Corner Clinic

This month we discuss the HPV vaccine for boys, effective treatments for opioid addiction and when surgery is required for a hernia.

By: UC San Diego Health Experts   |   December 22, 2016
  1. Should my son get the HPV vaccine?
  2. What’s the most effective treatment for opioid addiction?
  3. I have a hernia. Do I need immediate surgery?
Maya Kumar

Should my son get the HPV vaccine?

Maya M. Kumar, MD, adolescent medicine specialist at UC San Diego Health 

According to the Centers for Disease Control, 79 million Americans are infected with human papillomavirus (HPV), with 14 million new infections each year. Many people know about the association between HPV infection and cervical cancer in women. As a consequence, HPV has been dubbed a “woman’s infection.” However, approximately 40 percent of HPV-related cancers occur in men.

The most common HPV-related cancers in men are oropharyngeal cancers, such as mouth, tongue or laryngeal cancer. Women can get these too, but men are three times as likely as women to carry oral HPV. Rarer HPV-related cancers in men include penile cancer and anal cancer. HPV can also cause warts in the head and neck region (example: laryngeal warts affecting the voice box) and on the genitals. While these warts are not life-threatening, they significantly impact quality of life.

Large trials in many countries have demonstrated that the HPV vaccine effectively prevents HPV infection in boys and girls, including HPV-16, the strain of HPV most likely to cause oral cancer. Therefore, pediatricians strongly recommend HPV vaccination in both boys and girls. Vaccination can begin as early as nine years old, but is routinely included in the vaccine schedule for 11-to-12 year olds, along with Tdap and meningococcal vaccines.

Parents have often heard that the virus is sexually transmitted and wonder why their child would need vaccination. Most STDs affect a small proportion of the population and can generally be avoided with safe sexual practices alone, making vaccination against these diseases on a large scale unnecessary. HPV is different. About 90 percent of all men and women will be infected with HPV at some point in their lives, even with safe sexual practices. Even if you only have one partner for your whole life, you can still get HPV and suffer its devastating consequences. HPV vaccination is the only dependable way to prevent it because it is almost impossible to avoid with lifestyle and behavioral decisions alone.

Parents may also wonder why it is necessary in childhood. Vaccines work best when they are given well before a person is exposed to a disease. The CDC recommends age 11-to-12 years old as the ideal time for vaccination. Recently, the CDC announced that if HPV vaccination is initiated before age 14, only two doses of the vaccine (at least six months apart) are required. If, however, vaccination begins at age 15 or older, three doses of the vaccine (at 0, 1-2 months and 6 months) are needed. This may be because the antibody response to the vaccine appears to be more robust in children 14 years and under, so fewer doses still provide sufficiently strong protection.

The HPV vaccine is an extremely safe vaccine. It contains no mercury, thimerosal or any other harmful preservatives. It also does not contain any live virus, or even any inactivated viral components that could cause infection. Because it is a completely synthetic vaccine, getting infected from it is impossible. As with any vaccine there are some risks. However, as of March 2016, almost 90 million doses of HPV vaccine had been distributed in the United States with no new long-term serious adverse effects identified.

On a personal note, I elected to be vaccinated against HPV when the vaccine became available years ago. I would have no hesitation vaccinating my own children or the children of my friends or relatives. So take it from someone who walks the walk: I strongly recommend the HPV vaccine for both your sons and your daughters.

Carla Marienfeld

What’s the most effective treatment for addiction to opioids?

Carla B. Marienfeld, MD, psychiatrist at UC San Diego Health

Once addicted to opioids, many people find that they no longer use them to relieve pain or to get high. Instead, they need them to prevent the severe withdrawal symptoms or just to feel normal. Indeed, much of what drives the use of opioids is to feel normal enough to do everyday things, like interact with your family and work. Preventing the withdrawal symptoms requires using opioids frequently, and even after withdrawal has ended, the constant cravings to use opioids can prevent being able to focus on normal day-to-day life.

Treatment involves participating in the recovery process, which includes addressing the situations and factors that make use of opioids more likely. Fortunately, for opioid use disorder, we have very effective medications that help most people return to a normal life. This is not true for all addictions. The medications allow for once daily oral or sublingual dosing of a medication that prevents withdrawal and cravings and allows the person to feel like they would before the addiction. These medications are not without their own risks, but when used as part of a comprehensive recovery plan, can be used safely and are incredibly life-changing. The biggest problem is the lack of access to these medications because of the few numbers of doctors or clinics that can prescribe them, the distances many patients have to travel to get them, the lack of insurance coverage or ways to pay for the medications and the stigma associated with treating opioid use disorder.

Alternatives to opioids depend on what the opioid is being used for. If the opioid is being used for pain, there are many alternative pain treatment options that have been shown to be effective, including cognitive behavioral therapy, non-opioid medications, physical therapy, exercise, and even implanted devices. If the opioid is being used as part of an opioid use disorder, the most effective treatments are methadone and buprenorphine, but naltrexone, an opioid blocker, has also been effective in certain situations. Detoxification alone or even inpatient rehabilitation for opioid use disorder both have high rates of relapse to use after the intervention. Each alternative has benefits and problems, but all options should be reviewed when deciding how to best proceed for that person’s particular situation.

Some of the concerns about medication-assisted treatment for opioid use disorder include misuse or diversion of the medications and taking the medications daily so that they can work best. There are several studies looking at long-term implants and long-acting injectable versions of these medications that might be able to address these concerns. 

If someone is experiencing an opioid overdose, it is important to recognize the signs quickly and to respond quickly to prevent death. If someone has used opioids and becomes confused or hard to arouse, they are at risk for overdose. The main cause of death from overdose is when the person stops breathing. If someone is suspected of overdose, call 911 and seek help immediately. If you have access to naloxone, administering this can briefly reverse the effects of the opioid. You must still seek medical attention because the naloxone can wear off, and if the other opioid is still in the system, it can cause the same problem to happen again. If you or friends or loved ones use opioids, it is important to have naloxone, sometimes called Narcan or a Narcan kit, on hand in case of an overdose. In addition to having it available, you should know in advance how to use the medication. Sometimes it is injected via syringe, sometimes it can come as an auto-injector and sometimes it can be a nasal spray. In most states, including California, the laws have been updated to allow people to use naloxone in good faith, and for doctors to prescribe it to friends and family members, even if they aren’t a patient of the doctor’s.

Garth Jacobsen

I have a hernia. Do I need immediate surgery?

Garth Jacobsen, MD, minimally invasive surgeon and director of the Hernia Center at UC San Diego Health

Not necessarily — it depends on whether or not the hernia is painful and inhibiting daily life. Most hernias are relatively asymptomatic and many people choose to put off repair for various reasons.

The question of recovery time can be complex as it relates to time off of work, childcare and travel — not to mention anxiety about undergoing surgery. However, there are certain times when watchful waiting (or willfully ignoring) becomes a hazardous strategy.

While hernias may occur in any area of the abdomen, the most common areas are in the groins, at the belly button or at a prior incision. While it may be safe to delay repair of a completely asymptomatic hernia, it is not safe to delay a painful one. Pain that becomes limiting to your lifestyle — you can no longer go to the store, work, go for a walk, etc. — is the most concerning and should be evaluated.

Today’s repairs are often achieved in the outpatient setting and stays can be as short as a few hours for small hernias, with a quicker return to activity. However, all hernias grow with time, so simple small defects, which may be amenable to outpatient repair, could later grow to be more complex. Larger hernias require more repairs that may require longer hospital stays and recovery periods.

As with all areas of our lives, procrastination is not always the best strategy. Bottom line: while it’s safe to wait on a painless hernia, it may not be the best long-term strategy.


To learn more about the featured medical specialties, please visit:

Cancer

Pediatric and Adolescent Medicine

Psychiatry and Behavioral Health

Surgical Services