CVS-Aetna Deal Could Mean End of Era in How Drugs Are Paid For

If Aetna Inc. is eventually swallowed by CVS Health Corp., an important part of the health-care business will be changed — perhaps for good.

For years, pharmacy benefits were largely carved out from the rest of a medical coverage plan. But increasingly the two services are being combined, a move that in theory will make it easier to verify whether expensive drugs are worth the cost. A merger of the third-biggest health insurer with the largest U.S. drugstore chain, which also operates a pharmacy-benefit management company, could speed the process.

“You are hearing the warning for the end of the road for the classic standalone” pharmacy-benefit business, said Pratap Khedkar, managing principal at consulting firm ZS Associates.

Drugmakers are producing more pricey treatments for cancer and rare diseases. Combining drug and medical benefits in the same place is “the only way” payers will figure out whether such expensive new drugs are actually making people better and saving money by keeping them out of the hospital, he said.

A merger of CVS and Aetna would create a health-care behemoth and put huge pressure on standalone players such as Express Scripts Holding Co. and Walgreens Boots Alliance Inc. Express Scripts would become the last major standalone pharmacy-benefit manager not allied with a major insurer. 

All Channels

CVS and Aetna have held discussions about a potential deal, according to people familiar with the matter who asked not to be identified as the details aren’t public. A newly combined company would “own the entire chain, from prescribing and filling prescriptions to the health plans that pay for them,” said Michael Rea, of Rx Savings Solutions, which has an app that helps patients find lower cost drugs.

Under a combined roof, the insurance arm of CVS-Aetna could help keep costs down by routing patients needing basic urgent care to CVS-owned walk-in clinics and keeping them out of expensive hospital emergency rooms, analyst Ann Hynes of Mizuho Securities said in a note to clients. The company would also become a formidable competitor to UnitedHealth Group Inc., the biggest health insurer and owner of its own PBM unit, OptumRx.

But even with the new clout, a merger isn’t likely to be derailed by federal antitrust authorities, said John Briggs, an antitrust attorney at Axinn Veltrop & Harkrider in Washington.

CVS and Aetna declined to comment.

Walgreens, the No. 2 drugstore operator, could also feel the pressure. A CVS-Aetna marriage could cause the drugstore chain to look for its own acquisition targets, with Express Scripts being the most likely, Charles Rhyee, an analyst at Cowen & Co., wrote in a note to clients Friday.

And then there’s Amazon.com Inc., which recently gained drug-wholesaler licenses in 14 states. The looming threat of the e-commerce behemoth entering the mail-order pharmacy business and pushing down profit margins for drug distributors, benefit managers and retail pharmacies intensifies the pressure on standalone players.

For CVS, the move is “a natural defense against the potential threat of Amazon entering the retail pharmacy market,” Rhyee said.

Another possibility is that Amazon could buy Express Scripts. That would give the internet retailer an instant and large foothold in both the PBM industry and the mail-order pharmacy business.

‘Strong’ Model

Health insurer Anthem Inc., Express Scripts’ biggest current client, announced earlier this month that it would leave Express Scripts when its contract ends at the end of 2019 to form its own PBM unit. And Prime Therapeutics, another major player, manages drug benefits for nonprofit Blue Cross and Blue Shield plans in numerous states.

“Our model is strong and thriving,” said Jennifer Luddy, a spokeswoman for Express Scripts. “We believe in the value that we provide to our customers as an independent PBM.”

On an earnings call this week, Express Scripts Chief Executive Officer Tim Wentworth said he was open to a deal with Amazon to help serve cash-paying patients.

Walgreens declined to comment.

In terms of the CVS-Aetna deal, antitrust authorities will look closely at the competition between the companies in selling Medicare Part D plans for the elderly, said Briggs, the attorney.

There could be fight between the Justice Department and the Federal Trade Commission, which share antitrust enforcement, over which agency will investigate the merger, according to Briggs. The Justice Department handles insurer mergers and successfully stopped the combination of Aetna and Humana Inc. this year. The FTC investigates retail pharmacy deals. In September, it cleared Walgreens’ acquisition of 1,900 Rite Aid Corp. stores after Walgreens shrank the size of the deal.

Still, a CVS-Aetna deal would likely win approval because a number of other major players will remain in the Part D market, he said.

“That’s an easy fix,” Briggs said. “The whole deal is not going to crater on account of Part D.”

    Read more: http://www.bloomberg.com/news/articles/2017-10-27/cvs-aetna-deal-could-mean-end-of-era-in-how-drugs-are-paid-for

    Acid reflux drug linked to more than doubled risk of stomach cancer study

    There are more than 50m prescriptions for proton pump inhibitors in the UK, though they have previously been linked to side-effects and increased risk of death

    A drug commonly used to treat acid reflux is linked to a more than doubled risk of developing stomach cancer, researchers have claimed.

    Proton pump inhibitors (PPIs) reduce the amount of acid made by the stomach and are used to treat acid reflux and stomach ulcers.

    A study published in the journal Gut identified an association between long-term use of the drug and a 2.4 times higher risk of developing stomach cancer. In the UK, there are more than 50m prescriptions for PPIs every year but they have been linked to side-effects and an increased risk of death.

    A link between PPIs and a higher stomach cancer risk has previously been identified by academics but never in a study that first eliminates a bacteria suspected of fuelling the illnesss development.

    Research by the University of Hong Kong and University College London found that after the Helicobacter pylori was removed, the risk of developing the disease still rose in line with the dose and duration of PPI treatment.

    They compared the use of PPI against another drug which limits acid production known as H2 blockers in 63,397 adults. The participants selected had been treated with triple therapy, which combines PPI and antibiotics to kill off the H pylori bacteria over a week, between 2003 and 2012.

    Scientists then monitored them until they either developed stomach cancer, died or reached the end of the study at the end of 2015.

    During this period, 3,271 people took PPIs for an average of almost three years, while 21,729 participants took H2 blockers. A total of 153 people developed stomach cancer, none of whom tested positive for H plyori but all had long-standing problems with stomach inflammation, the study found.

    While H2 blockers were found to have no link to a higher risk of stomach cancer, PPIs was found connected to an increased risk of more than double.

    Daily use of PPIs was associated with a risk of developing the illness that was more than four times higher (4.55) than those who used it weekly. Similarly, when the drug was used for more than a year, the risk of developing stomach cancer rose five-fold, and as high as eight-fold after three or more years, the findings showed.

    The study concluded no firm cause and effect could be drawn, but doctors should exercise caution when prescribing long-term PPIs even after successful eradication of H plyori.

    Responding to the study, Stephen Evans, professor of pharmacoepidemiology at the London School of Hygiene and Tropical Medicine, said: Many observational studies have found adverse effects associated with PPIs.

    The most plausible explanation for the totality of evidence on this is that those who are given PPIs, and especially those who continue on them long-term, tend to be sicker in a variety of ways than those for whom they are not prescribed.

    Read more: https://www.theguardian.com/science/2017/oct/31/acid-reflux-drug-linked-to-more-than-doubled-risk-of-stomach-cancer-study

    Amazon Threat Causes Shakeout in the Health-Care Industry

    Amazon.com Inc. is casting a long shadow over the health-care industry.

    The prospect of the giant Internet retailer entering the business is beginning to cause far-reaching reverberations for a range of companies, roiling the shares of drugstore chains, drug distributors and pharmacy-benefit managers, and potentially precipitating one of the biggest corporate merger deals this year.

    On Thursday, the pressure was plain to see. A report that Amazon had received pharmacy-wholesaler licenses in a dozen states triggered a fast and steep selloff that wounded the likes of McKesson Corp., AmerisourceBergen Corp. and Cardinal Health Inc. And late in the day, shares of Aetna Inc. surged after a report that it was in talks to be taken over by CVS Health Corp.

    Executives in the drug industry say that Amazon could use its expansive online reach and its logistical muscle to threaten companies that ship and sell medicines to consumers and cut pricing deals with drug makers.

    “Size and scale-wise, they can disrupt anywhere they want to disrupt,” said Chip Davis, president of the Association for Accessible Medicines, a trade group for generic medication, in an interview Thursday.

    Competitive Squeeze

    A deal for Aetna could conceivably move CVS further away from the business of brick-and-mortar retail drugstores and deeper in health services such as pharmacy benefits, where it already has a sizable presence.

    Combining Aetna and CVS would create a health-services giant and a bigger competitor for UnitedHealth Group Inc., which is the largest U.S. health insurer and has its own own clinics and a pharmacy-benefits unit.

    The presence of Amazon is already being felt by retailers and companies that sell drugs over the counter. The head of of Bayer AG’s consumer-health business said on a conference call with analysts Thursday that the wider shift to online shopping by U.S. consumers was hurting its business. Erica Mann, the division’s chief, dubbed it the “Amazon effect,” saying buyers are looking for value.

    At the same time, the pecking order in the health-supply chain is beginning to shift.

    Earlier this month, insurance giant Anthem Inc. said it was cutting ties with Express Scripts Holding Co. after a long dispute over pricing and starting its own pharmacy-benefits manager in 2020. A bulked-up CVS and Anthem’s new venture could raise the pressure on Express Scripts, which has touted its independence.

    Any tie-up of Aetna and CVS would follow a pair of failed mergers among health insurers. The deals would have reduced the ranks of big U.S. health insurers from five to three, a prospect that led the Justice Department to oppose both prospective tie-ups.

    If the Aetna deal happened, “CVS would have a dominant position” in the drug-benefits business, said Michael Rea, founder of Rx Savings Solutions, which has an app that helps patients find low cost drugs.

    Pharmacy Threat

    Analysts have speculated that Amazon could soon enter the business of selling prescription drugs, threatening to disrupt retail drugstores, drug wholesalers, and the pharmacy-benefits management business. While Amazon has never publicly commented on what its plans may be, CNBC reported this month that the Internet giant could make a decision about selling drugs online by Thanksgiving. The network didn’t name its sources.

    McKesson slid 5.2 percent at 4 p.m. in New York, while AmerisourceBergen shares fell 4.2 percent and Express Scripts sank 3.7 percent following the report on Amazon’s state licenses by the St. Louis Post-Dispatch.

    Bloomberg News confirmed that Amazon had obtained wholesale-pharmacy licenses in at least 13 states, including Nevada, Idaho, Arizona, North Dakota, Oregon, Alabama, Louisiana, New Jersey, Michigan, Connecticut, New Hampshire, Utah and Iowa. An application is pending in Maine. Some of the licenses were obtained late last year and some this year.

    Amazon declined to comment.

    The licenses could be part of Amazon’s business-to-business sales effort, which would include sales to hospitals, doctor’s offices and dentists. Amazon on Tuesday announced “Business Prime Shipping,” which brings the quick delivery associated with Amazon household orders to workplaces. 

    The Seattle company launched Amazon Business in 2015, offering tractor parts, latex gloves, file folders and millions of other products needed in factories, hospitals, schools and offices. Businesses are shifting their supply shopping online from less-efficient methods such as browsing print catalogs, faxing orders and telephoning sales representatives.

    Online business-to-business sales – a broad category that includes pens and paper for the office as well as lab equipment and parts used in factories — will grow to $1.2 trillion in 2021 from $889 billion this year, according to Forrester Research Inc.

    On a conference call Thursday with analysts, McKesson CEO John H. Hammergren said the wholesaler doesn’t “take the entry of any competitor lightly,” but said the company already has a large online order operation and similar to what Amazon does logistically. “To some extent, we were Amazon before it was cool to be Amazon.”

      Read more: https://www.bloomberg.com/news/articles/2017-10-26/drug-wholesalers-slump-after-amazon-com-obtains-state-licenses

      Trump Officials Dispute the Benefits of Birth Control to Justify Rules

      When the Trump administration elected to stop requiring many employers to offer birth-control coverage in their health plans, it devoted nine of its new rule’s 163 pages to questioning the links between contraception and preventing unplanned pregnancies.

      In the rule released Friday, officials attacked a 2011 report that recommended mandatory birth-control coverage to help women avoid unintended pregnancies. That report, requested by the Department of Health and Human Services, was done by the National Academies of Sciences, Engineering and Medicine — then the Institute of Medicine — an expert group that serves as the nation’s scientific adviser.

      “The rates of, and reasons for, unintended pregnancy are notoriously difficult to measure,” according to the Trump administration’s interim final rule. “In particular, association and causality can be hard to disentangle.”

      Multiple studies have found that access or use of contraception reduced unintended pregnancies. 

      Claims in the report that link increased contraceptive use by unmarried women and teens to decreases in unintended pregnancies “rely on association rather than causation,” according to the rule. The rule references another study that found increased access to contraception decreased teen pregnancies short-term but led to an increase in the long run.

      “We know that safe contraception — and contraception is incredibly safe — leads to a reduction in pregnancies,” said Michele Bratcher Goodwin, director of the Center for Biotechnology and Global Health Policy at the University of California, Irvine, School of Law. “This has been data that we’ve had for decades.”

      Riskier Behavior

      The rules were released as part of a broader package of protections for religious freedom that the administration announced Friday.

      The government also said imposing a coverage mandate could “affect risky sexual behavior in a negative way” though it didn’t point to any particular studies to support its point. A 2014 study by the Washington University School of Medicine in St. Louis found providing no-cost contraception did not lead to riskier sexual behavior.

      The rule asserts that positive health effects associated with birth control “might also be partially offset by an association with negative health effects.” The rule connects the claim of negative health effects to a call by the National Institutes of Health in 2013 for the development of new contraceptives that stated current options can have “many undesirable side effects.” 

      The rule also describes an Agency for Healthcare Research and Quality review that found oral contraceptives increased users’ risk of breast cancer and vascular events, making the drugs’ use in preventing ovarian cancer uncertain.

      Federal officials used all of these assertions to determine the government “need not take a position on these empirical questions.”

      “Our review is sufficient to lead us to conclude that significantly more uncertainty and ambiguity exists in the record than the Departments previously acknowledged.”

        Read more: http://www.bloomberg.com/news/articles/2017-10-06/trump-officials-dispute-birth-control-benefits-to-justify-rules

        It was all yellow: did digitalis affect the way Van Gogh saw the world?

        Extracted from foxgloves, digitalis was once used as a treatment for epilepsy. Could a side effect have triggered the artists yellow period?

        It was recently the 127th anniversary of the tragic death of Vincent van Gogh. His short life came to an untimely end two days after he shot himself in the chest; he had experienced mental health issues through much of his life. In the absence of a definitive diagnosis, speculation as to the true nature of his illness fills volumes.

        Although he came under the care of several doctors during his life time, knowledge of diseases of the mind was in its infancy in the late nineteenth century. As a result, many of the treatments used at the time would have been ineffective if not potentially dangerous. From our point of view, however, one drug that might have been given to Van Gogh is particularly interesting.

        Towards the end of his life, under the care of Dr Gachet, it seems that Van Gogh may have been treated with digitalis for the epileptic fits he experienced. Digitalis, extracted from foxglove plants, is a powerful medicine still in use today as a treatment for certain heart conditions, but not epilepsy. In Van Goghs day, and for a long time before then, digitalis was known to be an effective treatment of dropsy, or accumulation of fluid in the body. Dropsy could have been caused by inefficient beating of the heart or because of liver disease. But with little understanding of the underlying causes of many diseases, almost anything shown to have an effect on the body even if that was simply to induce vomiting was considered a medical benefit. If the treatment for one disease was successful, it was often tried out on a host of others, just in case it proved to be a panacea. Extracts of foxglove really would have been effective in treating dropsy caused by heart failure, but would have done nothing for Van Goghs epilepsy. However, it is just possible it may have contributed to his artistic output.

        Portrait
        Portrait of Dr Gachet, by Vincent van Gogh. Gachet holds a foxglove, seen by some to suggest that he treated Van Gogh with digitalis. Photograph: DEA / G. DAGLI ORTI/De Agostini/Getty Images

        Digitalis is, in fact, a mixture of several different compounds that today are separated and used individually to treat heart conditions. One of the compounds, digoxin, is listed by the World Health Organisation as an essential medicine because of its huge benefit in the treatment of abnormal heart rhythms such as atrial fibrillation. Digoxin has two effects on the heart. Firstly, it helps to control the electrical signals that are sent across the heart to trigger the cells to beat in a coordinated way producing a heartbeat. Secondly, it makes the individual heart cells contract more slowly and strongly, improving the efficiency of the pumping action to move blood round the body.

        To achieve these effects on the heart, digoxin and related compounds interact with the enzyme Na+/K+ ATPase. Digoxin is a very potent drug, the therapeutic dose is miniscule, and it is very close to the level that can also produce digitalis intoxication. Such a narrow gap between a therapeutic and potentially harmful dose would simply not be tolerated in a new drug being brought to market. However, the undoubted benefit of digoxin and its long history of use means it is a vital part of modern medicine. Because the drug has been in use for so long over 200 years, since the physician William Withering advocated its use in 1775 we have had plenty of time to understand how the drug works and the potential side-effects. Patients taking digoxin are carefully monitored and a number of antidotes have been developed to treat overdoses.

        The problem, as with all drugs, is side-effects. To achieve its effects on the heart, digoxin and related compounds interact with the enzyme Na+/K+ ATPase.Digoxins strong interaction with the enzyme means it is very potent, but Na+/K+ ATPase is distributed throughout the body. It is therefore the interaction between the drug and the enzymes located elsewhere in the body that is the cause of side-effects. The most common problems associated with digoxin are nausea and loss of appetite, but its other effects are more intriguing.

        Particularly high concentrations of digoxins target enzyme are found in the cone cells in retina of the eye. These are the cells that give us our colour perception. It is very rare, but some people taking digoxin and related drugs can experience haziness to their vision, or a yellow tinge to everything they see, known as xanthopsia. Occasionally, points of light may appear to have coloured halos around them. Rarer still are effects on pupil size, such as dilation, constriction or even unequal-sized pupils.

        The effects of digitalis intoxication have been suggested as the cause of Van Goghs yellow period and the spectacular sky he painted in The Starry Night. More circumstantial evidence comes from the two portraits Van Gogh produced of his doctor, Paul Gachet, showing him holding a foxglove flower. One of Van Goghs self portraits also shows uneven pupils.

        All of this is very interesting but it is pure speculation. Van Gogh may not have taken digitalis, and perhaps simply liked the colour yellow and the effect of swirling colours around the stars he painted. Unequal pupil size in his self-portrait may have been the result of a simple slip of the paintbrush.

        There are also many other factors to consider. Van Gogh was known to drink large quantities of absinthe (though not enough to produce yellow colour perception) as well as turpentine (which can affect vision but not colour perception). Whatever the reason for Van Goghs particular artistic choices, we can still appreciate his remarkable output from such a tragically short life.

        Read more: https://www.theguardian.com/science/blog/2017/aug/10/it-was-all-yellow-did-digitalis-affect-the-way-van-gogh-saw-the-world

        Rule that patients must finish antibiotics course is wrong, study says

        Experts suggest patients should stop taking the drugs when they feel better rather than completing their prescription

        Telling patients to stop taking antibiotics when they feel better may be preferable to instructing them to finish the course, according to a group of experts who argue that the rule long embedded in the minds of doctors and the public is wrong and should be overturned.

        Patients have traditionally been told that they must complete courses of antibiotics, the theory being that taking too few tablets will allow the bacteria causing their disease to mutate and become resistant to the drug.

        But Martin Llewelyn, a professor in infectious diseases at Brighton and Sussex medical school, and colleagues claim that this is not the case. In an analysis in the British Medical Journal, the experts say the idea that stopping antibiotic treatment early encourages antibiotic resistance is not supported by evidence, while taking antibiotics for longer than necessary increases the risk of resistance.

        There are some diseases where the bug can become resistant if the drugs are not taken for long enough. The most obvious example is tuberculosis, they say. But most of the bacteria that cause people to become ill are found on everybodys hands in the community, causing no harm, such as E coli and Staphylococcus aureus. People fall ill only when the bug gets into the bloodstream or the gut. The longer such bacteria are exposed to antibiotics, the more likely it is that resistance will develop.

        The experts say there has been too little research into the ideal length of a course of antibiotics, which also varies from one individual to the next, depending in part on what antibiotics they have taken in the past.

        In hospital, patients can be tested to work out when to stop the drugs. Outside hospital, where repeated testing may not be feasible, patients might be best advised to stop treatment when they feel better, they say. That, they add, is in direct contravention of World Health Organisation advice.

        Other experts in infectious diseases backed the group. I have always thought it to be illogical to say that stopping antibiotic treatment early promotes the emergence of drug-resistant organisms, said Peter Openshaw, president of the British Society for Immunology.

        This brief but authoritative review supports the idea that antibiotics may be used more sparingly, pointing out that the evidence for a long duration of therapy is, at best, tenuous. Far from being irresponsible, shortening the duration of a course of antibiotics might make antibiotic resistance less likely.

        Alison Holmes, a professor of infectious diseases at Imperial College London, said a great British authority, Prof Harold Lambert, had made the same point in a Lancet article entitled Dont keep taking the tablets as early as 1999. It remains astonishing that apart from some specific infections and conditions, we still do not know more about the optimum duration of courses or indeed doses in many conditions, yet this dogma has been pervasive and persistent.

        Jodi Lindsay, a professor of microbial pathogenesis at St Georges, University of London, said it was sensible advice. The evidence for completing the course is poor, and the length of the course of antibiotics has been estimated based on a fear of under-treating rather than any studies, she said. The evidence for shorter courses of antibiotics being equal to longer courses, in terms of cure or outcome, is generally good, although more studies would help and there are a few exceptions when longer courses are better for example, TB.

        But the Royal College of GPs expressed concerns. Recommended courses of antibiotics are not random, said its chair, Prof Helen Stokes-Lampard. They are tailored to individual conditions and in many cases, courses are quite short for urinary tract infections, for example, three days is often enough to cure the infection.

        We are concerned about the concept of patients stopping taking their medication midway through a course once they feel better, because improvement in symptoms does not necessarily mean the infection has been completely eradicated. Its important that patients have clear messages and the mantra to always take the full course of antibiotics is well known. Changing this will simply confuse people.

        The UKs chief medical officer, Prof Dame Sally Davies, said: The message to the public remains the same: people should always follow the advice of healthcare professionals. To update policies, we need further research to inform them.

        [The National Institute for Health and Care Excellence] is currently developing guidance for managing common infections, which will look at all available evidence on appropriate prescribing of antibiotics.

        The Department of Health will continue to review the evidence on prescribing and drug-resistant infections, as we aim to continue the great progress we have made at home and abroad on this issue.

        Read more: https://www.theguardian.com/society/2017/jul/26/rule-patients-must-finish-antibiotics-course-wrong-study-says

        People taking heartburn drugs could have higher risk of death, study claims

        Research suggests people on proton pump inhibitors are more likely to die than those taking different antacid or none at all

        Millions of people taking common heartburn and indigestion medications could be at an increased risk of death, research suggests.

        The drugs, known as proton pump inhibitors (PPIs), neutralise the acid in the stomach and are widely prescribed, with low doses also available without prescription from pharmacies. In the UK, doctors issue more than 50m prescriptions for PPIs every year.

        Now researchers say the drugs can increase risk of death, both compared with taking a different type of acid suppressant and not taking any at all.

        We saw a small excess risk of dying that could be attributed to the PPI drug, and the risk increased the longer they took them, said Ziyad Al-Aly, an epidemiologist from the University of Washington and co-author of the study.

        The team say the study suggests those who take the drugs without needing to could be most at risk. They urged people taking PPIs to check whether this was necessary.

        Previous research has raised a range of concerns about PPIs, including links to kidney disease, pneumonia, more hip fractures and higher rates of infection with C difficile, a superbug that can cause life-threatening sepsis, particularly in elderly people in hospitals.

        But the latest study is the first to show that PPIs can increase the chance of death. Published in the journal BMJ Open, it examined the medical records of 3.5 million middle-aged Americans covered by the US veterans healthcare system.

        The researchers followed 350,000 participants for more than five years and compared those prescribed PPIs to a group receiving a different type of acid suppressant known as an H2 blocker. They also took into account factors such as the participants age, sex and conditions ranging from high blood pressure to HIV.

        The results show that those who took PPIs could face a 25% higher risk of death than those who took the H2 blocker.

        In patients on [H2 blocker] tablets, there were 3.3 deaths per 100 people over one year. In the PPI group, this figure was higher at 4.7 per 100 people per year, said Al-Aly.

        The team also reported that the risk of death for those taking PPIs was 15% higher than those taking no PPIs, and 23% higher than for those taking no acid suppressants at all.

        Similar levels of increased risk were seen among people who used PPIs but had no gastrointestinal conditions, a result which the authors speculated might be driving the higher risk seen overall.

        Gareth Corbett, a gastroenterologist from Addenbrookes hospital in Cambridge who was not involved with the study, cautioned against panic, pointing out that in most cases the benefits of PPI far outweighed any risk. What was more, he said, while the increased risk sounded high, it was still very low for each person.

        PPIs are very effective medicines, proven to save lives and reduce the need for surgery in patients with bleeding gastric and duodenal ulcers and several other conditions, he said.

        The studys authors said it was important that PPIs were used only when necessary and stopped when no longer needed.

        Corbett agreed that many people take PPIs unnecessarily. They could get rid of their heartburn by making lifestyle changes, such as losing weight and cutting back on alcohol, caffeine and spicy foods, he said.

        The authors said the study was observational, meaning it did not show that PPIs were the cause of the increased risk of death, and that it was unclear how the drugs would act to affect mortality. They said the drugs could affect components within cells, known as lysosomes, that help break down waste material, or shortening protective regions at the end of chromosomes, known as telomeres.

        Aly said people on PPIs should check with their GP whether the drugs were still needed, adding: In some cases we expect that PPIs can be safely stopped, particularly in patients who have been taking them for a long time.

        Read more: https://www.theguardian.com/science/2017/jul/04/people-taking-heartburn-drugs-could-have-higher-risk-of-death-study-claims

        Leafing Las Vegas: recreational marijuana goes on sale in Nevada

        Five states now allow sale of drug for recreational use as hundreds line up at only dispensary on the Las Vegas Strip

        Nevada has become the fifth state in the US selling marijuana for recreational purposes, opening a market that is expected to outpace any other in the nation thanks to the millions of tourists who flock to Las Vegas.

        People began purchasing marijuana in the state shortly after midnight on Saturday. Voters approved legalization in November, making Nevadas the fastest turnaround from the ballot box to retail sales in the US.

        The state joins Colorado, Oregon, Washington and Alaska in allowing adults to buy a drug that is still banned by the federal government.

        More than 100 people were in line at the Source dispensary, at a Las Vegas-area strip mall on Saturday morning. Kristin Deneal said she got in line at 5.45am, after a store that opened at midnight closed before she could make a purchase. She brought a folding chair and sat by the door, striking conversations with the security guard and others as the line continued to grow before doors opened at 9am.

        Deneal, a Las Vegas resident, said she was happy to be able to legally buy a drug that for decades she has had to buy through acquaintances. She said smoking marijuana helped her cope with health conditions while working a stressful job at a bank.

        It looks like they have enough stuff for everyone, its just a question of getting through the door, she said.

        State senator Tick Segerblom, one of the main proponents of marijuana legalization in Nevada, made the first purchase. Deneal and others followed.

        On the Las Vegas Strip, hundreds of people lined up at Essence Cannabis Dispensary. People were excited and well-behaved as a lone security guard looked on. A valet was available to park the cars of customers. A cheer erupted when the doors opened.

        Those 21 and older with a valid ID can buy up to 1oz of pot. Tourists are expected to make nearly two of every three recreational purchases in Nevada, but people can only use the drug in a private home.

        It remains illegal to light up in public areas, including the Las Vegas Strip, casinos, bars, restaurants, parks, convention centers and concert halls places frequently visited by tourists. Violators face a $600 fine. Driving under the influence of marijuana is still illegal.

        Despite the limits on where people can get high and restrictions on where the industry can advertise, dispensaries worked furiously to prepare for the launch. They stamped labels on pot products, stocked up their shelves, added security and checkout stations, and announced specials.

        Desert Grown Farms hired about 60 additional employees. Workers in scrubs, hair nets and surgical masks slapped stickers on sealed jars this week as others checked on marijuana plants or carefully weighed buds.

        It would be a good problem to have if I couldnt meet my demand, said chief executive Armen Yemenidjian, whose Desert Grown Farms owns the only dispensary selling recreational pot on the Las Vegas Strip, across the street from the Stratosphere hotel.

        Some dispensaries used social media to spread the word or tried to draw in buyers with special events. Some planned to give away free marijuana to their first 100 customers or throw parties with barbecues and food trucks later in the afternoon. Some facilities are in strip malls, while others, in stereotypical Las Vegas fashion, are in neighborhoods shared by strip clubs.

        Deneal, 57, said she has a bipolar disorder and a bad neck. She said she never got a medical card for fear of a federal crackdown on those who provided their information to obtain it. Now, she said, she no longer has to fear being arrested for possessing marijuana.

        Im going to spend the whole $100 bucks, she said.

        Read more: https://www.theguardian.com/society/2017/jul/01/leafing-las-vegas-recreational-marijuana-nevada

        In Seattle US old-timers rediscover the high life on cannabis tours

        Retirement home residents take a trip to a producer

        Forget bingo, tea dances and seaside trips. Residents from a chain of Seattle retirement homes are going on Pot for Beginners tours to learn about and buy cannabis in the city, where its now legal.

        Connie Schick said her son roared with laughter when he heard she was joining a field trip to a cannabis-growing operation, an extraction plant and shop. The 79-year-old, who smoked the odd joint in the 70s, wanted to know how legalisation has changed the way the drug is used and produced.

        Schick was one of eight women, from their late 60s to mid-80s, who descended from a minibus emblazoned with the name of their assisted living centre, El Dorado West, outside Vela cannabis store last Tuesday.

        You can only play so many games of bingo, said Schick. My son thought it was hilarious that I was coming here, but Im open-minded and want to stay informed. Cannabis has come so far from the days when you smoked a sly joint and got into trouble if they found out. We used to call it hemp then and didnt know its strength. It just used to make me sleepy, so I didnt see the point.

        Schick, who uses a wheelchair after suffering a stroke, is interested in the therapeutic effects of cannabis. Its so different now. There are so many ways you can take it, and all these different types to help with aches and pains.

        They used to say it was a gateway drug to other things, like cocaine Lots of peoples views are changing.

        Certainly, the number of people aged 65 or older taking cannabis in the US is growing. The proportion of this age group who reported cannabis use in the past year rose more than tenfold from 0.2% to 2.1% between 2002 and 2014, according to the National Survey on Drug Use and Health. A Gallup poll last year showed that 3% of those over 65 smoke cannabis.

        Much of this is attributed to the ageing of the baby-boomer generation, who dabbled with the drug when they were young and are returning to it for medical or recreational use as it becomes legal and more normalised. Cannabis is now legal for medical use in 29 states and for medical and recreational use in eight (since 2012 in Seattle and the rest of Washington state).

        Most of the women on the tour were more interested in the medical use, although Denise Roux, 67, said: I would like to buy it to get high too but Im a cheap high, it doesnt take much.

        A seminar over sandwiches was held for thegroup as they sat in front of the large windows of the cultivation room, where they could see scores of plants growing under intense lighting.

        They were told about the different strains: uplifting sativa plants and more sedating indicas. They learned about tetrahydrocannabinol (THC), which gives a high, and cannabidiol (CBD) which does not, making CBD-rich cannabis appealing for medical use. A scientist in a lab coat who worked in the processing facility spoke about terpenes fragrant oils secreted by glands in the flower that give strains their different smells and flavours. Vials were sniffed and various ways to take cannabis were also covered, including smoking, vaporising and eating it.

        Roux, a retired administrative assistant, said: Im a big Google girl, but I wanted to talk to people who know about it so I can understand it all better. I have an autoimmune disease, which stops my appetite, and Im interested in marijuana from that standpoint. She added she had used cannabis recreationally in the 80s and had returned to it to help with her illness. I use a vape. It makes me sleepy and its a pain control, and it gives me an appetite.

        After the briefing, it was time for shopping. The store looked like an upmarket jewellers, with muted lighting and art on the walls, except the glass cabinets in the store were stocked with pre-rolled joints, edibles including chocolates and sweets, vape pens and bags of different strains of cannabis rather than diamond rings and necklaces.

        Darlene Johnson, 85, a former nurse, perused their contents. On the advice of a bearded bud tender, she bought a deep tissue and joint gel and a tincture to put in drinks, which she hopes will help with her severe neck pain. I wanted a non-psychoactive option, she said. I dont want to get high. I used to work in the emergency room and saw people come in sick from taking too many drugs, though not usually marijuana.

        Her friend, Nancy Mitchell, 80, has never tried cannabis. She has MS and had read that cannabis could help with her symptoms. I wanted to know more details, she said. My kids keep telling me, Mom, try it. I dont want to smoke things, but I see there are other ways.

        Smoking is not allowed at El Dorado West. Village Concepts, which runs the chain, has a no-smoking policy and it is illegal to consume cannabis in public in the state.

        The chains director of corporate development, Tracy Willis, said: There was one man who was smoking it on his patio and he refused to stop, so he had to leave. If youre using an edible, we dont have any issue with it, thats your own business. We treat it as a recreational thing.

        The tours began in response to questions from residents.They wanted to know where it was sold, how much money was made from it, where it was grown, said Willis. Weve had a good reaction [to the tours] from nine out of 10 relatives, but some are horrified. One angry daughter said we were encouraging marijuana use. Her mother told her to butt out.

        Participants
        Participants on the tour learned about different ways to use cannabis. Photograph: Jason Redmond/Reuters

        Read more: https://www.theguardian.com/society/2017/jul/01/seattle-retirement-home-cannabis-tours

        Carrie Fisher would have wanted us to know about the drugs

        Carrie Fisher and her constant companion, the French bulldog Gary, at a signing for her final book last November.
        Image: MediaPunch/REX/Shutterstock

        There’s a wonderful sight gag in Postcards from the Edge, the movie based on the novel based on Carrie Fisher’s life. The Fisher character, just released from drug rehab, is in the kitchen having an argument with her mother. Personifying her cleaner-than-thou attitude, the mother is making herself a smoothie, filling the blender with the healthiest fruit and veggies you can imagine.

        And just before hitting the go button, blink and you’ll miss it, she adds a generous splash of vodka.

        That’s it, right there the kind of societal hypocrisy that Fisher noted and skewered throughout her life, hilariously. Sure, I have drug problems, she said. I self-medicate, and I’m not alone.

        She wanted to stop this kind of stuff mental health problems and their medications from hiding in the shadows where it does the most harm. She named it, all of it: the too-strong pot she smoked with Harrison Ford during the filming of Star Wars; the cocaine problem she brought to Empire Strikes Back (she had plenty of jokes about snow on the Hoth set); and yes, the booze that causes just as many problems as any illegal or prescription drug.

        When the official coroner’s report on Fisher’s untimely death was released Monday, there was a move on the part of some fans to draw a discreet veil over parts of it specifically the fact that she had cocaine, heroin, codeine, oxycodone and MDMA in her system.

        Especially given that the nearest thing to a cause of death was sleep apnea, they reasoned, wasn’t this just invasion of privacy from beyond the grave?

        But as other fans swiftly pointed out, Carrie never wanted to draw a veil over anything involving substance use, abuse or her mental health.

        She wanted it all out there, the pain and the things she used to alleviate the pain. She wanted everyone who struggles with these matters to know they are not alone.

        After all, lest we forget, this is a woman who left strict instructions that her ashes were to be interred in a giant Prozac pill.

        “Without her drugs, maybe she would have left long ago,” her brother Todd said in a statement last week.

        Let’s be honest: Nobody would be splashing vodka into their smoothies if they didn’t at least feel like they needed it.

        “I used to refer to my drug use as putting the monster in the box,” Fisher said in the book of her one-woman show, Wishful Drinking. “I wanted to be less, so I took more.”

        Later in the book comes this gem: “You know how they say that religion is the opiate of the masses? Well, I took masses of opiates religiously.”

        Drugs have always been with us; it’s only society’s attitude to them that changes. Yes, cocaine is a damaging and addictive drug. And 9 milligrams of it were in every bottle of Coca-Cola until 1903. Heroin was once considered less dangerous than aspirin (the same German chemist synthesized both). Small trials have even suggested that MDMA can alleviate symptoms of PTSD.

        Oxycodone and codeine are currently legal; they are also partly responsible for the largest opioid epidemic in American history. (Given the Trump Administration’s plan to defund the fight against this epidemic, we most definitely need to be talking about it at every opportunity.)

        I have personally met many people whose lives were changed by Carrie Fisher’s desire to talk openly about every aspect of her mental health struggles, from the suicidal thoughts to the electroshock therapy. Millions more could be helped if we started having an open and honest discussion about drugs.

        That starts with not sweeping them under the carpet. We all have something to alleviate the pain of living (and if you don’t think that includes you because you don’t use “substances,” I’m willing to bet that food, caffeine, tobacco, TV, shopping, sex or religion has helped ease your troubles).

        Could we possibly admit to ourselves that it isn’t really about what we use so much as the quantity? Could we identify the fuzzy line where self-medication ends and abuse begins, and talk about when and why we cross that line?

        If we could, it would be one more victory to chalk up to Carrie Fisher a woman in full, who was not just a princess, but a hypocrisy-seeking missile.

        BONUS: Carrie Fisher was a bold advocate for people with mental illness

        Read more: http://mashable.com/2017/06/19/carrie-fisher-drugs/