ASTHO Annual Meeting: NewPublicHealth Q&A with Terry Cline, PHD, Health Commissioner of Oklahoma
For the last several years, each incoming president of the Association of State and Territorial Health Officials (ASTHO) has introduced a President’s Challenge for the year of their presidency to focus attention on a critical national health issue. Previous challenges have included injury prevention, health equity and reducing the number of preterm births. This year, incoming ASTHO president Terry Cline, PhD, will focus his President’s Challenge on prescription drug abuse, a national public health crisis that results in tens of thousands of deaths each year.
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Just before the ASTHO annual meeting began, NewPublicHealth spoke with Cline about the scope of the issue and steps Cline will introduce to help health officers collectively focus their attention on reducing this public health crisis.
NPH: Why have you chosen prescription drug abuse as your President’s Challenge?
Terry Cline: If you look at the trend lines in the United States, we’ve seen a very rapid increase in the number of deaths from the misuse of prescription drugs. We’ve also seen a huge increase in the number of children born with neonatal abstinence syndrome, which has actually tripled in the last decade. Prescription drug abuse has created an incredible burden on the health of people in the United States. Deaths are just one indicator; others include lost productivity, absenteeism and health care costs. Just using neonatal abstinence syndrome as an example, in 2000 the total hospital charges were about $190 million and in 2009, which is the last year we have that data, it was $720 million. Because in many states Medicaid pays for a large percentage of the births, in 2000 that amount was about $130 million out of the $190 million, and in 2009 it was $560 million of the $720 million. So that is becoming a larger and larger financial burden on states as well, and that does not include the long-term effects on babies.
The President’s Challenge will be looking at the absolute number—bringing down the number of deaths, which stand at more than 16,000 deaths per year. We’ve seen opioid deaths increase and continue every year over the last decade. And in most states now, the number of deaths from prescription drugs is actually greater than the number of deaths from automobile accidents, which has steadily gone down over the last decade. So, one is an example of a public health success; the decrease in motor vehicle deaths stems from a comprehensive approach and work with multiple sectors to bring that death rate down. The other, prescription drug deaths, is an alarming increase. My hope is that with the President’s Challenge, we can really increase awareness and leverage public health agencies across the country to mobilize around this issue.
NPH: What are some of the proposals to reduce prescription drug abuse you’ll be discussing with the state health officers at the ASTHO meeting?
Cline: There are several things that can be done. Some are legislative, some are training, some are education, some are monitoring. ASTHO pulled together a group of stakeholders and developed a strategic map about a month ago, which has basically four pillars or strategic objectives.
One is to expand and strengthen prevention strategies. We know that there are effective community prevention strategies and we know that some of those can involve education for providers, as well.
A second leg of that strategic map is to improve monitoring and surveillance so that we have a good idea of what’s going on in terms of epidemiology of the misuse of prescription drugs. Wielded properly, the monitoring system—which is the system where providers are required, in some states, to check a registry of names and medications they take when prescriptions are written for controlled substances—it is a way to minimize the potential for doctor shopping, also for inadvertent prescribing, and also a way to identify prescribers who are outliers. We know that it varies by state, but on average it’s safe to say that a small percentage—about 10 percent of prescribers—are prescribing about 80 percent of the opioids in many states. So there’s a lot that can be done with the prescription drug monitoring programs.
A third leg is to expand and strengthen control and enforcement, and this really is looking at dispenser education and training, making sure that we’re improving collaboration between public health and law enforcement. A lot of this work gets siloed at times, and what we know in public health, like we saw with the partnership between public safety and public health around seatbelts, is that when we make a concerted effort to work together the outcomes are exponentially more powerful.
And that last leg is improving access to effective use of treatment and recovery support. So on one end of this issue we have prevention strategies, then we have points of intervention in between with monitoring, surveillance, law enforcement control and education. Then on the other end treatment and recovery. And it’s important to have this comprehensive approach. We know that if we squeeze the balloon in one section—say, reduce the supply of these drugs—a concern that we have is if we’re not addressing addiction, then we have people who are addicted to substances but aren’t able to access their supply. And we may see a spike in other types of drugs, and we have seen that in some states where authorities successfully decreased the amount of prescription drugs that were either being diverted or over prescribed, but as a result they’ve seen a spike in heroin use. So we have to make sure that we’re addressing treatment and recovery as well.
NPH: What role does drug abuse education play?
Cline: There’s a very important role for education at multiple levels. So you have the individual level, you have the community level, you have the health care provider level, you have the state level—they all involve education. At the individual level, one of the things we know from the national surveys is that individuals who misuse prescription drugs are actually getting those drugs from medicine cabinets of friends or relatives. They’re not getting them from the internet; they’re not getting them from a drug dealer. So we need to educate everyone. Typically what happens is people keep unused medication in those medicine cabinets and someone comes over and steals it. It could be a relative, it could be somebody going over to their grandparents’ house. They go into the grandparents’ medicine cabinet and take some of the pills. Or it could be a friend of somebody who goes over and raids a friend’s parents’ medicine cabinet, and so there’s a role for appropriate disposal of unused medications. Education is important there. Some states have put educational information on the pharmacy bag, so when you get the prescription it makes it very clear, if you do not use all of it, how to dispose of it appropriately, such as mixing it with coffee grounds or mixing it with kitty litter and not putting it down the toilet or in the water system. So there’s an individual role that we can all play.
At the community level, there are communities that have instituted disposal nights where at certain times, and usually in conjunction with law enforcement, there are disposal drop-off sites. Some communities actually have a sort of fortified mailbox where you can put your unused medications in to get rid of them.
And then for prescribers, really following appropriate guidelines and making sure that you’re not overprescribing or that you’re making sure that you’re taking advantage of your prescription drug monitoring program to see if someone has been doctor shopping, and to also have that information to know if you’re an outlier in the amount of drugs that can be abused that you prescribe. That’s important information to have in terms of education. In Oklahoma we had funded through the Center for Substance Abuse Treatment, at the Substance Abuse and Mental Health Administration (SAMHSA) some prescription guideline training, and the classes that were taught here literally were sold out. So I think there is a strong interest on the part of the prescriber community level as well.
Then at the state level, you have legislation that could be passed that can address some pieces of the prescription drug misuse, such as limiting the number of refills for medications such as the pain reliever hydrocodone. Oklahoma actually passed a law this last year that limits the number of refills to two, except for certain medical conditions such as terminal illness.
We also passed a law this last year that allows the Department of Mental Health to use aggregate data from the prescription drug monitoring program so that we can help design interventions. So, if you see spikes in certain communities, we can make sure that the education is targeted for those communities and that there are appropriate resources to address that. And then we also passed a naloxone bill that allows first responders to administer naloxone with the same kind of Good Samaritan protections. Naloxone’s been found to be a very, very effective overdose prevention tool, where if someone is actually experiencing an overdose, having that first responder administer naloxone is a life saver. Education at all different levels is critical so that you can tailor appropriate interventions.
>>Bonus Link: Read a NewPublicHealth interview with Caleb Banta-Green, PhD, MPH, MSW, Research Scientist at the Alcohol and Drug Abuse Institute and Affiliate Assistant Professor at the University of Washington School of Public Health, on the critical needs for laws throughout the United States to expand the use of naloxone to reduce deaths from drug overdose.