The drug abuse epidemic that started with prescription opioid abuse in Kentucky and other Appalachian states during the late 1990s has moved to a new and challenging terrain, with heroin and synthetic opioid abuse spiking in the past couple of years. Between 2014 and 2015, the number of overdose deaths in the commonwealth from heroin and associated drugs increased from 1,088 to 1,248.
Kentucky Health host Dr. Wayne Tuckson cites those numbers as a call to action, and welcomes two guests who are experts in public health policy to discuss strategies for developing a comprehensive drug use prevention program that can be enacted in communities across the state. As Tuckson notes, one of the tenets of public health is that “the best way to treat a disease is to prevent it before it starts.”
Dana Quesinberry, JD, is an attorney with the Kentucky Drug Overdose Prevention Program and the Kentucky Injury Prevention and Research Center at the University of Kentucky’s College of Public Health. Dr. Joann Schulte, DO, MPH, is the director of the Louisville Metro Department of Public Health and Wellness.
Both guests agree that the drug abuse crisis is growing in Kentucky, despite the success of recent legislation in curtailing the distribution of prescription opioids. In addition to the death toll cited by Dr. Tuckson, Quesinberry says that there are increased numbers of people visiting emergency rooms for overdoses, and that there are likely large numbers of unreported drug abuse incidents that do not reach overdose levels.
“We know that the scope of the problem is much larger than we can get a handle on at this time,” she says.
Schulte says that during the first six months of 2016, there were 183 overdose deaths from heroin and other opioids in Jefferson County. She says that there were approximately 5,700 overdoses reported in Jefferson County through the end of October.
That number reflects instances where the Jefferson County EMS responded to an overdose incident and includes episodes where the overdose prevention drug naloxone was used as well as more dire cases that required a trip to the hospital. It also represents 5,700 specific events, not 5,700 unique individuals, Schulte says. Many addicts have multiple overdoses within a calendar year.
“In an average day at the University of Louisville Hospital, they get about 200 patients,” Schulte says. “And about 10 to 20 percent each day are overdoses. So, that’s 10 to 20 overdoses per day, in that one hospital.”
Isolating the Root Causes of Substance Use Disorder
Drug abuse “cuts across all socio-economic lines,” Quesinberry says. “It’s not necessarily a race issue. Males and females are disproportionately affected. Men seem to have more negative health outcomes from their misuse.”
Schulte relates how often she sees drug addicts who come from middle- or upper-class backgrounds, or who have college degrees. She agrees with critics who have pointed out that heroin abuse was not regarded as a public health priority during the late 20th century when it was largely confined to urban areas, and argues that this past inequity should motivate current policy makers to redouble their efforts to address the socio-economic issues endemic to inner-city America as they work to solve the current crisis.
According to Quesinberry, what makes substance use disorder so hard to address within a broad, public policy framework is that it impacts each person on such an individual, personal level.
“There’s three of us here” in the studio, she says. “All three of us could have the same exposure to a medication or to an illicit substance, and all three of us will have an individualized response. Some of that is biology, some of it is exposure through the environment, if the drugs are accessible. That’s why when looking at substance misuse you have to have a comprehensive plan that addresses both the access and the demand.”
Regarding prescription opioids, the problems begin with diversion, says Schulte, when persons raid the medicine cabinet and use the drugs for reasons other than managing acute or chronic pain. She says that recently, government officials at the federal and state level have begun to address the over-prescription of opioids and have also developed better education programs that instruct both doctors and patients about proper use. One such example, she says, is a relatively new initiative in several states whereby doctors and patients enter into a contract that lays out in detail the scheduled prescription and use of opioids throughout a specific timeframe, and is reviewed periodically.
The Center for Disease Control’s “start low, go slow” recommendation for opioid prescription is one both guests agree with, and Quesinberry also points out that recent changes in the compensation structure for doctors who treat chronic pain should encourage them to utilize alternative modalities such as physical therapy and behavioral therapy instead of opioids, which is a positive development. (KET’s recent Health Three60 examined these alternative therapies for pain management in detail.)
Both Quesinberry and Schulte agree that the most pressing problem for public health officials is finding the best way to devise and implement an education and prevention program for children which incorporates the characteristics of the current epidemic. Quesinberry says that, based on the Kentucky Incentives for Prevention Youth Survey, Kentucky children first use tobacco around age 11 on average, and have their first initiation to alcohol between 12 and 14. With opioids, the first exposure comes a few years later, but both guests stress that the drug education and prevention efforts must begin long before adolescence.
The Components of Successful Drug Abuse Prevention
Quesinberry says that her goals for an effective drug education and prevention program would require training parents on how to approach their children at an early age and instruct them to avoid tobacco, alcohol, and all drugs. She also says that the program must be able to identify and provide extra counseling, education, and recovery services to parents who themselves have a history of substance use disorder, since they are at greater risk of passing their misuse on to their children.
“When you get to adolescence, you’ve got to have some frank conversations,” Quesinberry says. “Our children in Kentucky still have a little bit of an issue of rite of passage with some substances. And that’s a hard community norm to break. But that’s essentially where we are as far as having those frank conversations – you may not see a consequence now, but you’re going to see a consequence later.”
Delaying the age of initiation to all [addictive] substances is the ultimate goal of any prevention program, Quesinberry says, since the longer a person waits, and the older a person becomes, the less susceptible he or she is to using tobacco, alcohol, or drugs to self-medicate. Opioids compound the problem, she adds, due to the fact that they cause physical dependence within a few days of use that affects anyone who uses them. Quesinberry also stresses that for a prevention program to be successful, it must adopt a long-term platform, since for most opioid addicts, relapse is likely and multiple attempts at recovery will be necessary.
Schulte says that another important part of drug use prevention involves community education. She discusses drug takeback programs in Kentucky communities that are organized by the Drug Enforcement Administration and local police departments, and recalls one from last fall in Louisville where citizens came in droves bearing sacks full of medications. “We got 954 pounds in that one day,” she says, “and that was not by any means the record haul.”
Overall, both Quesinberry and Schulte believe that the rising costs of the current drug abuse epidemic – in money, medical resources, and most importantly, lives – will ensure that health policy makers come together and develop a definitive drug use prevention program that can be broadly disseminated and is flexible enough to be revised if unintended consequences occur.
Schulte cites the recent finding from the Surgeon General’s report that one in seven Americans will have a substance use disorder at some point in their lifetime. “Just don’t get started if at all possible,” she says, “and we have to do a better job in figuring out how that message gets across at different ages.”