Fungus's threat; pot users vomiting; prescription drug access for kids: Upstate Medical University's HealthLink on Air for Sunday, Aug. 13, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an infectious disease expert explains why fungal infections are on the rise.

Ramiro Gutierrez, MD: ... These are organisms that we come in contact with pretty frequently, if not every day. ...

Host Amber Smith: A doctor of pharmacy discusses a rare vomiting syndrome seen in people who smoke marijuana daily.

Christine Stork, PharmD: ... The cyclic vomiting that we see in patients presenting to emergency care after having this syndrome report a history of daily high-level use of cannabis for months and years. ...

Host Amber Smith: And the director of the Upstate Golisano Children's Hospital shares advice about filling prescriptions after emergency visits.

Greg Conners, MD: ... Certainly the cost of the medications and the lack of insurance is one factor. But probably a bigger factor is the access to a pharmacy. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn about hyperemesis syndrome from the Upstate New York Poison Center. Then, we'll hear some potential solutions to filling prescriptions after visits to the emergency department. But first, why are fungal infections becoming more of a concern?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." "The Last of Us" was a TV series about life in a post-apocalyptic world during a rapidly spreading pandemic caused by a fungus. While the TV show was fictional, the threat fungi posed to humans is real -- and on the rise.

Here to explain is Dr. Ramiro Gutierrez. He's an assistant professor of medicine and deputy chief of infectious disease at Upstate.

Welcome to "HealthLink on Air," Dr. Gutierrez.

Ramiro Gutierrez, MD: Thank you very much. Happy to be here.

Host Amber Smith: The outbreak on "The Last of Us" was caused by cordyceps. Is that a real fungus?

Ramiro Gutierrez, MD: It is, it is. And I did not know much about that show before my kids asked me about it and asked me a similar question. But, yes, there is a real, based on a real fungus that infects insects, as I understand it.

Host Amber Smith: So it infects insects. What does this fungus do?

Ramiro Gutierrez, MD: So, cordyceps, I think has fascinated people because, certainly, of the show and nature documentaries. But it is a relatively quite specialized, invasive fungus of really very simple organisms, so ants, insects, perhaps spiders. And it's very specialized to infect that type of animal, which obviously is quite a simple organism, compared to people or mammals.

Host Amber Smith: Does it make the insects sick?

Ramiro Gutierrez, MD: It does. And it has an interesting mode of spread in that these insects that have become infected with this organism tend to behave differently once they are infected and seem to move to high ground and then, at that point, become disabled. And this fungus germinates. So it seems to use these organisms, these insects that they infect, to spread. So, it changes their behavior a little bit.

So I think that's where the show and the science fiction show kind of took on that aspect that it's the fungus that makes the infected host behave in a different way. But again, these are very simple insects, ants, that have become infected, and the behaviors that the fungus causes are quite simple as well.

Host Amber Smith: On the TV show, this mutated form of cordiceps begins infecting humans. Is that something that could happen in real life?

Ramiro Gutierrez, MD: You know, I think in infectious disease we've learned to be humble about organisms and how they can mutate and change in several ways. But, frankly, this is probably in as far as that show goes, and the game, that's where science fiction kind of comes in.

These cordiceps fungi that you mentioned are very specialized to infect very simple organisms. And you don't see this type of behavior or manifestation in more complicated mammals, and so on. So I think it's probably unlikely for humans to experience something like it's depicted on the show, and probably not. These are not the fungi that keep me up at night and worry me as far as human infections. But it's an interesting idea and certainly fascinating from a science fiction perspective.

Host Amber Smith: Well, let's talk about how a fungus differs from a bacteria or a virus. Which of these organisms is the biggest threat to humans, and why?

Ramiro Gutierrez, MD: Well, I think they're all threats in different ways. But probably in most simple terms, viruses are the simplest of all these infectious organisms, or infectious agents. Bacteria are a little bit more complex. And fungi are probably even further, more complex and more similar in some respects to humans and human cells.

They vary. So, they're all big problems in their own way. We saw COVID being a virus, being quite a significant and impactful infection worldwide. And so can bacteria and fungi, just in different ways.

Host Amber Smith: Does one spread faster than another, necessarily?

Ramiro Gutierrez, MD: It's variable. I think viruses are known for their ability to spread rapidly, whereas bacteria, perhaps, have a, depending on the organism, they can spread pretty rapidly as well. Fungi are present around us constantly. I think that's an important thing to remember, and many of these fungi that are important for human disease are fungi that we live with every day and we're exposed to almost daily. The humans who become infected with these that are more medically important often have some vulnerabilities. So that's kind of a key aspect here. For invasive fungal infections in humans is that we're actually pretty good at fending off these infections and invasive disease from a fungus. But most of the folks affected have some vulnerability, some immune defect, some medical intervention that's made them vulnerable and such that make them more likely to be infected. So, it's a little bit different than some of these other infections.

Host Amber Smith: So how do fungi infect humans?

Ramiro Gutierrez, MD: Well, like I said, a lot of these, the ones that are medically important -- and it's a short list of most important medically invasive fungi -- like I said, in many instances are around us or live on us. Some of these are yeasts that are normal, form part of our normal microbiome that exists in us. But when individuals become vulnerable, that is, they're sick, they're in the hospital, they have devices, perhaps, to help them treat their condition. Maybe they're intubated in an ICU (breathe through a tube in their windpipe in an intensive care unit), or they're having therapies, like cancer therapy or bone marrow transplants, things to treat an underlying condition. Those things make them vulnerable to these fungal organisms to then get into places where they shouldn't be and cause infection, serious infection.

Host Amber Smith: Once somebody is infected with fungi, can they spread it to other humans?

Ramiro Gutierrez, MD: Some of these fungi live in the environment, so they are already present in soil and so on. Depending on the fungal infection, some are found in hospitals and, again, health care facilities, where there are patients who are, again, vulnerable and susceptible to these infections in those environments. There could be spread in the environment. So there are infection control and other methods that are used to prevent the organisms from spreading. But, they are often present in the environment.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith.

I'm talking with Dr. Ramiro Gutierrez. He's an assistant professor of medicine and deputy chief of infectious disease at Upstate.

Why is the risk of fungal infections, in general, on the rise?

Ramiro Gutierrez, MD: There's a few factors. So, vulnerable hosts or people, individuals who are vulnerable to these infections, that population has grown. So certainly in a resource-rich setting, a place like the United States, where, if you are diagnosed with a serious illness like cancer or require a complicated surgery that may require you to stay in the ICU for a prolonged period of time, those therapies are available.

But those therapies also make you vulnerable to some of these fungal infections. So in a country like ours, I think it's an indication of the ability to treat folks with very serious illnesses and getting them through those periods of time where they are very weakened, from an immune standpoint or a surgical standpoint. I think that's one factor.

The preponderance of the ability that we have now to treat serious bacterial infections and using a lot of antibiotics in very broad spectrum, or antibiotics that can have activity against a lot ofgerms and organisms, bacteria, also results in fungal infections going up as well.

So I think in our setting, those are some of the drivers. In resource-poor settings, places outside the United States where there are still problems with HIV infection, which also makes people immune compromised, and perhaps even climate change effect has been associated with different sets of invasive fungal infections as well.

So I think it's multiple factors. And here in our setting in the United States, probably one of the largest is probably that we provide very advanced medical care and are able to take care of people who have weakened immune systems and are very vulnerable to these infections.

Host Amber Smith: You mentioned antibiotics. Are antibiotics used to treat fungal infections?

Ramiro Gutierrez, MD: The word antibiotic, in general, refers to pharmaceuticals that affect bacteria. So antifungals is the general term we refer to for drugs and agents that are specific to fungi. They are quite different. Fungi, are, like I said earlier, a little more similar to humans in terms of our cell machinery. Bacteria are quite different. So it is, perhaps, a little easier to make antibiotics against bacteria because they have a number of, if you will, targets in their cells that are different than ours. An ideal antibiotic or antifungal, or antimicrobial for both, are drugs that would not affect the person, and it would just target the infecting organism. So fungi, being a little more similar to us, we have a few less targets to go after. So that is a challenge to develop new antifungals.

But, to answer your question, yes, antifungals and antibiotics generally refer to very different types of drug.

Host Amber Smith: The antifungals that exist, can they be used on more than one type of fungus?

Ramiro Gutierrez, MD: Since the first antibiotics were developed, there's been quite a few antibiotics, many antibiotics, generated over time. Antifungals, there's a much shorter list of available drugs. For a very long time there were only three classes of antifungals, and for about 20 years there were no new ones, until fairly recently when an additional class became available.

So, they are specific to different fungal agents. But the list is frankly much shorter of different drugs that are available for fungal organisms, as supposed to bacteria, which we've been dealing with for quite a long time.

Host Amber Smith: In healthy people, does the immune system effectively fight fungal infections? Is that part of how it's treated, is just by letting the immune system do its job?

Ramiro Gutierrez, MD: Yeah. The immune system, the human immune system, is really exquisitely good at dealing with fungal infections. It's a very important protection from these infections. And, like I said earlier, I think one of the biggest changes that has led to us seeing more of these infections happens to be that there are just more and more patients that are vulnerable, so their immune systems are affected in some way, in part due to their illness or the illness we're trying to treat. So the immune system is very important. Normally it's quite good at fending off these infections -- other than the common ones that people may experience, like athlete's foot and some of these superficial skin fungal infections. So invasive fungal infections like we're talking about here, generally our immune system is very good at protecting us, and usually we have to be vulnerable in some way to fall subject to it.

And indeed, although the antifungals are important and can be a critical piece of treating someone with these infections, remedying some of the immune defects or some of the other vulnerabilities and addressing those becomes an important part of the treatment as well.

Host Amber Smith: In the vulnerable population, or someone with a compromised immune system, what are some of the most common fungal infections that you see that you treat in the hospital regularly?

Ramiro Gutierrez, MD: Probably one of the most common are infections caused by candida, which is, within fungal infections, it's a yeast. We call it a yeast. Candida are yeast that live on us and in us. They are a normal part of our microbiome. Most of us have some candida in us. However, if you're quite ill, maybe you've received a lot of antibiotics, you've been in the intensive care unit, dealing with an illness or trauma, and perhaps you're getting antibiotics to treat a pneumonia or something like that, then that candida that's within us can then become invasive and get into somewhere it shouldn't get, into the blood or somewhere else and cause a very, very serious infection.

Those types of situations are probably the most common we see in the hospital. And then there's a few others, diseases caused by another fungus called aspergillus. That one is an environmentalfungus that is, again, present in many environments. We're exposed to it probably daily. But again, certain very vulnerable populations can become infected with it as well. So those are probably among the most common.

Host Amber Smith: So if someone is treated successfully for a fungal infection, does that protect them from future fungal infections from the same fungi?

Ramiro Gutierrez, MD: These are more complex organisms, and the immune response to them is probably just as complex. Probably the answer is generally no. If you have been treated for one of these infections, you could be at risk for another one. But probably only if you become vulnerable again or that vulnerable state. Again, these are organisms that we come in contact with pretty frequently, if not every day.

Host Amber Smith: Well, Dr. Gutierrez, I appreciate you making time for this interview.

Ramiro Gutierrez, MD: Oh, absolutely. It was a pleasure talking to you.

Host Amber Smith: My guest has been Dr. Ramiro Gutierrez. He's an assistant professor of medicine and deputy chief of infectious disease at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

A rare but dangerous risk of daily marijuana use -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

It's rare, but some daily longtime users of marijuana develop a condition that leads to repeated and severe bouts of vomiting. Here to tell us more about this condition is Dr. Christine Stork. She's a doctor of pharmacy and a clinical professor of emergency medicine at Upstate, and she's part of the Upstate New York Poison Center.

Welcome back to "HealthLink on Air," Dr. Stork.

Christine Stork, PharmD: Thank you so much. Happy to be here.

Host Amber Smith: What can you tell us about cannabinoid hyperemesis syndrome?

Christine Stork, PharmD: The cyclic vomiting that we see in patients presenting to emergency care after having this syndrome report a history of daily high-level use of cannabis for months and years prior to having this syndrome.

And it's really very interesting in that it could be many other things. People present to emergency care for cyclic vomiting, and there's a variety of medical causes that could be and need to be evaluated in these syndromes, but the difference is that many of these patients describe relief with heat, and most of that heat is surrounding the use of hot showers. So they'll say they'll get in a hot shower, they'll feel better, and then they'll remove themselves from the shower, and the symptoms will come back.

Host Amber Smith: Does this affect old and young, male and female?

Christine Stork, PharmD: Yeah, there's no real free disposition to having this. It can occur in all people. Again, the use pattern is fairly high use of cannabis, again, over a period of time, so we don't see it in too many younger folk, who are just starting to use cannabis, but once people become kind of older, teenage years, certainly in the college population and moving beyond then, we do have patients who have this and present with it.

Host Amber Smith: Do you see it in people who smoke cannabis, or what about ingesting edibles? Is that a risk also?

Christine Stork, PharmD: It's pretty interesting that it's not seen as much with edible marijuana products, and it's really unclear as to why that is. But some hypotheses have to do with dose. So when smoking a cannabis product, the blood levels, so the amount of cannabis that's in your body, is high almost immediately.

And then if you're continually using the product throughout the day, again, you're maintaining this high level of cannabis. When you ingest an edible cannabis product, the level kind of creeps up over a period of time, and then it goes down over a period of time. And we don't have a lot of people who are continually using edible marijuana-type products throughout the day.

Host Amber Smith: Well, how soon after becoming a daily user might this develop? You said months to years. Could it be as soon as a couple months?

Christine Stork, PharmD: Not usually, but again, if someone escalates their use and has a very high level of use daily, it could be within months. It's usually within years, and it's usually somebody who's built up their use over time.

And pharmacologically, it's not exactly known how this results in vomiting because we all know that cannabis products are used as anti-emetics, or anti-vomiting agents. So the current thought process is that when you use cannabis, it interacts with cannabinoid receptors. They have their own receptors, and those receptors modulate other activities throughout the body, so the normal things, like, in your brain, your chemoreceptor trigger zone is central causes of vomiting and, when interacted, are causing enhanced activity or decreased activity there, you'll have anti-vomiting effect. But I wonder if it really has to do with a little bit of drug withdrawal, because you're using this high-level product over long periods of time, that intermittent flux, or the change that this high-level use has on your other neuro systems then results in a perceived lack of some neurotransmitters that would result in this cyclic vomiting.

So it really requires that high-level use over a prolonged period of time.

Host Amber Smith: So is the cyclic vomiting the first symptom? Do you wake up one day, and this begins? Or are there other symptoms that would clue someone in that this is about to start?

Christine Stork, PharmD: I think most of the time people have gastrointestinal effects that start first.

So they may have some nausea, or they may have some other kind of gastritis-type effects, like feeling not well in their upper gastrointestinal system over time. And then that will then evolve with continued use into having vomiting and then vomiting that's difficult to manage over time.

So it doesn't all kind of flip a switch, and you're starting to vomit.

Host Amber Smith: So you mentioned that a hot shower often makes these people feel better. So that would stop the vomiting at least temporarily, or does that have a lasting power?

Christine Stork, PharmD: It's mostly a temporary effect, so you feel better while that heat is interacting with what we think is a substance they call "substance P" within our neurosensory system. Again, it's fairly complicated, but there's another receptor, there's TRCP, that we think is influenced by that cannabinoid effect or long-term cannabinoid effect. And that's also the reason why topical substances that modulate substance P, which is also influenced with pain, not just vomiting, they sometimes are effective for this cyclic vomiting. So the known drug that's out there that people will use occasionally is capsaicin, which is usually for more pain phenomenon, but there are cases, and case series, where it has been effective for cyclic vomiting.

Host Amber Smith: Have you ever seen this in weekend users of marijuana? So, maybe they don't use for five days, but then they use heavily on the weekends, or does it have to be daily?

Christine Stork, PharmD: It really has to be daily, chronic, high-level use to result in this. Unfortunately, they're the same people that have some degree of at least psychological dependence on these medications.

So it's very difficult for them to go without using these cannabis products. So again, it's not usually a weekend user, so they're usually recreationally using the product, not dependent in any fashion. It's just part of their social activity, so it usually does not occur in those patients.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Christine Stork. She's a doctor of pharmacy and clinical professor of emergency medicine at Upstate, and she's part of the Upstate New York Poison Center. We're talking about cannabinoid hyperemesis syndrome, which is rare, but can be severe.

Now, Dr. Stork, how is this diagnosed if someone comes to the emergency room with vomiting that they can't control?

Are there tests that will be done?

Christine Stork, PharmD: Diagnosis includes all the other potential medical causes that are, disposition-wise, more important, could require things like surgery or more aggressive medications, but are not cannabinoid hyperemesis. They're something else.

So, that whole evaluation will likely occur, and then questioning the patient as to their use of cannabis products and any relief measures really does clue the caregivers into the diagnosis of cannabinoid hyperemesis. Once that has been established or is on the kind of higher level of the differential as to what is causing the symptoms, then the clinician can use things that, as I talked about, like capsaicin. But more often, we'll use things that inhibit dopamine receptor activities. So we know that it's also affiliated with dopamine 2 and dopamine 3 receptors. So giving drugs like we, what we classically would call antiemetics or antipsychotics, that have that activity, is very useful in helping these patients in turning off that cyclic vomiting episode.

So, it's a mix. There's no blood test for it, and there's no diagnostic screen for it, unfortunately. But getting those clues in the (patient's) history, ruling out more severe diagnostic findings, and then using those treatment modalities and seeing the effect, is really how these patients are treated.

Host Amber Smith: So it can be treated. Now, can they take the treatment and still continue using marijuana? Will that work?

Christine Stork, PharmD: Unfortunately, the only real treatment that will stop the cyclic vomiting for sure is, abstinence from cannabis smoking products. And that is seen throughout the (medical) literature as a cyclical event, where people will start using their cannabis product, they'll go on to have gastric distress and then have the cyclic vomiting and to recognize that, "Geez, I can't do this; this is awful," stop using the cannabis product, symptoms will go away, and then weeks, months later, the whole thing starts up again.

Host Amber Smith: Is there research that would show why some heavy users develop the syndrome and others don't?

Christine Stork, PharmD: There really is not much out there to help define that patient population. But I really think it has to do with the individual, their receptors and how their receptors respond to having that high level of cannabinoid receptor activity occurring after use. So there is likely a genetic predisposition to some of this, but none of that's known.

It's all conjecture at this point.

Host Amber Smith: So, I know this is somewhat rare, but it can be severe. Do people end up hospitalized with this, and what are the risks of this if it's not treated?

Christine Stork, PharmD: Usually, no. Usually, patients do not need to be hospitalized because the clinicians at this point are pretty clued in, in terms of figuring out the person has the cannabinoid hyperemesis, and then, treatment.

However, if it's not identified, not treated, and the patient continues to have cyclic vomiting, consequences include not being able to achieve nutrition and also dehydration. And both of those things can require hospitalization in those patients. I don't know if there's a 100% response rate to the therapies that we have. So in non-responders, those patients may need some hospitalization until the effects of their cannabinoid use wears off. So supportive measures are really the mainstay of therapy, but dehydration really can cause a lot of altered or even significant findings in some of these patients.

Host Amber Smith: Well, let me ask you a little more about how marijuana affects the body in general. What does it do to the digestive tract?

Christine Stork, PharmD: It has more of a secondary messenger effect throughout the body.

So cannabinoid receptor, we call it agonism, but when a drug is, or in this case, cannabis, is interacting with those receptor sites, it then goes on to secondary messenger type things. So for regular cannabis use, for example, if someone is using it while they're having chemotherapy, and they're not eating well, it actually is an appetite stimulant.

So it almost has anti-nausea, appetite-stimulation effects, which, again, speaks to the Yin and the Yang of sporadic low-level use. And the doses that are used for that are very low doses,somewhere between 1 and 5 milligrams, very low doses, whereas a very high-level use over a prolonged period of time would lead to the exact opposite.

Host Amber Smith: Does it have effects, lasting effects, on the brain and the heart?

Christine Stork, PharmD: I think some of that is still being researched. The problem with most cannabis products is that they were scheduled (classified) so early in their development by the Food and Drug Administration such that they were considered a Schedule 1, meaning that they have no human use.

And during that time, if someone designates that the chemical has no therapeutic use, you can't do research on that chemical. And that has been a struggle throughout many years. So knowing the long-term effects is really hard to know at this point because it's been such a short period of time, still federally regulated, so federal research trials are not ongoing. So this is more local research trials, but maybe sometime In the future, we'll know whether there's lasting effects of of use and then, what level use, kind of weekend use, as you had mentioned, or chronic high-level use as well.

Host Amber Smith: With marijuana being legal to purchase and use in New York now, I'm curious if the poison center is receiving more calls tied to marijuana usage.

Christine Stork, PharmD: We are, but not in the population that's going out there and buying these products, so they seem to be relatively safe for adults who are using these products in an occasional manner.

It does have acute clinical effects, as we all know, appetite stimulation, but also neurologic effects, and that it causes some alteration in the central nervous system. And that is many times the desirable effect. The kind of unintended consequence that we're seeing at the poison center is when small children, toddlers, are getting into their caregivers' cannabis-containing product.

And even in the past we weren't so concerned about the (marijuana) cigarettes because, as you know, marijuana leaf cannot be absorbed from the gastrointestinal tract because it needs a fatty substrate to be absorbed. So that wasn't a huge deal. It's a much bigger deal, say, to ingest cigarettes themselves,from a toddler perspective, versus the actual cigarette. However, edible marijuana products cause severe toxicity in toddlers and after very small doses. And then, what toddler eats (just) one gummy? As these thingsare being promoted, and many times look like, edible, candy-type products, their chances of getting higher doses is also higher, and we see a lot of significant effects in this age population.

Mental status, depression, like coma, is commonly found in this patient population. It takes time for this to develop because the peak sometimes is two, three, four hours after the ingestion. Some of these patients also develop the need to have a breathing tube, which is really consequential, requires the intensive care unit, and some of these patients have developed seizures.

So toddlers, we do see every year, at least for the past several years, even prior to it being legalized, every year we're seeing about a doubling of our case volume.

Host Amber Smith: And now that it's legal and out there for purchase and use, are there people who shouldn't try marijuana at all for medical reasons?

Christine Stork, PharmD: I think the biggest population who may be at risk from using these products are people who have underlying psychiatric illnesses or are predisposed to psychiatric illnesses. Many people will use and say they use cannabis products for anxiety or depression, but the research thus far is showing that it actually does not help and may make things worse for anxiety and depression and people at risk for having psychosis.

We know that cannabis use, even the first-time use, can cause acute psychosis. Most of the time that resolves. It doesn't mean all the time it resolves. So that would be the highest group of problematic, or people who may want to stay away from using cannabis products.

Host Amber Smith: Well, getting back to the hyperemesis syndrome, at what point should a user seek medical help for vomiting, or would they necessarily need medical help?

Christine Stork, PharmD: I think, many times, once someone's having hyperemesis, meaning they're continually vomiting, they really do need to seek help. I think if their stomach's bothering them, they should stop their cannabis use, and then hopefully they will not progress to having that cyclic vomiting.

But I would encourage people who, they're vomiting and it's not stopping, they should seek medical help because we have things that can help them stop vomiting and move on. And they also need to stop their cannabis use.

Host Amber Smith: Well, Dr. Stork, thank you so much for making time for this interview.

Christine Stork, PharmD: OK, thank you. Thanks so much.

Host Amber Smith: My guest has been Dr. Christine Stork from the Upstate New York Poison Center. She's a clinical professor of emergency medicine and a doctor of pharmacy at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air:" hospitals consider ways to make filling prescriptions after emergency visits easier for patients.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

About a third of patients who leave the emergency department never have their prescriptions filled.

For help understanding why and what can be done about it, I'm speaking with Dr. Greg Conners. He's professor and chair of pediatrics, and the executive director of the Upstate Golisano Children's Hospital.

Welcome back to "HealthLink on Air," Dr. Conners.

Greg Conners, MD: Oh, thanks. I'm glad to be with you.

Host Amber Smith: Let's begin by talking about the reasons so many people don't fill their prescriptions after they're discharged from the emergency department.

Greg Conners, MD: Sure.

Host Amber Smith: How often Is it because of the cost of the medications, or because the family lacks insurance to help pay?

Greg Conners, MD: Yeah. That would be nice to be able to just tell you. It's a certain percentage, but that's a hard thing to figure out. What several researchers have done is looked into why it is that about one third of people who leave the emergency department, or in our case, the pediatric emergency department, don't end up filling their prescriptions. And it turns out to be a complex and thorny problem.

Certainly the cost of the medications and the lack of insurance is one factor. But probably a bigger factor is the access to a pharmacy. And the combination of that and sort of the logistics of getting to the pharmacy if it's night or evening and maybe pharmacies aren't open or as available as they could be. So while cost is part of it, there's actually quite a bit more to it than that.

Host Amber Smith: So cost, and then the ability to get to a pharmacy, whether because of time of day or because of transportation. Do you ever see situations where the family doesn't seem to understand that the medicine's important, and they need it?

Greg Conners, MD: Sure. Yeah. And I'm just picturing someone who's been in the emergency department for several hours. It's, let's say, 11 p.m. They're there with their child. Maybe they have two more at home. And what's on their mind when they're finally done? Not going to the pharmacy. I mean, sometimes it is. But sometimes it isn't. Sometimes it's getting home, getting the child in bed, taking care of the other kids. And so the pharmacy visit becomes kind of important, but less important. So it can all factor into why a medication ultimately doesn't get picked up.

But do people have a problem finding a pharmacy that's open? Absolutely. The 24/7 pharmacies are really getting fewer and further between. And I'll tell you the truth also, when we prescribe medication, we don't always know the hours in which the pharmacy's going to be open.

As far as prescribing from an emergency department, here at Upstate and actually across New York state, almost all of our prescribing is done electronically, so through the computer. And it doesn't automatically tell us what the hours of operation are for the pharmacy on the other end. So sometimes we have to ask the family's advice or we have to call the pharmacy and find out their hours. Or sometimes we just do our best.

Host Amber Smith: Can providers accurately predict which families will or will not fill prescriptions, or do you just sort of not have any idea?

Greg Conners, MD: Well, it's the subject of research. People have tried to find factors that are predictive of that, and it's actually pretty hard. Some factors have been associated with it, whether it's families with other children, or younger kids who have been in the emergency department a long time.

Sometimes language has a role, so someone who speaks a language other than English. We do really well with interpreters, and yet still, sometimes something is lost, or the understanding isn't quite there.

If it's late at night, as I mentioned. Of course, if people have not picked up their medications in the past, that's another sort of sign that it might not happen again. Or they don't seem to agree with the plan, as you alluded to, and we'll talk more about that. Or they, maybe they just don't understand the plan.

There's actually been research that unaccompanied teens maybe who are there on their own aren't always as reliable in picking up medications that are prescribed as other patients are.

So lots of factors. But in the end it's very hard to predict who does and who doesn't pick up their medications. So, we have to be, we in the emergency departments, have to be somewhat proactive and ask, "Are you going to be able to get this medication? I want you to know it's important." And physicians, but also a lot of this falls to nurses, but hopefully somewhere in the team, we make sure to ask families that. And if we only ask families that we think are high risk, we're going to miss a bunch. So we have to be pretty universal about bringing this up with everybody. Families sometimes don't understand why we're prescribing medications, and so we do have to re-emphasize that as part of the touching base with families about why the medications are important.

Host Amber Smith: You mentioned the electronic prescribing. Does the pharmacy alert you when the person picks up their prescription?

Greg Conners, MD: No. There really isn't much in the way of feedback. When we hear from pharmacies, it's usually when there's a question, whether it's an insurance coverage question or the family doesn't think this is what they expected to pick up, something along those lines. And that's really actually a pretty small percentage of the prescriptions that we write. So most of the time we aren't alerted that a family did or didn't pick up a prescription.

Host Amber Smith:

So let me talk to you about the dangers of not filling a prescription. What sorts of things could happen to a patient with certain conditions that doesn't get the medicine?

Greg Conners, MD: I kind of, when I think about that, I kind of break things up into two categories. One is chronic conditions. For example, a child with asthma who has asthma now, and is going to continue to have asthma or who has seizures, or maybe diabetes, somebody who needs chronic medications to stay on track and to stay healthy. If they go without their medications, then their chronic problem, which might be well controlled, would be less well controlled, and they might end up having more seizures, or their blood sugar goes out of control, or they have trouble breathing from their asthma because they didn't pick up their medications.

Then there are the acute things. For example, if someone comes in with an infection, let's say ear infection or something else, as an example. This isn't a chronic condition, but at the time it's an important health problem for them. And whether they pick their medications up or not, it's going to make a big difference in if the acute infection or the acute problem gets better.

Host Amber Smith: So they may leave the emergency department feeling better and thinking, oh, I don't really need that, but they do. The infection is still there.

Greg Conners, MD: It happens, yeah.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with pediatrician Greg Conners, the executive director of the Upstate Golisano Children's Hospital. Dr. Conners also leads the department of pediatrics, and he's a professor of emergency medicine and public health and preventive medicine.

Now, Dr. Conners, you're chair of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, which has a report published in the journal Pediatrics that gives some suggestions for how to increase compliance with filling these prescriptions. Can we go over some of the potential solutions?

Greg Conners, MD: Sure, let's do it. I just want to just point out that this technical report that we published just this month of June in 2023 is really a wonderful resource for emergency department leaders who are thinking about dispensing medications from the hospital at the time of discharge in the emergency department.

And it's quite a balanced report. I think it talks about pros and cons, issues and things that a leader should think about. So I think that's really well done. And I'm saying that because -- although I am the committee chair, I'm not the principal author -- and I do really do admire the job that the principal authorship team did in producing this document. And it's available from the American Academy of Pediatrics at the Pediatrics Journal website.

Host Amber Smith: So is it essentially suggesting that hospitals become pharmacies of their own, and they dispense the medicine to the patient before they leave?

Greg Conners, MD: Actually this doesn't make any recommendations for or against. It mostly talks about factors that go into making such a decision. I think what it does is, it increases awareness. But this is something that is on the table. It can be done. If you hadn't thought of it as an emergency department leader, now you can think about it. Or if you're thinking about it, but don't really know enough by the time you read this technical report, you have a lot of information and also a lot of additional resources.

Of course it is something that many emergency department leaders have thought about, and yet this, for the pediatric leadership, it helps really frame some of the thinking. But I will just tell you that the report falls short of mentioning or recommending you should do this or you should do that. It's mostly an informational type of report.

Host Amber Smith: Are there existing barriers to prescribing medications from the emergency department?

Greg Conners, MD: Well, the short answer is yes. And the long answer is, I'm going to tell you more about what some of those barriers are. And there are several, quite a few, and it often boils down to money.

Sending patients home with prescriptions, I mean, it sounds wonderful, and it would be great if families could just get everything they need and then leave. It does require a lot of additional infrastructure from emergency departments, pharmacists, for example, to prepare the medications, to label them properly, all the things that a pharmacy will do when you go there, to explain, to think about billing and financial considerations for medications also. This is what a pharmacy is really good at. This is what they do. And so we would be required to be just as good at it.

A lot of hospitals -- for example, Upstate has an outpatient pharmacy. And so it's really nice if the pharmacy is open. And while we maybe can't send patients home with the medication right in their pocket, we can say, "And there's an outpatient pharmacy that's just wonderful, just around the corner and down the, within our same building. And if you'd like, we can send your prescription electronically to that pharmacy. They can start preparing it, and you can just go over and pick it up." That's really a wonderful option that we have. Not all emergency departments have that, but we do at Upstate. Of course, it has limited hours.

Some additional considerations include the fact that when you're in an emergency department, you want to leave, and if it takes extra time to prepare and then dispense the medications, that can slow things down and sometimes present a barrier also.

And of course, we in the emergency department have a limited number of rooms, a limited amount of space. We want to get patients out safely and not in any way too fast. But once they're ready to go, we want them to be able to leave. And sometimes this can slow down the works. But there are lots of pros too. Those are some of the cons.

Host Amber Smith: Let me ask you what Upstate is doing to help solve some of this.

Greg Conners, MD: So in the Upstate emergency department, of course, we're subject to New York state regulations, which really limit the availability of filling outpatient prescriptions in the emergency department setting. Although we do have some ways of getting around things. And so for example, what we can do is give a first dose of, let's say, an antibiotic, right in the emergency department. And if it's an every eight hour medication or an every 12 hour medication, then the patient has eight or 12 hours before the next dose is due. And that may make the difference, and often does, in giving families time to get to the pharmacy, let's say, the next morning, and yet not missing a dose. So it's really nice that we're able to do that. And I will tell you, I've worked in other emergency departments where we haven't been able to do that. You know there have been rules against it or so forth. So it's nice when we can give the first dose. Also sometimes we will use a, let's say, an asthma inhaler with the patient, and then no one else is going to use that inhaler, so we can give it to them to go. That's sometimes available, too. But there are New York state regulations, as I said, that limit the availability of using the emergency department as a distinct pharmacy. And it's something that actually our Upstate pharmacy leadership -- and I have to just say that our Upstate pharmacy leadership and our Upstate pharmacists are really a wonderful bunch, well educated, wonderful about being flexible. I always have great admiration and appreciation for those folks -- so we have some of our leadership working at the state level to try to get regulations updated, upgraded to be more what we would consider patient friendly.

I will just tell you that we also keep in mind that every time we dispense something, that's a pharmacy in town that has one less opportunity to dispense something. And I would hate to have a pharmacy no longer become a 24-hour pharmacy because we've sort of taken over giving their nighttime medications, if you see what I mean, providing too much competition, so that it's no longer economically feasible for them to stay open all night. So all that goes into the thought about whether or not we should be prescribing medications on discharge from the emergency department.

Host Amber Smith: So this report is a roadmap, essentially, to other children's hospitals for how to do this maybe more efficiently than they're doing it now?

Greg Conners, MD: Sure. Yeah. I like to think it'll be really helpful to people who haven't given this as much time and research as it really requires. And so the authorship group got together and put a lot of time into making as comprehensive as they could.

Host Amber Smith: Well, Dr. Conners, thank you for taking time to tell us about it.

Greg Conners, MD: Oh, I'm happy to do that. Thanks.

Host Amber Smith: My guest has been Dr. Greg Conners. He's a pediatrician and executive director of the Upstate Golisano Children's Hospital. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from pharmacist Eric Balotin from Upstate Medical University. How should a person pick a pharmacy?

Eric Balotin: I think when a patient should be looking for a pharmacy, they should be looking for a pharmacy that they can make a connection with. So is that pharmacy delivering the type of care that they expect from a pharmacy? I mean, you want a pharmacy that's going to pay attention to the medications that you're taking and making sure there's no drug interactions. You want a pharmacy that's going to be looking out for your best interest so that if you can't afford a medication, looking for resources that can provide that medication at a discount or looking for an alternative therapy so that you can get some sort of a medication to treat your issue or your problem. You should look for a pharmacy that has outreach phone calls. So our pharmacy and other pharmacies communicate with patients on a monthly basis to say, "Hey, you're due for your refill," kind of a reminder phone calls. We also should look for a pharmacy that says, "Hey, my prescription's ready for me. Should I come pick it up?" So, I always say, as a pharmacist, that you should really try to find a pharmacy that you can make a connection with, that's going to service you well, and that really has your best interests at heart.

Host Amber Smith: You've been listening to pharmacist Eric Balotin from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Elise Chadwick, high school teacher and poet, describes an upscale ICU, which nonetheless can't offset the ordeal unfolding in this beautiful room.

"The Five Star ICU"

There's space enough

for two chairs and a cross-legged

sprawl in the five star ICU.

Extra-wide bed offers contortions

to delight a yoga guru.

Fluorescent monitor

squiggles appear

disappear

then

reappear

in hypnotic loop.

It's quiet here.

No sticky floor squeaking.

Nobody shouting

from across the hall.

Even upward facing

bulbs beam soft light.

No institutional glop either.

You order from a glossy menu

boasting sandwiches made

on artisanal bread.

We spend companionable time.

You wear headphones moaning

part boredom, part pain.

IV bags of clear fluid

a swarm of jellyfish suspended

tangled tentacles dangling drip

ever so

slowly into your veins.

Dad on his computer escapes

into a world of words

and shipments.

And me,

determined to document

then bury this nightmare

so deeply it will never

ever surface,

no matter the Richter magnitude

of the next quake that threatens

to unearth it.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," pancreas transplants to treat diabetes.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org

upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broekel.

This is your host, Amber Smith, thanking you for listening.