opioid
FILE - This Feb. 19, 2013, file photo, shows OxyContin pills arranged for a photo at a pharmacy in Montpelier, Vt. (AP Photo/Toby Talbot, File)(Matthew Perrone Associated Press WASHINGTON -- Federal health)
Abraar Karan
By Abraar Karan MD, MPH, an internal medicine resident at the Brigham and Women's Hospital and Harvard Medical School; and Junaid Nabi MD, MPH, a postdoctoral research associate at Brigham and Women's Hospital and Harvard Medical School
As Governor Kay Ivey takes the helm of the state of Alabama, the opioid epidemic is one of the key challenges she faces. With 1.2 prescriptions per person--the national average is 0.71-- it is clear that Alabama faces a daunting situation requiring smart, directed legislation and action.
Since 2015, thousands of dollars in federal grants have been poured into the state's regulatory agencies in an attempt to control the epidemic. More recently, legislative efforts have focused on punitive measures, which we argue is the wrong direction to take in overcoming the issue.
In February 2017, Rep. April Weaver passed a bill in the House Committee to strengthen trafficking penalties for fentanyl, making them as steep as those for cocaine. A similar bill is in the Senate (Senate Bill 154), backed by Attorney General Steve Marshall, which would make possession of fentanyl a Class C felony resulting in ten years in prison. Currently, fentanyl possession is of Class D status, which holds a 2 year prison sentence. However, we believe that incarcerating our way out of the problem will be costly, will drive illicit use further underground, and will penalize those who are suffering from medical addiction.
Junaid Nabi
Beyond the high financial cost of incarceration, there is a moral cost as well, which we as physicians cannot accept. Opiate addiction is exactly that-- an addiction-- which is out of the hands of those who are addicted once they have crossed a threshold of dependence. While the environments that cause their demise deserve our reprimand, the people who are suffering deserve our compassion and care.
Efforts to support potential addicts that have been undertaken in the state include the Zero Addiction Prescription Drug Abuse Prevention Campaign in 2015, which was funded by a $125,000 federal grant and implemented by the Alabama Office of Prosecution Services and the Alabama Department of Public Health. The campaign has a website which links people to treatment centers in areas near them by providing contact information, but this is hardly sufficient in itself. Beyond websites that people must find on their own, outreach in the community is needed, and is a hallmark of any successful public health intervention.
Understanding the drivers of the epidemic in Alabama is essential to crafting the best strategy. Recent reports presented by Dr. Robert Moon (CMO of the Alabama Medicaid Agency) suggest that half the teenage Medicaid patients in the state in 2016 received their first opioids from dentists and oral surgeons. This, of course, is only from legal prescriptions. The state is also facing a large number of illegal prescriptions, which are naturally causing legislators to focus on the justice system as the way out.
We believe a public health approach holds the most promise. First, Alabama needs to more closely map which counties are suffering the most from opioid abuse and ensure that adequate medical resources are in place, namely addiction centers with available stocks of Naloxone for emergencies. Furthermore, primary care physicians and medical students, as well as dentists and dental students, need to be adequately trained to manage pain and prescribe opiates correctly and safely. This should occur in Continuing Medical Education (CME) programs for practicing physicians, in review lectures during medical and dental residency, and in coursework for medical and dental students.
Addicts are currently stigmatized and seen in many ways as criminals rather than patients. Even among physicians, drug addiction elicits mixed feelings-- some correctly recognize that addiction is a medical disorder, while others hold strong to personal views that addicts are responsible for their own demise. Efforts to change this perception are critical. One important way to do so is through integration of former addicts into society through increasing employment opportunities and ensuring they are away from poor environments which might lead to continued abuse. Public education is key to starting dialogue around addiction, and should be spoken about by Alabama's state leaders.
Importantly, addiction to opioids can stem from underlying mental health disorders. A landmark study in the journal JAMA Internal Medicine revealed that individuals who suffer from common mental health issues such as depression, anxiety, or panic disorder were three times more likely to initiate and continue opioid use. In such scenarios, community support and institutions, like churches and support groups, can be of pivotal influence -- particularly in helping those in recovery to regain important social networks.
It is also important to explore innovative solutions to tackle opioid misuse that go beyond the printed label. Packaging and storage of medications need to be redesigned in order to prevent misuse by those who are in need of pain relief, as well as to safeguard against those who have illegal access to the medications. It would be prudent to invest in technologies that can regulate safe dispensing.
Alabama can be an example for the country if Governor Ivey and her administration approach the epidemic through compassion, care, and innovation--not metal bars.