Cline, Terry L. PhD
We have all benefited from successful public health strategies that have improved our lives. While many of these strategies began decades ago, much to our benefit today, many also began during our lifetime, from tobacco control strategies to all-hazards preparedness. The success of these strategies is a testament to the power of public health in action. And yet, while we strive to become a healthier nation, we continually encounter new public health challenges. One such challenge is the misuse of prescription drugs, resulting in countless human tragedies and an alarming number of deaths across the country.
Dr Tom Frieden, Director of the Centers for Disease Control and Prevention, has described the misuse of prescription drugs as an epidemic that ranks as one of the top 5 public health threats facing our country today.1 According to the Centers for Disease Control and Prevention, more than 38 000 individuals die each year from unintentional poisonings. As we analyze these data more closely, we see that 22 000 of these deaths were from prescription drugs, with approximately 16 000 deaths each year attributable specifically to opioid prescriptions, more commonly referred to as painkillers.2 The number of associated deaths has increased dramatically over the last decade; in fact, drug overdose death rates have increased 5-fold since 1980 and the number of deaths has increased steadily to the point that many states are now experiencing more drug overdose deaths than deaths from vehicular crashes.3 These converging trend lines speak to the continuing decline in deaths from vehicular crashes, thanks to more than a decade of coordinated, comprehensive efforts, at the same time, we have experienced a sharp increase in deaths from the misuse of prescription drugs. And while we can take pride in the role of public health in bringing down vehicular deaths, the prescription drug deaths have also taken place on our watch and warrant immediate action from public health (Figure 1).
As president of the Association of State and Territorial Health Officials (ASTHO), I have been afforded the opportunity to issue an ASTHO President's Challenge to my public health colleagues. The challenge must meet the following criteria: (1) be of significant import to public health in terms of population impact; (2) be amenable to public health strategies; (3) be an issue that public health can realistically impact in a relatively short period of time; and (4) be worth the effort, or as a couple of my public health colleagues are prone to say “the juice must be worth the squeeze.” With these criteria in mind, the ASTHO President's Challenge for this year is 15 × 15: To reduce prescription drug misuse and deaths 15% by the end of 2015. This is a very aggressive goal, perhaps a bit aspirational, but people's lives are at stake, literally thousands of lives every year, and I know my colleagues in public health are up to the challenge!
The Role of Partners
To meet this challenge, ASTHO convened a gathering of approximately 30 experts to develop an actionable strategic plan for public health to address the misuse of prescription drugs. These individuals represented a number of federal agencies, such as the Centers for Disease Control and Prevention, the Department of Justice, the Substance Abuse and Mental Health Services Administration, the White House Office of National Drug Control Policy, the Office of the Army Surgeon General, and the National Institute for Drug Abuse; someone in recovery who spoke from the individual and family perspective of prescription drug addiction; as well as professional organizations including the National Association of County & City Health Officials, the American Academy of Pain Management, the National Association of State Alcohol and Drug Abuse Directors, the National Governors Association, the American Society of Addiction Medicine, and the PDMP (Prescription Drug Monitoring Program) Center of Excellence at Brandeis University, among others. A gathering of experts of this quality speaks to public health's ability to bring together and facilitate diverse groups in a meaningful fashion. These individuals brought with them an incredible wealth of knowledge, as well as the ability to link to outstanding work that is already taking place across the country on this topic such as the efforts of the National Safety Council.
The Strategic Plan
This strategic plan emphasizes the importance of a comprehensive approach. The old adage of the plan “only being as strong as its weakest link” certainly holds true here. And while it is unrealistic that public health could carry out all of these functions on its own, public health does possess an enviable ability both to work across different sectors and to engage and leverage other sectors; this is a big part of what public health does, as demonstrated by our work in such areas as infant mortality, immunizations, all-hazards preparedness, and regulatory responsibilities. And as we know, we are often tasked with ensuring that the activities occur, somewhere, somehow, rather than taking responsibility to carry all of these out ourselves. These assurances also hold true for this strategic plan.
The plan comprises 4 different strategic priorities (Columns A, B, C, and D) that support the central challenge to reduce prescription drug misuse and deaths 15% by the end of 2015. Each of these priorities is then supported by numerous activities within that particular domain, column, or, to use the vernacular of the White House Office of National Drug Control Policy, pillar.
Details of the individual activities within each strategic priority can be found at www.astho.org/rx. Rows E, F, and G reflect cross-cutting foundational elements which should be incorporated into all aspects of the strategic plan (Figure 2).
Call to Action: Promoting a Comprehensive Approach
The ASTHO President's Challenge is supported by a call to action that addresses a number of priorities and focus areas. These domains characterize the extent of the prescription drug epidemic and identify key opportunities to collaborate among a wide range of partners and entities and build an infrastructure that appropriately addresses pain management, addiction, treatment, recovery, and results in well-aligned, comprehensive efforts.
Expand and strengthen prevention strategies
Recognizing the full spectrum of prevention (primary, secondary, tertiary), effective strategies reduce the impact of inappropriate use of opioids and drug-related consequences on individuals and communities, while engaging public health officials, health care providers, patients and consumers, community members, families, and other stakeholders. Education is offered through community-based programs, policies, trainings, certifications, and other interventions to prevent prescription drug misuse, abuse, and diversion. Guidelines may also encourage judicious prescribing, patient education, referral to primary care, appropriate disposal of unused medications, and substance abuse treatment when needed.
Improve monitoring and surveillance
Monitoring is a continuous, dynamic process of data collection and analysis. Surveillance extends monitoring by using data and translating it into improved practice. Improved monitoring and surveillance include greater application of clinical monitoring tools and use of PDMPs by physicians, pharmacists, law enforcement agencies, and others. If used properly, PDMPs are a critical tool to help reduce prescription drug misuse, abuse, and diversion and improve patient care. State licensing boards also play a critical role in establishing standards and protocols in the prescribing of controlled substances.
Expand and strengthen control and enforcement
Law enforcement authorities are responsible for upholding controlled substance laws, sometimes jointly with health agencies. Together, these authorities, along with other regulators and licensing boards, can identify individuals who unlawfully divert controlled substances. Effective coordination across treatment and enforcement disciplines can improve diversion control and create alternatives to incarceration. Law enforcement officers and first responders play a role in encouraging the use of naloxone and seeking emergency medical assistance to reduce opioid overdose deaths. Third-party payers' policies and practices can also contribute to improved clinical care and substance abuse reduction.
Improve access to and use of effective treatment and recovery support
Substance abuse treatment is shown to be effective and helps people achieve recovery. Effective treatment programs give people the skills to reduce or eliminate substance abuse and neutralize addiction's disruptive effects on mental health, productivity, and behavior. The stigma of addiction inhibits effective treatment and recovery; but, like other chronic diseases, addiction can be managed successfully. As noted by the Substance Abuse and Mental Health Services Administration, “Behavioral health is essential to health, prevention works, people recover, and treatment is effective.”4 A wide range of services, program models, and supports are available to individuals in recovery, including recovery-oriented systems of care and mutual aid groups. However, an interdisciplinary workforce must be recruited, trained, and retained to ensure a full spectrum of evidence-based care.
Concluding Cautionary Notes
While emphasizing a comprehensive approach and attention to each of the strategic priorities, it is also critical to offer a few cautionary notes. One, we have made great progress in our country in the last decade in the appropriate use of opioids in treating and managing pain. In our zeal to decrease the number of deaths from the inappropriate use of prescription drugs, it behooves us to be mindful and not overly restrict medications to the point that we inadvertently deny people access to appropriate pain management that has significantly improved the quality of life for many people in our country.
Two, likewise, we must increase the availability and access to treatment for people struggling with addictions from prescription drugs. To simply decrease the supply of prescription drugs to someone struggling with addiction, without providing him or her with appropriate treatment and a path to recovery, is an invitation for drug substitution; in fact, there is legitimate concern that while we are successful in decreasing prescription drugs, we will see an increase in the use of heroin, which is, in general, cheaper than prescription drugs and easily accessible in many parts of the country. The solution is not to simply throttle back our determination to decrease the misuse of prescription drugs, but rather to ensure that people have ready access to appropriate treatment for their addictions, whether for prescription drugs or heroin.
And a last cautionary note, there is no silver bullet in the battle against the misuse of prescription drugs. To be successful, we require a comprehensive approach with attention to all aspects of the strategic plan. While we may play just one role of many, public health is poised very well to ensure that we develop a comprehensive and actionable plan based on data and evidence-based interventions at the community and state levels and that we demonstrate our ability to facilitate, if not lead, the charge in successfully driving down the misuse of prescription drugs and its associated deaths. I hope you will join me, as someone committed to improving the health of our nation, in tackling this multifaceted problem. As we have seen over and over across the decades, we can once again use the full strength of public health to save lives and improve the quality of life for people across our country.