opioid overdose

GOP health care bills would cripple public health opioid response: ‘We’d essentially be putting up the white flag’

kkrisberg — Fri, 30 Jun 2017 04:31:02 +0000

GOP health care bills would cripple public health opioid response: ‘We’d essentially be putting up the white flag’

In Cuyahoga County, Ohio, nearly 200 people have died from opioid-related overdoses in the first five months of this year. That means that this one U.S. county is on pace to lose more than 700 people to fatal overdoses by the end of 2017.

Terry Allan, health commissioner at the Cuyahoga County Board of Health, and colleagues across the county have spent years building and scaling up a multifaceted response to the opioid addiction and overdose epidemic that includes getting people into treatment, changing clinical prescribing habits, preventing deadly overdoses, and dealing with the often-heartbreaking social and economic fallout for families and children. There’s no “one magic pathway” for dealing with this problem, Allan told me, “it’s a continuum that has to be well-supported given the trend we’re on.” Ohio now leads the nation in opioid overdose deaths.

Allan said work is paying off — for example, nearly 1,000 lives in Cuyahoga County have been saved from a fatal opioid overdose in the last few years thanks to expanded access to naloxone — but the opioid problem in no where even close to subsiding. The reality, Allan said, is “we’re not seeing this trend abate.”

He was just as honest about the kind of impact the GOP health care bills would have on the county’s opioid epidemic: “You’d end up with a lot of people being turned away from lack of services. …We’d essentially be putting up the white flag — and now is not the time to pull back.”

The most obvious impact from the GOP health care proposals, both of which severely cut Medicaid funding and are expected to result in more than 20 million additional Americans without insurance, is that people would lose access to addiction and behavioral health services. The loss of access would be the result of losing insurance, whether Medicaid or private coverage, or from scaling back the Affordable Care Act’s essential health benefits, which required insurers cover substance use disorder services along with a number of other basic health services. Both the House and Senate repeal-and-replace bills would allow states to redefine or opt out of the essential health benefits requirement.

But another, less talked about setback for those suffering from opioid addiction would be elimination of the ACA’s Prevention and Public Health Fund (PPHF), which the House bill eliminates in fiscal year 2019 and the Senate bill eliminates in fiscal year 2018. The PPHF — the nation’s first mandatory stream of funding for improving the public’s health — is now the sole source of funding for the Centers for Disease Control and Prevention’s Preventive Health and Health Services Block Grant. That block grant is a critical source of flexible funding for health departments in every state, where officials use the flexible monies to address localized problems, from improving food-borne illness outbreak response to ensuring access to emergency medical services in rural communities. If the GOP succeeds at eliminating the PPHF, the block grant goes away with it.

In Cuyahoga County, that flexible block grant money has gone to support its injury prevention work — and the biggest injury threat now facing the county is opioid addiction. Allan said his agency uses the grant money to procure and distribute naloxone (which is now being carried by police in nearly every jurisdiction in the county), educate local clinicians on better prescribing practices (this is essential, as prescribing is a main driver of the opioid epidemic) and for convening the Cuyahoga County Opiate Task Force, which coordinates a multisector response to the epidemic. Allan said the health board organizes its opioid response according to five buckets: prevention, education, treatment, enforcement and recovery. If the response effort doesn’t account for and coordinate across those five buckets, “we’re just playing whack-a-mole,” he said.

Cuyahoga’s opioid addiction and overdose problem is a complex one that requires the kind of equally complex response that public health is uniquely adept at leading. The loss of the Preventive Health and Health Services Block Grant would put all that work at risk.

“All those dollars are tied to the ACA and without those dollars, this work would really be in dire straits,” Allan told me. “I’m not sure the state would be in a position to fill in the budget gap if the block grant went away. …Our concern is that we’d likely see, on a statewide basis, the support system we’ve built begin to atrophy. We’d be at a loss to deal with the volume that we’re dealing with right now.”

Beyond the public health response, about 700,000 Ohioans have gained insurance coverage through the ACA Medicaid expansion that the GOP bills would eventually eliminate. The expansion has meant many more Ohioans are able to access addiction treatment services, Allan said. If that Medicaid coverage went away, he said, the fear is that many of those saved from a fatal overdose via naloxone would have no where to go for help after being released from the hospital. It’s a wasted opportunity to get people into treatment and keep them from ending up back on the streets and using, he said.

“The impact of this isn’t just to the individual,” Allan told me. “It has communitywide implications for families and to our economy.” To put it even more bluntly, Allan said a loss of coverage for and access to addiction services will simply mean “more people will die.”

Research has shown that the ACA Medicaid expansion has improved access to opioid addiction treatment. In a June report from the Urban Institute, researchers found that many low-income adults in the 32 expansion states have gained access to buprenorphine, which reduces the symptoms of opioid withdrawal and cravings. But while researchers found a more than 70 percent increase in buprenorphine prescriptions per enrollee in Medicaid expansion states, programs are still struggling to meet the needs of such a large addiction epidemic. Another recent report from the Urban Institute found that the ACA Medicaid expansion did indeed fill a significant access gap in substance use disorder treatment, and that efforts to repeal the ACA — such as the House GOP bill — would likely result in millions losing addiction treatment coverage.

“We feel like we’ve been able to make some significant progress with this problem because of the resources the ACA has provided,” said Jeff Duchin, health officer at Public Health — Seattle & King County. “All that would be lost if we lose the funding that’s given people access to (opioid addiction) treatment. It’s very worrisome.”

Like communities across the country, the Seattle and King County area has experienced an increasing number of people addicted to opioid drugs and heroin, with about one person dying every one-and-a-half days from an opioid overdose, Duchin told me. Because of the increasing number of deaths and rising prevalence of addiction, the opioid epidemic has become a high priority for the public health agency in the past two years. In 2016, city and county officials convened a Heroin and Prescription Opiate Addiction Task Force.

Duchin said Public Health — Seattle & King County works particularly close with its sister agency in the county, the Department of Community and Human Services, which coordinates inpatient and outpatient addiction treatment for residents. In addition, ACA-funded Community Transformation Grants are slowly enhancing the effectiveness of that care by supporting efforts to integrate physical and behavioral health services in a single location, Duchin said. Work is now underway to develop these more integrated models of care, where patients can access all the services they need at one place, including housing and social services, but such work takes time.

“It makes the most sense if you want to help people — it’s a big way to lower barriers and allow people to get all the care they need at one stop,” he said of such efforts. “We can’t achieve it overnight, but we’re moving in that direction. …But until we get there, we need to provide low-barrier access to treatment in more traditional contexts. That means increasing the treatment capacity in the community for people with addiction and at the same time, trying to make much of that treatment available where people can also get care for their physical health needs.”

Public Health — Seattle & King County now operates a number of safety net services that reach at-risk, marginalized and underinsured populations. For example, its needle exchange offers access to buprenorphine and its mobile medical units provide access to naloxone, as does its health care program for the homeless, to which Duchin said they hope to add buprenorphine access as well.

Right now, Duchin said the city and county are doing a good job of meeting demands for inpatient addiction care, “but we’re not anywhere close” to meeting demands for outpatient care. To fill that gap, Duchin and colleagues hope to recruit many more primary care physicians willing to integrate buprenorphine treatment into their practices.

“Without a doubt, the Medicaid expansion has greatly strengthened our safety net,” Duchin told me. “We can serve many more lower-income adults not only with physical medical care and preventive care, but we’re able to get them access to behavioral services too. Without that expansion, many would just lose access to those services and we don’t have the local revenues to continue to provide them. …Letting people progress untreated to more complicated stages of disease is not only inhumane and leads to unnecessary human suffering, but it’s more costly to the community.”

Allan in Ohio put it in even simpler terms: “This level of addiction is unprecedented. It needs to be a national priority, and we need to demonstrate that by putting resources toward it. We need to put our money where our mouth is.”

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.

kkrisberg Fri, 06/30/2017 - 00:31

County Health Rankings: Drug overdoses driving turnaround in premature death rates

kkrisberg — Wed, 12 Apr 2017 18:16:51 +0000

County Health Rankings: Drug overdoses driving turnaround in premature death rates

To get a clearer sense of just how bad our drug overdose problem has gotten, look no further than this year’s County Health Rankings. The annual report found that after years of declining premature deaths, that rate is on the rise and due primarily to overdose deaths. It means we could be seeing the first generation of American kids with shorter life expectancies than their parents.

“We often think of the opioid crisis either as happening in very rural communities or as an urban issue,” Kate Konkle, Action Center Team director for County Health Rankings & Roadmaps, told me. “But this is an issue everywhere and particularly in suburban and small metro counties. The good thing is we’re hearing lots of communities talk about this problem — they’re aren’t hiding it or ignoring it.”

Released March 29, the 2017 County Health Rankings measure health in every U.S. county and examine a variety of factors that influence people’s health, such as high school graduation rates, smoking rates, income and access to health care. This year, the “dramatic increase” in premature deaths topped announcements about the report’s release. Specifically, between 2014 and 2015, 85 percent of the increase in premature deaths was attributable to growing early death rates among people ages 15 to 44. Drug overdoses were the top factor driving that rate upward, though homicide, suicide and traffic crashes were even bigger factors for those ages 15 to 24.

In just one decade, large suburban counties went from having the lowest premature death rate due to drug overdoses to having the highest. That’s “alarming,” said Konkle, also an associate researcher at the University of Wisconsin Population Health Institute.

Getting into the numbers, the rankings report found that in 2015, more than 1.2 million people died prematurely, an increase of more than 39,000 people over the previous year. Such rates are highest — and have consistently been highest — among blacks, American Indians and Alaska Natives. Rural counties are home to the highest premature death rates, followed by small metro areas. (How exactly does the report define premature death? Like this: “Rather than examine overall death rates, we look at deaths that occur among people under age 75. These deaths are considered premature because loss of life prior to age 75 is often preventable.”)

Intentional and unintentional injuries — which include homicide, suicide, drug overdose and traffic fatalities — were the top drivers of the premature death increase among youth and younger adults. That’s in contrast to premature deaths due to HIV, cancer and heart disease, which have gone down. In 2015, among those ages 15 to 24, suicide and homicide rates — high percentages of which involved firearms — were highest among Asians and Pacific Islanders and blacks, respectively.

Konkle noted that while drug overdoses are a critical issue for young people in many communities, violence is the main injury threat in others. For example, in some communities, black teens are more likely to lose their lives to firearm-related deaths, many of which are suicides, than drug overdoses. The differences, she said, underscore the need for local engagement and locally tailored responses.

Brand new to this year’s rankings report is a measure on “disconnected youth,” defined as people ages 16 to 24 who are not in school or working. Researchers write of the new measure:

These years represent a critical stage in an individual’s journey toward independence, self-sufficiency, and civic engagement in adulthood. Disconnection can have health and economic costs not just for youth, but for their communities. Youth disconnected from opportunity — meaning the chance to advance in school, gain work experience, form relationships, and build social supports in the community — represent untapped potential to strengthen the social and economic vibrancy of our communities.

Konkle said adding the new measure reflected a renewed recognition that “we need to pay attention to and take care of our young people…and help communities think about avenues for reconnecting kids and making sure they don’t get off the path in the first place.” Here’s what researchers found: About 4.9 million youth and young adults — or one in eight — aren’t working or in school. Rates were highest among American Indians, Alaska Natives, blacks and Hispanics as well as in rural counties in the American West and South. Areas with high rates of youth disconnection were also home to high rates of child poverty, unemployment, teen births and low educational attainment.

“This represents so much creativity and skills that aren’t being tapped into,” Konkle told me. “Each community may have slightly different challenges based on when kids are leaving and where they’re falling out of the system. This data are just a starting point for each community — then they need to dig deeper to see where they’re falling short on creating opportunities for young people.”

However, the rankings report can offer help on that end as well, as it highlights successful local programs that are making a difference. For example, on the issue of youth disconnection, researchers highlighted an effort within the Menominee Nation in Wisconsin, where schools created classroom safe zones where students can develop positive coping techniques. Such efforts have helped dramatically turned around the community’s high school dropout rate: In 2008, less than 60 percent of students at Menominee Indian High School graduated, whereas during the 2015-2016 school year, the graduation rate was at 92 percent.

“We think of this report as a call to action,” Konkle said. “The data is a starting point — it’s not a full picture of everything happening in a community. We give you the numbers, but there are people living behind those numbers. What’s the rest of the story?”

She went on to say: “This helps us remember that health is local, and people have the power to make change happen in their communities.”

To access the new 2017 County Health Rankings, which are a joint endeavor of the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute, as well as a host of interactive tools, visit www.countyhealthrankings.org.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years. Follow me on Twitter — @kkrisberg.

kkrisberg Wed, 04/12/2017 - 14:16

Study: U.S. rate of babies born addicted to opioids has doubled

kkrisberg — Tue, 04 Oct 2016 17:18:53 +0000

Study: U.S. rate of babies born addicted to opioids has doubled

By now, the enormity of America’s opioid abuse and overdose epidemic is common knowledge. With 78 Americans dying every day from an opioid overdose and with enough painkillers prescribed to give just about every U.S. adult their own bottle of pills, there’s hardly a community that’s gone untouched by the deadly problem. And a new study reminds us that we’ll be dealing with the aftermath far into the future.

The study, published in the form of a “research letter” in JAMA Pediatrics, examined rates of neonatal abstinence syndrome (NAS), a condition that occurs when babies are exposed to drugs in the womb and is most often caused by opioid use. Babies with NAS are more likely to be born with low birth weights, birth defects, and breathing and feeding problems, among other issues. Treating NAS can take months, and the long-term effects are not entirely known. The new study aimed to describe current trends in NAS in the U.S. as well as in the rural state of Kentucky, where overdose deaths reached a record high in 2015.

In examining inpatient data nationally and from Kentucky, researchers found that the national rate of NAS has more than doubled, from 3.6 cases per 1,000 births in 2009 to 7.3 per 1,000 births in 2013. In Kentucky, which like many rural states has been hit particularly hard by opioid abuse, the NAS rate rose from 6.6 per 1,000 births in 2009 to 15.1 in 2013, peaking at 23.4 per 1,000 births in the last quarter of 2014. Between 2011 and 2013, Kentucky’s NAS rates were more than double the national rate.

The study notes that while state and federal efforts seem to be slowing down rates of opioid abuse and overdose, there’s been little impact on rates of NAS. Authors Joshua Brown, Pratik Doshi, Nathan Pauly and Jeffrey Talbert write:

The Protect Our Infants Act of 2015 is a federal, bipartisan law introduced specifically to combat the NAS epidemic. This law, along with several others currently being considered by Congress and covered by national media stories, has succeeded in bringing national attention to NAS. However, it fails to offer any tangible short-term solutions to the rapidly growing problem. Meanwhile, rural states, such as Kentucky, that are disproportionately affected by the opioid abuse epidemic must continue to enforce and supplement policies related to surveillance programs along with coverage for addiction services through state services. Because of the tremendous burden of NAS and the potential for lifelong complications for the neonate, tailoring of interventions to pregnant women or women of childbearing age should be a priority of national and state drug abuse efforts.

In July, President Obama signed the Comprehensive Addiction and Recovery Act of 2016 (CARA), a wide-ranging law designed to confront the opioid crisis by expanding education and prevention efforts, strengthening treatment options and widening access to overdose medications, among other measures. Still, the law needs enough funding to make a sustained difference. The White House has already directed millions to overdose prevention and addiction treatment, but Congress has yet to fully fund CARA.

In signing CARA, Obama said: “My administration has been doing everything we can to increase access to treatment, and I’m going to continue fighting to secure the funding families desperately need. In recent days, the law enforcement community, advocates, physicians, and elected officials from both sides of the aisle have also joined in this call. Now, it’s up to Republicans to finish the job and provide adequate funding to deal with this public health crisis. That’s what the American people deserve.”

To request a full copy of the new NAS study, visit JAMA Pediatrics.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Tue, 10/04/2016 - 13:18

Study: Prescription drug monitoring programs lead to less opioid prescribing

kkrisberg — Fri, 10 Jun 2016 15:44:18 +0000

Study: Prescription drug monitoring programs lead to less opioid prescribing

In 2014, more than 28,000 people in the U.S. died from an opioid overdose. That same year, more Americans died from drug overdoses than during any other year on record, with the escalating numbers fueled by opioid abuse. Solutions to the problem are as complex as the epidemic itself, however a recent study pointed to one tool that can make a significant difference: prescription drug monitoring programs.

In a study published this month in Health Affairs, researchers found that implementation of a prescription drug monitoring program was linked to a more than 30 percent reduction in the rate of prescribing schedule II opioids, which is the category with the highest risk of abuse and dependence. Such monitoring programs have been around for quite some time, but a new round of such systems began in the early 2000s. Today, according to the study, every state except Missouri has moved to either implement or upgrade their monitoring systems or have adopted legislation that authorize such actions. Electronic prescription drug monitoring programs allow prescribers to view a patient’s prescription drug history with a goal of preventing doctor shopping and drug diversion.

Study co-authors Yuhua Bao, Yijun Pan, Aryn Taylor, Sharmini Radakrishnan, Feijun Luo, Harold Alan Pincus and Bruce Schackman write:

More than ten million Americans reported using opioids nonmedically in 2014. Nonmedical users may obtain controlled substances by getting multiple prescriptions from multiple prescribers, a behavior known as “doctor shopping,” or from friends or relatives for whom the substances were prescribed, a practice known as “diversion.” Prescribers — generally primary care physicians and dentists, as opposed to pain medicine specialists — are thus an important link in helping address this deadly drug overdose epidemic. Information on potential misuse and abuse of prescription opioids can help these prescribers strike a balance between alleviating pain for patients and ensuring safe prescribing.

To conduct the study, researchers analyzed data from the National Ambulatory Medical Care Survey from 2001 to 2010, zeroing in on patients who reported pain as one of the reasons for their doctor visits. Ultimately, the dataset included more than 26,000 pain-related outpatient care visits in 24 states that had implemented a drug monitoring program sometime between 2001 and 2010. Overall, they found that 5 percent of visits resulted in at least one schedule II opioid prescription, 15 percent resulted in at least one opioid painkiller prescription, 41 percent resulted in the prescription of a pain medication, and 24 percent ended with a non-opioid painkiller prescription. However, the advent of a prescription drug monitoring program significantly slowed such prescribing trends.

Researchers reported that such systems were associated with a reduction in the prescribing of both schedule II opioids and opioids of any kind, as well as less prescribing of pain medications overall. In fact, such systems were associated with a slight increase in the prescribing of non-opioid painkillers. During the study period, the probability of receiving a schedule II opioid prescription during an office visit dropped from 5.5 percent to 3.7 percent, which marks a more than 30 percent reduction from the time period before the monitoring programs were in place.

As for a longer-term effect, the study found a 2.1 percentage point reduction in schedule II opioid prescribing in the first six months of a prescription drug monitoring program being implemented; a 2.2 percentage point reduction in months seven through 12; and a 1.8 percentage point reduction in months 19 through 24. Overall, researchers found that such monitoring programs had a sizeable impact on schedule II opioids, but a limited impact on other kinds of opioids and pain medications in general.

But even though the prescribing tool shows promise in helping to confront the opioid crisis, the study noted that prescriber awareness and participation is pretty low. It cited a report from the Prescription Drug Monitoring Program Center of Excellence at Brandeis that found a median drug monitoring program registration rate of just 35 percent among those who had prescribed at least one controlled substance from 2010 to 2012.

“As prescription drug monitoring program policymaking has shifted from implementation to enhancement, future research is needed to evaluate the comparative effectiveness of key policies and practices designed to promote the reach and effectiveness of these programs,” the study stated.

To request a full copy of the study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Fri, 06/10/2016 - 11:44

Great article. I must say, I read a lot of these blogs, but I am rarely as interested as I was when reading this one. Great work.