Early recognition of children at risk for these life-threatening diseases is crucial. The study provides strong evidence of the great need for obesity management and gives parents confidence to intervene in their children’s life more compassionately, helping them to lose weight.”

The next step for the researchers is to help understand how genetics affects lipids and what this means for metabolic diseases, as well as how these lipids can be changed to improve health.

The study targeted patients with blood pressure higher than 140/90 mmHg who were receiving care in clinics specializing in kidney conditions. The ConnectedCare365 Hypertension Management program provided people in central and northeast Pennsylvania communities with remote blood-pressure monitoring and other devices that transmit information to doctors. Patients were identified and enrolled through a centralized monitoring center, known as ConnectedCare365, to ensure consistent messaging and ample education on the devices and patient communication application. Doctors and pharmacists assigned by the program co-managed patient care and helped adjust medications for patients.

“In our study, we developed a program that builds off what others have done using telemonitoring and pharmacists,” said senior study author Alexander Chang, M.D., M.S., a nephrologist and associate professor in the department of nephrology and the department of population health sciences at Geisinger Health in Danville, Pennsylvania. “By deploying these extra resources to get blood pressure under control in high-risk patients and reducing hospitalizations, we are hoping that we can help provide more justification in expanding these types of programs.”

Notifications from the home blood pressure-monitoring devices were transmitted to the central monitoring center. During the first six months of the program, the notifications were first transmitted to doctors in collaboration with pharmacists through a virtual platform that connected to patients’ phones through an app, which connected to the devices over Bluetooth. Blood pressure measurements were assessed and blood pressure medications were prescribed and/or adjusted accordingly. During the second six months, the notifications were transmitted first to pharmacists, who co-managed blood pressure through a collaborative telehealth practice agreement. While patients were enrolled in the program, they also had real-time access to a nurse during business hours through a live chat feature in the central monitoring center.

Study results include:

• 67% of patients were able to achieve blood pressure control of <140/90 mm Hg at six months, and 74% of patients were able to achieve blood pressure control by 12 months. The 2017 clinical guideline from the American Heart Association and the American College of Cardiology set the threshold for stage 1 hypertension at 130/80 mm Hg and the threshold for stage 2 hypertension at 140/90 mm Hg.
• Systolic blood pressure was lowered by an average of 3.3 mm Hg/month for those with initial blood pressure readings greater than 150/90 mm Hg; lowered by 2.4 mmHg/month for those with initial readings in the range of 140-149/90-99 mm Hg; and lowered by 0.6 mm Hg/month for those with initial readings lower than 140/90 mm Hg.
• Pharmacist telehealth encounters, in which the patients talked directly with pharmacists about hypertension management, were documented in 65% of patients, and pharmacist interactions were associated with a 1.3 mm Hg/month decline in systolic blood pressure over time.
• During the 12-month study period, 46% of patients had a blood pressure medication adjustment, and 37% were prescribed new blood pressure medication.
• Patients experienced fewer hospitalizations during the study period compared to the previous 12 months; however, there was no difference in the number of reported emergency department visits.

“We know that home blood pressure monitoring can be done by patients accurately and can really help engage patients in their own health. However, we also know that these self-measured blood pressure readings often do not make it back to patients’ health care team, therefore, delays in adjusting medications are very common. This type of physician-pharmacist collaborative model with home blood pressure monitoring that is centrally received and monitored by the care team can help address these issues,” Chang said.

Study background and details:

• The study included 205 adults, with an average age of 62 years; 48% self-identified as women and 52% as men.
• 87% of participants self-identified as non-Hispanic white adults, 6% as Black adults; 5% as Hispanic adults, and 1.5% as “other” for race/ethnicity.
• 53% of participants had a diagnosis of chronic kidney disease at the time of enrollment.
• Participants’ blood pressure was tracked for up to 6-12 months between March 2022 and May 2024 with consistent improvements even after participation in the study ended.

The study’s strengths included its ability to review hospitalization data, inclusion of the pharmacists, the careful examination of the pharmacists’ role in this program and that it was conducted in a real-world setting, the authors noted. The study’s limitations included that patients were their own control group to determine the impact of the program and participants had to have internet access.

“This is an important program that allows for more efficient management of a high-risk patient group,” said Wanpen Vongpatanasin, M.D., FAHA, professor in the department of internal medicine at UT Southwestern Medical Center, director of UT Southwestern Medical Center’s Hypertension Section in the division of cardiology and clinical chair of the Hypertension Scientific Sessions 2024 Executive Committee. “This program’s team-based care approach including a pharmacist remotely makes it a feasible option to increase access. In addition, the study’s findings signal a way to reduce hospitalization and to improve blood pressure, which is very encouraging.”

Note: Moderated Poster Presentation MP11 in Session MPS02 New Paradigm and Lessons learn from Hypertension Clinical Trials in 2024 is Friday, September 6, 2024 at 9:35 a.m. CT.

The Inflation Reduction Act, enacted in 2022, included establishing a cap on out-of-pocket spending for those enrolled in Medicare Part D prescription drug plans.

Researchers from the University of Michigan’s Institute for Healthcare Policy and Innovation and Rogel Cancer Center used the online Medicare Part D Plan Finder tool to assess how much patients were paying for the most commonly prescribed oral chemotherapies. They compared data from 2023, when no out-of-pocket cap was in place, to 2024, when the policy first took effect.

For Medicare Part D beneficiaries, annual out-of-pocket costs for oral cancer medications averaged $11,284 in 2023. In 2024, the average annual cost for the same medications is estimated to be $3,927. The median cost saving from 2023 to 2024 is estimated to be $7,260, demonstrating the policy’s effect on decreasing costs for patients. The study is published in JAMA Network Open.

“People with cancer are already vulnerable to financial distress and medical debt. Our analysis suggests that legislative policy can have a big impact on the cost of cancer care. This is especially critical as lawmakers now consider extending an out-of-pocket cap to commercial insurance,” said lead study author Benjamin Pockros, M.D., M.B.A., a urology resident at Michigan Medicine.

In 2025, an out-of-pocket cap will be set at $2,000, which the researchers predict will result in even greater savings for patients.

Additional authors: Chad Ellimoottil, M.D.; Belal Sbei; Megan Caram, M.D.; Kristian Stensland, M.D., M.P.H., M.S.

Funding for this work is from the University of Michigan Institute for Healthcare Policy and Innovation.

Disclosure: None

Paper cited: “Changes in Out-of-Pocket Spending for Common Oral Cancer Medications After the Inflation Reduction Act,” JAMA Network Open. DOI: 10.1001/jamanetworkopen.2024.32456

Overall, individuals with past-month prescription amphetamine use had a greater likelihood of new-onset psychosis or mania than individuals without past-month use. The risk was highest in those taking 30 mg or more of dextroamphetamine (which corresponds to 40 mg of Adderall), according to the study.

Previous studies have linked stimulants to psychosis and mania risk; however, information had been lacking on whether dosing impacted risk.

“Stimulant medications don’t have an upper dose limit on their labels, and our results show that it is clear that dose is a factor in psychosis risk and should be a chief consideration when prescribing stimulants,” said lead study author Lauren Moran, MD, a pharmacoepidemiology researcher at McLean Hospital. “This is a rare but serious side effect that should be monitored by both patients and their doctors whenever these medications are prescribed.”

Moran said the study was born out of her past clinical observations as an inpatient psychiatrist. She and her McLean colleagues would regularly see patients coming in experiencing first episodes of psychosis, and their medical records would reveal they were prescribed high doses of stimulants by their doctors.

Researchers reviewed electronic health records of Mass General Brigham patient encounters between 2005 and 2019, focusing on adults aged 16 to 35, the typical age of onset for psychosis and schizophrenia. All patients were admitted to McLean Hospital following referrals from other hospitals in the Mass General Brigham healthcare system. The researchers identified 1,374 cases of individuals presenting with first-episode psychosis or mania, compared to 2,748 control patients with a psychiatric hospitalization for other conditions like depression or anxiety. They conducted a comparison analysis of stimulant use over the preceding month and accounted for other factors, including substance use, in order to isolate the effects of stimulants.

They found the attributable risk percentage among those exposed to any prescription amphetamine was nearly 63% and for high dose amphetamine was 81%. These findings suggest that among people who take prescription amphetamine, 81% of cases of psychosis or mania could have been eliminated if they were not on the high dose. While a significant dose-related risk increase was seen in patients taking high doses of amphetamine, no significant risk increase was seen with methylphenidate (Ritalin) use, which is consistent with previous research, including a 2019 study led by Moran.

While the study does not prove causality, the researchers note there is a plausible biological mechanism in neurobiological changes that include a release of higher levels of the neurotransmitter dopamine from amphetamines, that parallel dopaminergic changes observed in psychosis.

Limitations of the study include inconsistencies with how electronic health records are kept. Additionally, with the research taking place in a psychiatric hospital in the Boston area that sees many patients with psychosis, it may make these findings less generalizable to other parts of the country.

Moran said the findings need not create alarm but should lead to extra caution when these medications are prescribed, especially for those who have risk factors for psychosis and mania.

“There’s limited evidence that prescription amphetamines are more effective in high doses,” said Moran. “Physicians should consider other medications our study found to be less risky, especially if a patient is at high risk for psychosis or mania.”

Authorship: In addition to Moran, Mass General Brigham co-authors included Joseph P. Skinner, BA (BWH), Ann K. Shinn MD, MPH (McLean), Kathryn Nielsen (McLean), Vinod Rao, MD, PhD (MGH), Trevor Taylor, MD, MPH (MGH), Talia R. Cohen (McLean), Cemre Erkol, MD (McLean), Jaisal Merchant, MA (McLean), Christin A. Mujica, MA (McLean), Roy H. Perlis, MD, MSc, (MGH) and Dost Ongur, MD, PhD (McLean).

Funding: This work was funded by a grant from the National Institute of Mental Health (NIMH), R01 MH122427.

Disclosures: Perlis received personal fees from Genomind, Burrage Capital, Psy Therapeutics Inc, Circular Genomics Inc, and Vault Health unrelated to the submitted work. Dr. Ongur received honorariums for scientific presentations to Neumora Inc. and Guggenheim LLC unrelated to the submitted work. Dr. Moran is employed by Sage Therapeutics (unrelated to this work and after study completed and submitted for publication). All other authors report no financial relationships with commercial interests.

Paper cited: Moran, LV et al. “Risk of Incident Psychosis and Mania with Prescription Amphetamines,” American Journal of Psychiatry. DOI: 10.1176/appi.ajp.20230329

At least 11 of the 17 members of the Scientific Advisory Committee on Nutrition (SACN) have conflicts of interest with the likes of Nestle, sugar manufacturer Tate and Lyle, and the world’s largest ice cream producer, Unilever, reports freelance journalist Sophie Borland.

And at least six out of the 11 members of SACN’s Subgroup on Maternal and Child Nutrition have ties to food firms, including baby food manufacturers and formula milk brands.

SACN is a powerful group of people appointed as independent experts to advise the government, which in turn influences policy, explains Borland. Since being set up in 2000 it has produced high profile guidelines on daily salt and sugar intake, vitamin D supplements, and feeding babies.

But there is concern that both SACN – and the previous governments reviewing its recommendations – have not done enough to curb rising obesity levels and food-related ill health.

The BMJ looked at the interests declared by SACN members – in publicly available documents published on the government website – within the past three years.

Among them is David Mela, a retired senior scientist from Unilever, who has done consultancy work for Unilever, Tate and Lyle, Coca Cola’s Israel franchise CBC Israel, and Cargill, which produces cocoa and chocolate products among other things.

Another member, Julie Lovegrove, is chair of an expert group at the International Life Sciences Institute (ILSI) Europe, whose member companies include Pepsico, Cadbury’s US owner Mondelez, and General Mills, the American firm behind Cheerios and Haagen Dazs.

Members of SACN’s Maternal and Child Nutrition subgroup include Ann Prentice, a council member of the Nestle Foundation, and Marion Hetherington who has undertaken work for Danone and baby food brand Ella’s Kitchen, the latter on an unpaid basis. The group’s chair, Ken Ong, has also received research funding from Mead Johnston Nutrition, which makes formula milk.

The Department for Health and Social Care (DHSC) responded on behalf of SACN and all members named in this article, saying SACN members are required to declare any potential conflicts of interest annually – and new ones at the first appropriate committee meeting, which are included in the minutes and published on the SACN website.

It added: “No members of the committee are directly employed by the food and drink industry, and all have a duty to act in the public interest and to be independent and impartial.”

But Chris van Tulleken, associate professor at University College London and author of a best-selling book on ultra-processed food, says: “Even small financial conflicts affect behaviour and beliefs in subtle or unconscious ways,” while Rob Percival, head of policy at the Soil Association, says: “We’re concerned that the committee and its integrity might be undermined by those ties to the food industry.”

Experts tell The BMJ the make-up of SACN needs to be reviewed in light of members’ ties to the food industry. However, Kat Jenner, director of the Obesity Health Alliance, says these ties are partly a result of the lack of money in relevant research.

Alison Tedstone, former chief nutritionist for Public Health England, also suggests that refusing to allow experts with industry ties on SACN would “diminish” its expertise and could delay future legislation.

Yet Van Tulleken insists: “Despite two decades of work from a conflicted SACN there has been an explosion of suffering and death from diet-related disease in the UK so I don’t think it’s credible to claim that the committee has been very effective.

“There are some excellent independent experts but they are a minority and in my view their work has been hampered by conflicts of interest with the industry that has created this health crisis. SACN must become independent of the food industry.”

In November 2019, the Australian National Prescribing Service launched a federal initiative to improve opioid prescribing.  The initiative involved alerting high-prescribing clinicians that their opioid prescribing practices were outside typical ranges for that practitioner group (2019), providing training in opioid prescribing (2019), reducing the oxycodone package size (2020), and adding warning messages to oxycodone packaging (2020).

The study used wastewater-based epidemiology to estimate the quantity of oxycodone consumed by a community by sampling the community’s sewage as it flowed into a wastewater facility and measuring the levels of oxycodone and its metabolite, noroxycodone, excreted in urine.

For this study, the Australian National Wastewater Drug Monitoring program (NWDMP) collected and analysed 6,999 samples from over 50 wastewater treatment plants across Australia from April 2017 to April 2023.  The results of the analysis are listed below.

• Oxycodone use initially increased from 78 mg/day/1000 people in April 2017 to 120 mg/day/1000 people in August 2019.  This 52% increase occurred before the federal initiative to improve opioid prescribing began.
• Oxycodone use then decreased from 120 mg/day/1000 people in August 2019 to 65 mg/day/1000 people in December 2020.  This 45% decrease coincided with the introduction of prescribing guidelines in 2019 and oxycodone packaging changes in 2020.
• Oxycodone use showed a minor 2.4% increase from December 2020 to April 2023.

Lead author Dr. Rory Verhagen from UQ’s Queensland Alliance for Environmental Health Sciences explains, “The main finding from this study was that a big reduction in oxycodone use between 2019 and 2020 coincided with the introduction of national clinical and regulatory changes intended to reduce pharmaceutical opioid use.  It is likely that the combination of smaller package sizes and educational initiatives in 2019 and early 2020 reduced consumption of oxycodone in Australia.”

The reduction in oxycodone use has not been offset by an increase in heroin or fentanyl use in Australia.  NWDMP monitoring shows that throughout the study period, the consumption of heroin fluctuated without any clear trend while fentanyl followed a similar trend to oxycodone.

The study was conducted by researchers from The University of Queensland, the University of South Australia, and Queensland Health, Australia with primary funding from the Australian Criminal Intelligence Commission; it appears in the scientific journal Addiction.

Full citation for article: Verhagen R, Gerber C, Thai PK, Connor J, Loveday B, Bade R, O’Brien J, Jaunay EL, Simpson BS, Chan G, Hall W, Thomas KV, Mueller JF, Tscharke BJ.  Wastewater-based evaluation of the efficacy of oxycodone regulations in Australia. Addiction. 2024. DOI: 10.1111/add.16653.

Primary funding: The Australian Criminal Intelligence Commission and Queensland Health Australia provided financial support for this research.  Wastewater catchment mapping and sampling was conducted under an Australian Research Council Linkage Project (LP190101124, LP220100058).

Declaration of interests: None.

Even though health warnings need to be written on physical products sold in stores and included in traditional advertisements, a new research study led by Boston University found that the majority of ads posted on social media by synthetic nicotine brands left the warnings off.

Synthetic nicotine is a substance created in a laboratory that has the same, or very similar, chemical structure to the nicotine derived from tobacco leaves. Despite marketing that labels it as “tobacco-free nicotine,” it still has the same addictive properties and additives that can cause lung damage, cancer, and other health issues. Plus, since it’s commonly paired with appealing flavors—made from chemicals that are known to be unsafe to inhale—it can be even harder to quit.

“When synthetic nicotine started appearing in products, we really wanted to know how it was being received and how it was being promoted,” says Traci Hong, a BU College of Communication professor of media studies.

When she first started in her career as a health communication researcher, she says, it was a different era: social media was not widely used, cigarette use was declining, and electronic cigarettes and vapes were in their infancy. But when vapes containing synthetic nicotine started getting more and more popular, she turned her attention to social media to find out how the advertising of these products was being regulated—and what could be done to make them less appealing to kids and young adults.

In their new paper, Hong and her collaborators found that in over 2,000 Instagram posts from 25 different synthetic nicotine brands, the vast majority did not include warning labels informing users about the health risks. The findings have been published in JAMA Network Open.

“These are brands that I think have a legitimate responsibility to inform their potential consumers that there are health risks and you need to be aware of them,” Hong says. Especially considering that Instagram is one of the most popular social media platforms in the US for young adults.

The FDA passed a requirement in 2022 that says health warnings need to take up 20 percent of the advertising and appear in the upper portion of the advertisement for e-cigarettes that contain synthetic nicotine. Hong, who is a research fellow at BU’s Rafik B. Hariri Institute for Computing and Computational Science & Engineering, and her colleagues identified whether an image posted on Instagram included the required health warning and, if it did, whether it took up the right amount of space. The study involved interdisciplinary collaboration across the University, including experts from BU’s School of Public Health, Chobanian & Avedisian School of Medicine, and College of Arts & Sciences.

The Instagram posts were analyzed using a custom-built AI algorithm, called Warning Label Multi-Layer Image Identification (WaLi), which uses computer vision to detect if health warnings follow the FDA rules. The team found that only 13 percent of the analyzed posts complied with FDA health warning requirements. They also discovered that the posts with health warnings received fewer likes and comments than posts without the warnings. According to the paper, the larger the warning label, the less comments the posts received. This means that having health warning labels could reduce how many social media users, especially young adults, are seeing and engaging with this content.

“We need federal government policies to combat the appeal of e-cigarette advertising on social media and to prevent kids from using tobacco products,” says Jessica Fetterman, a Chobanian & Avedisian School of Medicine assistant professor of medicine and coauthor on the study. The FDA recently estimated that the number of middle and high school students using e-cigarettes in 2024 is about 1.63 million, down from 2.13 million in 2023, with the vast majority using flavored nicotine. Enforcing and requiring health warning labels on social media content is one way to make products less visible and appealing, Fetterman says.

“Our study indicates that e-cigarette brands are creating Instagram posts advertising their products with seemingly no enforcement by the social media platform or government,” Fetterman says. Instagram lists tobacco products, electronic cigarettes, “and any other products that simulate smoking” on their list of prohibited branded content. But, Fetterman says, synthetic nicotine products are flouting that rule.

“All our work is really trying to find evidence-based research to help people make informed decisions about their health,” Hong says. With synthetic nicotine and e-cigarette companies continuing to use flavors as a way to appeal to youth, she says, her team plans to monitor social media posts with WaLi to ensure brands are using the correct language to dissuade people from getting hooked.

This research was supported by the National Institutes of Health and the American Heart Association.

Original source

Why is opioid use before hip or knee replacement a problem?

Patients who require THA or TKA suffer from end stage osteoarthritis with chronic pain. Opioids often provide no better pain relief that simple analgesics and yet they carry the risk of additional side effects such as drowsiness and the risk of falls. Moreover, opioid use before surgery is linked to worse outcomes including slower recovery and persistent opioid use three months after surgery.

THA and TKA are among the most common elective surgical procedures performed around the world and numbers are expected to at least double over the next decade.

The OpioidHALT trial (Feasibility of responsible pre-operative opioid use for Hip and knee ArthropLasTy (OpioidHALT) pilot study) was designed to examine the feasibility and acceptability of an intervention to reduce opioid use before elective THA or TKA compared to usual practice.

How OpioidHALT tackles pre-operative opioid use?

There is little published evidence for the effectiveness of opioid dose tapering. One previous retrospective study showed that patients who tapered their opioids before surgery might have better post-surgical outcomes. However, as the study was not randomised it was not known if there was something different about the patients who tapered their doses.

The OpioidHALT study involved video or telephone consultations with a pharmacist starting three months before the date of the operation. The pharmacist worked with each patient to develop an opioid tapering plan that was evaluated for safety by a pain specialist. Patients determined the level of opioid tapering that they wished within the framework of national guidelines i.e. 10 to 25% of the patient’s baseline opioid dose tapered per month.

What the OpioidHALT pilot study tells us

The initial consultations in the OpioidHALT study took about one hour. Follow-up appointments started one week after each dose reduction and were typically shorter, Patients were educated about how to identify and manage opioid withdrawal symptoms. “If necessary, the patient was put back on a higher opioid dose”, says Dr Liu.

OpioidHALT was a pilot study designed to determine whether the intervention delivered by pharmacists led to successful tapering of opioid doses. The results showed that in the intervention group 90% of patients tapered their opioid doses by at least 50% before surgery compared with17% in the usual care group.

Although the pilot study was not powered to evaluate other outcomes, some of the emerging findings suggest important impacts. In the intervention group there were –

• Fewer opioids consumed in hospital
• Smaller quantities of opioids supplied on discharge
• Fewer days in hospital
• Fewer patients taking opioids three months post-operation

Patients in the intervention group also had improved physical function and improved overall body pain intensity.

Why pharmacists should manage pre-operative opioid use

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.

Recordings of the consultations showed that many patients were keen to discontinue opioid use but needed help with the process. “We’ve got patients who are crying [out] to have pharmacists to be more involved in their care …. and that’s something that a lot of pharmacists can do”, says Dr Penm. He adds that the whole multidisciplinary research team says “This is a really good intervention, we should be doing this, pharmacists should be leading it”

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

At the 2024 FIP Congress Dr Liu was awarded the International Pharmaceutical Federation Early Career in Pharmaceutical Practice Recognition Award. The purpose of the award is to recognise an outstanding early career pharmacist who has made important contributions to their field of practice at a national level, and who is emerging internationally.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.

Some 575 patients were screened for inclusion in the OpioidHALT study and 442 were excluded because of low opioid use. “That is the reality of clinical trials for you”, says Dr Shania Liu. “We know that approximately a quarter of patients in [this] population don’t use opioids on a regular basis”, she adds. Nevertheless, dosage tapering is still important for the many patients who are using opioids regularly.

OpioidHALT II

As a result of the impressive results from the OpioidHALT study Dr Jonathan Penm has now received funding of $1.5 million to run the definitive trial (OpioidHALT II). Recruitment started two months ago.  “What’s great about it is all of the pilot sites were so impressed by the pilot that they’ve all stayed on for this definitive trial. Other sites have also expressed interest because they’ve been so excited about it”, says Dr Penm. “We’re going to have more pharmacists, a lot more patients – and [it] will be primarily powered to look at those pain and quality of life outcomes”, he explains.

Pharmacists often improve medication regimens but rarely find out how much of an impact the changes have on patients’ lives. One of the useful and important findings in the OpioidHALT study was that the early benefits of reduced opioid use were sustained for three months. “It just shows you the value that pharmacists can provide to their patients – that when we improve their medicines we could be improving it for much, much longer than you realise and having much, much stronger impact”, says Dr Penm.

All the opioid-tapering consultations were recorded and patients’ reactions made a profound impact on Dr Penm.

“Many of them were just so grateful to have someone listen to them,  to validate what they’ve been going through with their pain and to support them through the opioids. In fact, most of them said, “I’ve never had any benefit from these but I just don’t know how to get off them – and I really would love some help”,  so I think we’ve got patients who are crying [out] to have pharmacists to be more involved in their care, to be more present, to listen to them, to validate what they’re going through – and that’s something that a lot of pharmacists can do”, he says.

In summary Dr Penm says:

“Any work of this calibre is extremely difficult to do with one person and we have a very large team. One of the unique aspects is how multidisciplinary it was – we have pharmacists, we have nurses, we have GPs, we have anaesthetists, we have physiotherapists, we have orthopaedic surgeons – and we know how rare it is to get all these people together in one spot and for all of them to say, “This is a really good intervention, we should be doing this, pharmacists should be leading it”. It’s just beautiful to hear. You don’t always hear that the pharmacist is the most obvious choice but in this case they are. They’re happy, they’re competent, they’re capable – and everyone else doesn’t want to do this because it is not their area of expertise. Well, with pharmacy we’re very comfortable because we know this, we know opioids, we see tapering, we know how to taper, we know what to expect”.

About Dr Shania Liu and Dr Jonathan Penm

Dr Shania Liu  BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FSHP, FHEA completed her PhD at the University of Sydney looking at a pharmacist-led opioid tapering program for patients undergoing total hip and knee arthroplasty. Currently, she is a post-doctoral research fellow working at the University of Alberta in Canada where she is leading two large randomised trials looking at pharmacist-partnered management of chronic conditions such as cardiovascular disease. She also  continues to be involved in the pharmacist-led opioid tapering work looking at the impacts of opioid tapering before hip and knee replacement surgery.

Dr Jonathan Penm BPharm (Hons), GradCertEdStud (Higher Ed), PhD, FFIP, FSHP, FPS, FHEA, FANZCAP (PainMgmt, Research) is a senior lecturer at the University of Sydney School of Pharmacy in Australia. He is involved in both teaching and research and is also affiliated with the Prince of Wales Hospital, where he is involved in research with the pain team. His area of interest is evaluating hospital pharmacy services to reduce patient harm and the need for hospital care.  He currently runs several randomised controlled trials and is the Principal Investigator for OpioidHALT II.

Read and watch the full series on our website or on YouTube.