Overdose Deaths in Adolescents; Hip Injections for Osteoarthritis

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include hip injections for osteoarthritis, treatment of Achilles tendon rupture, neoadjuvant therapy for lung cancer, and overdose deaths among U.S. adolescents.

Program notes:

0:50 Overdose deaths in U.S. adolescents

1:51 1,146 overdose deaths in 2021

2:53 Use of drugs down but mortality up

3:56 Improving early-stage lung cancer treatment

4:55 Three doses of nivolumab

5:55 CT scans in those with a history of smoking

6:10 Operative versus nonoperative treatment of Achilles rupture

7:10 Follow up for a year

8:10 More likely to have nerve injury

9:00 Osteoarthritis in hip

10:00 Much better at 2 and 4 months

11:00 When pain is removed

12:00 End

Transcript:

Elizabeth Tracey: Drug overdose deaths among U.S. adolescents.

Rick Lange, MD: Improving treatment of early stage lung cancer.

Elizabeth: What’s the best way to manage a ruptured Achilles tendon?

Rick: And the effectiveness of steroid injections into the hip for people that have osteoarthritis.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University of Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, we have to note that, gosh, this is the first time in quite a while that we have not discussed any COVID material this week, although cases are rising.

Rick: They are, and unfortunately I have an upper respiratory tract infection, which makes it sound like I have a COVID infection. Let’s power on and just talk about some things today Elizabeth.

Elizabeth: Let’s talk about this research letter that’s in JAMA because I have seen so much press coverage of it and I think it’s deserved press coverage. This is taking a look at adolescent drug overdose deaths from January 2010 to June 2021. They note that adolescent drug use rates remained generally stable between 2010 and 2020 when they take a look at 10^th graders who report any illicit drug use in the past 12 months. In fact, they actually even declined to just shy of 19% in 2021, while previously in 2010, for example, it had been 30%. Let me just define adolescents — that’s those aged 14 to 18 years.

When they take a look at overdose deaths among this population, there were 518 deaths in 2010. Rates remained stable through 2019 and then there was an uptick to 492 deaths, and then 954 in 2020, and 1,146 in 2021.

They said, “OK, among these, what’s going on?” What they were able to really point to is fentanyl, and that’s not surprising to us because that’s the same thing we have seen in other populations. The fentanyl-involved fatalities increased from 253 in 2019 to 884 in 2021. American Indian and Alaska Native adolescents experienced the highest overdose rate in 2021. Again, that’s also reflective of things we have seen in other populations.

The authors note, of course, that since 2015 fentanyl has been increasingly added to counterfeit pills that resemble prescription meds like opioids, benzodiazepines, and other kinds of drugs. So if adolescents are just experimenting with these things, they wouldn’t necessarily identify them as dangerous.

Rick: Elizabeth, you’re right. I mean, this is very disconcerting. I mean, the use of drugs has gone down, but the mortality has gone up and you gave numbers. Let’s give percentages. Between 2019 and 2020, overdose mortality increased by 94% and from 2020 to 2021 by another 20%. And as you mentioned, three-fourths of this is due to fentanyl, not because individuals are known to be taking fentanyl, but because it’s lacing other drugs that they’re trying. This is a serious national problem.

Elizabeth: I just have nothing on how we are going to get our arms around this. Because when you lace something that’s a counterfeit prescription drug — it’s I guess fairly easy to do — it looks like the other stuff, and how are we going to help?

Rick: Well, the first thing we need is we need to educate adolescents about the harm that’s associated with taking illicit drugs, even if they think it’s something else. We need to have increased access to naloxone, for example. We need to increase mental and behavioral health services to adolescents that are having psychologic issues or have substance use disorders.

Elizabeth: Well, we need to get after it, I think. Which of yours would you like to turn to?

Rick: Let’s talk about improving treatment for early-stage lung cancer. Lung cancer still remains the leading cause of cancer-related deaths worldwide. We have made improvements in other types of treatments for other types of cancers, but lung cancer has been fairly resistant. We haven’t really put a big dent in it.

This looks at what’s called non-small cell carcinoma. For early stage, the treatment is usually to resect it if possible — and about 25% to 30% of those are resectable — but then as many as half of those come back. What this study did was, besides using the routine therapy, they used pre-surgery treatment — that’s called neoadjuvant — using an immune checkpoint inhibitor. That’s things that stimulates the body for the old immune system to attack the cancer cells, not only the large cancer cells in the large tumor, but also the micrometastases.

In this phase III trial with people who had otherwise resectable non-small cell carcinoma, they randomized it to routine therapy, surgery plus a cisplatin-based chemotherapy, or three doses of neoadjuvant therapy with nivolumab. They looked at overall survival and then how many of those patients had a complete response.

For those who received the neoadjuvant therapy, the overall survival was about 32 months, which was better than 21 months in those that received the routine therapy. More importantly, those that received routine therapy had a complete pathologic response of about 2%. It was 24% in those who received neoadjuvant therapy. About a month ago on March 4^th, the FDA approved use of this particular drug, prior to surgery, in individuals with early stage non-small cell lung cancer.

Elizabeth: This is, of course, extremely interesting because there are a number of these agents that are out there and this strategy of using it in a neoadjuvant capacity is provocative. I’m also wondering with regard specifically to lung cancer, now that we have [this] increased ability to detect early cancers, about using it maybe even earlier.

Rick: We have talked before about the value of having CT scans in individuals who have a history of smoking to identify them because you’re right; you do want to get it earlier because it’s more likely to be successful.

Elizabeth: Lung cancer, of course, the prognosis improving all the time, so that’s excellent news. Staying in the New England Journal of Medicine, let’s turn to this issue of should we use operative or non-operative treatment of acute Achilles tendon rupture.

I had no idea that acute Achilles tendon rupture is one of the most common musculoskeletal injuries, with an annual incidence of 5 to 50 events per 100,000 people. It more commonly occurs in older age with more active lifestyles and male sex, and has been increasing in incidence over the past few decades.

This is a study that was done in Norway, and I’m going to respectfully suggest that it would have been really tough to do this study here in the United States. They had a total of 554 patients who underwent randomization and even in Norway, it took them 5 years to accrue all the patients who ultimately ended up being reported on in this study. They ended up with 526 ultimately. They were randomized into 3 groups: a non-operative group, one an open repair group, and one a minimally invasive repair group.

They took a look at them over the course of the next year. What they found was that their outcomes were really more or less the same. When they asked them, “Hey, how are you doing here at a year?,” they did note re-ruptures were higher in the non-operative group than in the open repair or minimally invasive group. There were nine nerve injuries in the minimally invasive group, compared with five in the open repair group and only one in the non-operative group. So it’s sure looking like physical therapy might be a way to really confront acute Achilles tendon rupture.

Rick: Elizabeth, as you mentioned, it’s somewhat geocentric. In the U.S., if someone has an Achilles tendon rupture, at least in my experience, they always have surgery. I didn’t realize non-operative therapy was even an option and I certainly was surprised that it was as good as either open surgery or minimally invasive surgery in terms of outcome — not only at 12 months, but even along the way.

You’re more likely to have rerupture, but even that’s relatively rare — 6% of the individuals that had the non-operative therapy. But the flip side is, you’re more likely to have nerve injury — about 3% to 5% of individuals who had surgery. It’s a little bit of a tradeoff. Armed with that information, you let the patient know.

Elizabeth: Yeah. I think this is really interesting and part of a trend that we have noted in the past. I mean, we are looking at the treatment of acute appendicitis non-operatively. We look at, “Umm, knee arthroscopy, maybe not,” and so it just seems like, “Hmm.” This one, I agree. I mean, I would have thought, of course, you need to have surgery, but it sure looks like you really don’t need to.

Rick: No, we didn’t mention the fact that this is most likely to occur in older individuals, those that have a more active lifestyle, individuals that take an antibiotic called a quinolone, and individuals that have had a steroid injection near the Achilles tendon. Those are the individuals that are most likely to suffer a rupture.

Elizabeth: Finally, let’s move on to the last one for this week, “Can we also treat conservatively this pain in the hip?”

Rick: This was a British Medical Journal [study]. Let’s talk about hip osteoarthritis in its early stages or when tolerable. We’ll talk about the different treatments. Obviously, in its most severe form, individuals will need to have a hip replacement.

What they were primarily looking at is what’s called “best current treatment” that doesn’t involve a hip injection — things like physical therapy, education, non-steroidal anti-inflammatory medications — versus having a hip injection with steroids. That’s best done if you use ultrasound guidance. You want to get right into the joint in the proper place. Which of those is most effective over a period of 1 year in relieving pain?

They enlisted 199 adults over the age of 40 that all had hip osteoarthritis and had moderate pain. They divided them into 3 groups: those that had best current therapy, those that under ultrasound guidance had an injection with steroids and lidocaine, and those that just had injection only with lidocaine.

Those individuals that had the injection with the steroid did much better at 2 months and 4 months in terms of pain and functional status than those that just had non-injection therapy. But at 6 months there was no difference. It was effective in the first 2 to 4 months, but then the therapy kind of wore off.

The interesting thing, Elizabeth, was that those individuals that had an injection only with lidocaine also had improvement at 2 months and 4 months. To me, that instructs me that at least some of this is a placebo effect.

Elizabeth: I’m wondering about the utility of adding additional things to this after you give the injection and there is pain relief, what about physical therapy to help build up all the musculature around there and other forms of therapy that might then allow there to be improvement after the anesthesia wears off?

Rick: I’m glad you mentioned that. I failed to report that. All these individuals got the same best current treatment. They all got the same physical therapy, the same advice, and the same education. But in addition to that, some got the injection and some did not.

Elizabeth: I’ll just note that I have been seeing an awful lot in the literature lately about different ways of reframing pain. To me, this suggests that when the pain component is removed, that the mechanical aspect of this deterioration of the hip joint is not so prominent. That just says to me, okay, then what’s the role of pain in actually the promotion or the worsening of this condition?

Rick: There is some thought that once you relieve the pain, whether that’s just with lidocaine and anesthetic, or the use of steroids, is it does allow people to engage more fully in physical therapy and they’re more likely to recover or have some improvement than those whose pain persists, and they are just not able to fully engage in that type of treatment. That’s why the lidocaine itself may be just as effective as lidocaine with steroids.

Elizabeth: On that note then, that’s looking at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.