A Prescribed Epidemic

Prescription opioids (aka painkillers) like morphine, OxyContin, Percocet, and Vicodin (to name just a few) peaked in 2012, with 81.3 prescriptions per 100 persons. The rate of prescriptions has since fallen, but the United States still represents 80% of world opioid prescriptions (via 2015 data), and has high rates of opioid prescriptions among people under the age of 65 (i.e. the population that is younger and should be healthier). This problem of prescription is deeply embedded in how the United States (fails to) regulate the pharmaceutical industry:

Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.

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Image via postsecret.com

Opioid abuse is rampant, and is frequently cited as one of the “gateway” drugs to heroin . Opioids are highly addictive drugs because they target parts of the brain that are susceptible to feeling pleasure. Since opioids are more intense than the natural endorphins that humans produce, users of pharmaceutical opioids or illegal opioid drugs (like heroin) feel pulled to chase the high, continue using opioids (and use in increasing amounts), and may become addicted.

Prescriptions for opioids have fallen since an all-time high in 2012, but are still above CDC recommendations. Additionally, length of prescription was found to have actually increased between 2006 and 2015, meaning patients are exposed to the affects of prescription opioids for longer periods, against CDC recommendations. Prescriptions are also doled out unevenly, and a CDC report found that  “the places with the largest number of prescriptions filled tended to have more white residents and higher rates of poverty and unemployment…” See the maps below. On left, rates of opioid prescriptions by state in 2012, on the right, poverty rate by state in 2013. States with higher rates of poverty also have higher rates of opioid prescription.

Just about this time last year, Last Week Tonight did a segment on opioid prescriptions that highlighted the role of aggressive marketing from pharmaceutical companies to influence doctors’ prescriptions of opioid painkillers. [Note: There are some things I find grating in the format of Last Week Tonight but I think this does really quality work at communicating the history of opioid marketing and prescription in the US.] In sum – big pharma played fast and loose with marketing, many doctors fell for it, and now we have huge rates of opioid abuse.

It takes time to change trends in medical practices. It took time for the prescription rates to reach the 2012 highs! So it tracks that it’s going to take some time, even with increased surveillance, research, and awareness before doctors really change opinions about what pain management strategies should look like.

Most articles that I see in local news focus on the opioid epidemic in population health – through interviews with people affected by the opioid crisis and investigations into the areas where opioid addiction is most prevalent. I think many of these articles are great, but they do obscure the macro-level issue of how opioids have come to saturate the medical industry. Fortunately, now more attention is being paid to the source: big pharma. 

41 States of Investigate Pharmaceutical Companies over Opioids (9.19.17 via NPR) – A coalition of state attorneys general have come together to investigate potential impropriety in pharmaceutical companies’ role in the opioid crisis.

“Our subpoenas and letters seek to uncover whether or not there was deception involved, if manufacturers misled doctors and patients about the efficacy and addictive power of these drugs,” New York Attorney General Eric Schneiderman said during his press conference announcing the investigation. “We will examine their marketing practices both to the medical community and the public.”

Are Pharmaceutical Companies to Blame for the Opioid Epidemic? (7.2.17 via The Atlantic) – “Big Tobacco” faced lawsuits in the pursuit of improved public health and has been required to make changes – this article examines the legal possibility of states attorneys general pursuing these cases.

With the tobacco-industry lawsuits, customers were using the product as instructed and got sick. With opioids it’s a different story: Customers are not using the pills as directed, and so it is harder to blame the pharmaceutical companies for the effects of that misuse, according to Lars Noah, a professor of law at the University of Florida. In addition, doctors, not consumers, were the ones targeted by the aggressive marketing campaigns undertaken by pharmaceutical companies, so it can be difficult to link consumer deaths with aggressive marketing.

Whether suits against pharmaceutical companies will be successful is to be determined – already cities and states that have been hit hard by the opioid crisis have taken steps to sue pharmaceutical companies, and it’s possible that in the next year or so we could see court decisions go one way or another. I’m definitely interested to see what happens — but hopeful that this increased attention on the issue of opioid prescriptions will ultimately result in better treatment for those facing addiction and helpful changes made in medical care to prevent exacerbating an already unfortunate epidemic.

 

Climate Change, Hurricanes, and Humans

This Vox video is a really helpful primer on the impact of climate change on weather events. On top of that, Houston is located in a wetland area that has largely been paved over in the last few years, decreasing drainage opportunities. Where water might go naturally into the ground, it’s now sitting on top of tar and the city has filled up like a bathtub.

People are suffering in Houston because of climate change. It is stressful and difficult to deal with homes that have been destroyed, on top of physical risks to health like increased diseases, insects, and injuries.

If you’re looking for places to donate, I urge you to think more locally than large, national relief organizations . Here are links to some people and organizations that will really benefit from any donation, small or large.

Donate: 

Healthy Outdoor Spaces & Environmental Pollution

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A plastic bottle floats in the Darby Creek.

The first time my partner and I used our inflatable tandem kayak (yes, I know that’s very dorky but we’re renters and don’t have space for a real kayak) we took it to the John Heinz National Wildlife Refuge at Tinicum to go out in Darby Creek. We had been to the Heinz before, but on foot. The Heinz is the nation’s first “urban refuge,” established in 1972 to preserve the marshland and the ecosystem that relies on it.

Last year while I was taking a class on environmental public health for my MPH degree, we had Josh Barber, the EPA Remedial Project Manager at the Clearview Landfill come speak to us about Superfund sites. The Clearview Landfill is located above the Heinz, while the Folcroft Landfill is located downstream, partially in the Heinz. Both landfills are Superfund designated sites, which are highly polluted areas identified by the government for remedial action in the interest of environmental and human health.

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That big body of water is the Heinz refuge. Image from: https://response.epa.gov/site/site_profile.aspx?site_id=5864

So this was in the back of my mind, but I didn’t think much of it until we we lugging our equipment out and passed a paddle boarder who was leaving the Creek. He asked if we were headed down to the boat launch.

“It’s gross,” he said. He explained he’d been in bodies of water all around Philadelphia, but Darby Creek seemed to be the most litter-filled and brown. He said he was glad he was an experienced paddle boarder and didn’t fall in. My partner and I got our kayak out and went out anyway, but on the water, it was hard to not think about litter since every few feet or so, we passed more plastic bottles, condoms, soda cans, and unidentifiable plastic pieces.

The US Fish and Wildlife Service page for the Heinz even lists out 10 points of interest for those going out in canoes and kayaks to look for, which includes the Folcroft Landfill, a Sun Oil tank, and a sewage treatment plant. Scenic!

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It’s hard to escape visual reminders of the pollution that impacts Darby Creek
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Trash collects in little islands along with fallen branches in Darby Creek

For people living in large, urban areas like Greater Philadelphia, access to nice outdoor spaces is really important for human health. I grew up in Maine, and access to nature was definitely something I took for granted because it just… wasn’t something I had to think about. It was everywhere. Since I’ve lived in Philadelphia for almost 10 years, getting out into green spaces is something I have to be more intentional about.

In my public health classes we frequently discuss interventions that are aimed at improving population access to outdoor spaces and increasing the amount of time people spend outdoors being physically active. In Philadelphia, pediatric doctors are now even prescribing children with time out in nature as part of the NaturePHL partnership to increase physical activity.  Even small modifications to urban environments, like cleaning and greening vacant lots, can have an impact of residents’ health and stress levels.

So… what happens when those outdoor spaces are polluted? 

Environmental pollution has very real impacts on human health. For the Eastwick community that surrounds the Heinz and the Folcroft and Clearview Landfills, they have long reported elevated rates of asthma and cancer, believed to have come from their polluted environment besieged by frequent floods. Dr. Marilyn Howarth (who taught the class I took when I originally learned about the Heinz as a Superfund site) recently did an interview with the Philadelphia Inquirer where she spotlighted the issues in Eastwick:

If your only exposure is to a particular chemical in the soil that might be left over from a hazardous waste site, in and of itself, it might not pose a very big risk to you for cancer or some other health effect. But say you are being exposed at the same time to air pollution from a nearby highway, and you’re also close to refineries that have emissions, even if those emissions are lower than allowed by their permit. Adding all these together, the opportunity for these exposures to cause you harm increases.  The varied exposures  might be working on the same body parts and the same mechanisms of causing disease. That cumulative exposure might mean you’re more likely to get the disease than if you’re exposed to any one toxic chemical singly.

This concept of cumulative exposure is pretty important, because interacting with one’s accessible outdoor environment is generally thought to be healthy, however, many people are not so lucky if the actual environment is itself unhealthy! Studies have found that poor, minority-majority neighborhoods are more likely to be exposed to higher levels of air pollution, and that minorities and low-income individuals are more likely to live near a toxic waste site.  In old cities like Philadelphia, lead-contaminated soil is a concern for developers, gardeners and children playing outside.

The amount of trash in a space is often a factor in whether you decide to hang out there or not. Trash is unfortunately pretty much ever-present in Philadelphia (we’re trying to be better!), and on top of the more-unseen environmental pollutants like air quality and lead in soil, I know for me personally, I’d much rather hang out in a park that appears clean than one filled with a bunch of gross litter. Clean outdoor spaces influence people to spend more time outside where they are more likely to be physically active and outdoor spaces in poor condition influence people to stay inside, where people are more likely to be sedentary.

That said, individual bottles and pieces of plastic in the creek aren’t probably a huge threat to my personal health, but I am definitely not going out of my way to touch the water. There are still tons of turtles, fish, and birds in the Heinz but their health is most likely negatively impacted by the amount of trash in their living space! People who have lots of easy, close access to pristine outdoor spaces are very privileged, but should also feel pressure to help maintain the cleanliness of those spaces. Trash is something that all humans produce, but where where that trash ends up is often where people already have less access to outdoor spaces and fewer social and economic resources to enjoy outdoor spaces.

So if you’re feeling kind of Not-In-My-Backyard about trash- remember the earth is everyone’s backyard! Clean spaces and less trash are better for everyone.

PSAs Two Ways: Zika Virus

 

I saw this bus-shelter PSA about the Zika virus recently and thought it was interesting for a couple reasons.

  1. It’s an ad about the sexual transmission of Zika, but does not mention actual sexual transmission.
  2. There are kind of a lot of instructions  (1. Love your partner. 2. Wait to get pregnant. 3. If pregnant, use condoms to protect the baby. 4. Prevent Zika) and without knowledge that Zika can be transmitted sexually, it may seem kind of confusing.

There might be some rules about what can and cannot be said in public-space ads like bus shelters, but the coyness of this particular PSA in avoiding saying the words sexually transmitted seems maybe a little too coy.

A few days later, I saw a targeted ad on Facebook from the Philadelphia Department of Public Health with a slighty different picture and different text. The link makes it clear that it is about the sexual transmission of Zika and the 2 sentence caption is clear and informative.

The exact wording here and the sentence format may not work for a large bus shelter ad, but it seems much more direct and easy to follow than the bus shelter ad.

 

Racism is a Public Health Issue

“Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”, that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” —APHA Past President Camara Jones, MD, PhD, MPH

The news out of Charlottesville this weekend is sickening. Unsurprisingly, lately I’ve been thinking a lot about how racism impacts individual and societal health. Experiencing racism is stressful, and stress impacts health. In a 2013 article in the Atlantic, the impact of racial discrimination on health is described thusly:

Discrimination has been shown to increase the risk of stress, depression, the common cold, hypertensioncardiovascular diseasebreast cancer, and mortality. Recently, two journals — The American Journal of Public Health and The Du Bois Review: Social Science Research on Race — dedicated entire issues to the subject. These collections push us to consider how discrimination becomes what social epidemiologist Nancy Krieger, one of the field’s leaders, terms “embodied inequality.”

Embodied inequality. When you examine health outcomes by race, it is really striking how far-reaching the divide goes, from infant mortality rates, to life expectancy, and disease rates. Then there are the psychological impacts of dealing with racism. Trauma has devastating impacts on physiological health. On top of that, medical professionals have exploited racial minorities for centuries, from slavery to eugenics to medical experiments to discrimination in medical practices. These gross racist, exploitative practices have happened and continue to happen, and I recommend that anyone who is interested in the history of racial discrimination in healthcare read Medical Apartheid by Harriet A. Washington.

I’ve linked a bunch of articles in this post, and it’s all good reading, but I’d urge anyone who is interested in public health to consider anti-racist work as an integral part of improving society-level health outcomes. It is not and should not be the responsibility of Black people, or Latinx or any other racial and ethnic minorities to “fix the racial divide.” Racism is perpetuated by systems and the white people who benefit from them, even when they do not individually work to maintain them. It is all our responsibility to dismantle racism and the toxic effects it has on society.

How can we support anti-racism? There are many organizations that are in need of donations, like the Charlottesville Solidarity Legal Fund, which fights white supremacy in Charlottesville, VA.  We can also have conversations with our friends and family to challenge racist assumptions, attend protests and physically show up for anti-racist events. I think particularly for white people, it is important to listen and educate ourselves as much as possible. Read and watch media created by people of color. When you feel like your own beliefs are being challenged, listen and wait. Really listen. It’s uncomfortable and hard to think about our own biases, but it’s not more uncomfortable or hard than receiving racist treatment and dealing with racist systems every day. Our society is better when everyone has access to the things they need to live healthy and stress-free lives, and it’s essential that we treat racism like the public health issue it is.

 

Links Roundup: Opioid Addiction

Opioid abuse is a growing epidemic in the United States, and frequently makes headlines. I think it’s particularly hard to get nuanced stories about the opioid epidemic because drug use is highly stigmatized and many journalists, even sympathetic ones, frequently write stories pumped with *shocking* details and descriptions, which is less humanizing than what they’re probably hoping for.

That said, it is a significant issue, and one that is tied to the over-prescription of opioid painkillers. Prescriptions are down since 2010, but even short-term prescriptions for opioid painkillers increase one’s risk of developing an addiction. In 2015, drug overdose was the “leading cause of accidental death in the United States,” with 38% of those drug overdose deaths from prescription pain killers and 25% from heroin.

I find reading stories about the opioid crisis, especially in my home city of Philadelphia, to be particularly difficult not because of the subject matter, but because of many people’s total disdain and disgust for people who use drugs. Reading comments on the internet is always a (mentally) dangerous endeavor, but people are particularly cruel about drug addiction, and this simply does nothing to help the crisis.

The above video from Vox is a really helpful primer on one of the reasons why heroin deaths are spiking, but I also read 2 articles this week that I thought offered some really important, nuanced perspectives on what the lives of opioid drug-using women are like:

Sex Workers and Drug Users Speak Out in Philadelphia – The Fix

Establishing a sense of empowerment and community is crucial – even lifesaving –for sex workers, said Amanda Spitfire and Aisha Mohammed, Project SAFE volunteers and the evening’s organizers.

“A lot of the stories were really painful, involved a lot of pain and sadness and hardship and difficulty, and I think that that’s really important to recognize that that’s a part of it, too,” Mohammed said after the event. “But that’s not a reason to abolish the sex industry altogether. Those are the reasons to make it safer – to make conditions safer and better and more lucrative for people who are doing it.”

Getting An Abortion In Alabama Is Hard. The Opioid Crisis Is Making It Even Harder. – Huffington Post

Although the patient Parker and Johnson were talking about was from Birmingham, she was 21 weeks and 1 day pregnant, which meant her procedure would have to be a dilation and evacuation, or D&E. Parker would have to use drugs to soften her cervix to conduct the abortion procedure in order to be able to insert his instruments into her uterus and remove the fetus.

…The clinic wouldn’t be open again until the following Wednesday, by which point she would be perilously close to the 22-week cutoff. … To add to the patient’s concerns, Alabama has been aggressive about prosecuting women who use drugs while pregnant. Given the abortion restrictions in surrounding states, given the looming public holiday and given this woman’s desire not to become a mother, Parker and Johnson both knew they were her last best hope.

It’s a complicated topic, but I hope that when readings articles about opioid addiction that you look for articles that present facts in a neutral tone and with respect for the people they’re interviewing.