May 2020: The Opioid Epidemic
by Lloyd F. Novick, MD, MPH
As this May/June issue of the Journal of Public Health Management and Practice goes to press, we are facing a public health challenge of a magnitude unseen since the 1918 influenza pandemic (John S. Marr and Lloyd F. Novick, podcast). The 2019 Novel Coronavirus (COVID-19) is now pandemic. This disease, first identified in China, has now spread around the world. There have been various estimates of death rates associated with COVID-19 from 3.4% from the World Health Organization to 0.6% in South Korea. A helpful discussion of these reported variations in death rates can be found in a JPHMP DIRECT post by Jason Brinkley. Readers should consult JPHMP DIRECT for the latest information relevant to public health on COVID-19. The July issue of the Journal of Public Health Management and Practice will focus on the impact of the coronavirus on population health.
According to modelling by the Centers for Disease Control and Prevention (CDC), between 160 million and 214 million people in the US could be infected during this epidemic. The pandemic can last months or longer than a year. Deaths in the US could range from 200 000 to 1.7 million with potential hospitalizations from 2.4 million to 21 million people, overwhelming our US medical system. Former CDC Director Tom Frieden, at the nonprofit organization Resolve to Save Lives, finds it is not implausible that half the US population would become infected and more than 1 million people would die. On March 31, 2020, in a White House briefing, Dr. Anthony Fauci issued revised and reduced estimates of 100,000 to 200,000 deaths by the end of August 2020 if mitigation is effective.
Another major concern is supporting the health care and public health care workforce during the global epidemic. The pressure is dual in nature: the crushing number of ill individuals stressing health system capacity and adverse health outcomes for these workers. In China, an estimated 3000 have been infected with 22 deaths. In less than three weeks, COVID-19 has overwhelmed the health system of Northern Italy. While health workers often accept the risk of infection, as part of their commitment to care, they are concerned about members of their families.
During the coming months, public health efforts will increasingly be targeted to control of this pandemic. However, local and state health departments are still reeling from budget and staffing cuts that date to the Great Recession. Local health departments have lost a quarter of their workforce. The lack of investment in public health has left these departments ill prepared to respond to the coronavirus. With the virus demanding attention, staff have been diverted to answering phone calls from frightened individuals, quarantining people, and supervising mitigation practices.
Other public health concerns remain of critical importance now and in the future. This May/June issue of the Journal of Public Health Management and Practice focuses on the opioid epidemic. This public health crisis, fueled by suicide and drug overdoses, was responsible for a decline in life expectancy from 78.7 years in 2016 to 78.6 in 2017. The rate of drug overdose deaths is largely driven by the opioid epidemic. Auerbach and Miller, in the July/August 2018 issue of JPHMP, described a triple set of epidemics referred to as “deaths of despair,” resulting in more than 1 million Americans dying from drug overdoses, alcohol, and suicide.
The lead editorial in the current issue is authored by Hillary Kunins, of the New York City Department of Health and Mental Hygiene (DOHMH). She oversees the DOHMH’s major strategic initiatives to improve the mental health and behavioral health of all New Yorkers. A public health approach to the opioid epidemic is espoused that identifies and repairs the harms of structural racism driving our nation’s punitive approach to drug policy and practice. US drug overdose deaths fell for the first time since 1999 with a 4% decrease in overdose mortality from 2017-2018. In New York City, after implementing a broad overdose response plan, Healing NYC, Kunins reports a 3% decrease in the rate of overdose deaths from 2017 to 2018. But as she points out, in NYC and elsewhere, these decreases in overdose deaths are not equitably distributed. The highest number of deaths occur among middle-aged and older black New Yorkers. Guidance for public health practitioners includes developing programs for opioid use that are place-based, multisectoral, address racial equity, and prioritize reform with a focus on repealing punitive policies.
Two articles by Deborah-Fulton Kehoe describe surveillance of opioid prescribing as a public health intervention in the state of Washington. The development of Washington State Opioid metrics is described to facilitate employment of guidelines that recommend lower doses of prescribed opioids, shorter duration of use, and avoidance of concurrent sedatives. A set of 6 strategic metrics was tested across 3 different health systems to address risks associated with prescription opioid medications.
In their article, Ian Motie, Henry Carretta and Leslie Beitsch examine the important question—do syringe exchange programs (SEP) improve health at the population level? They analyze the different state legislation enabling safe syringe exchange programs. They compare states with this type of legislation versus those that lack these laws with respect to transmission rates of hepatitis B, hepatitis C and HIV infection. The results show promise that SEPs do reduce disease transmission.
The research of Dawn Pepin and colleagues focuses on how state telehealth laws intersect with the opioid epidemic. A legal mapping study yielded laws from 17 states with relevance to the opioid epidemic. These laws address a variety of measures including prescribing limitations, opioid treatment, and provider collaboration.
Holly Hackman and co-authors describe a pilot study of multidisciplinary team reviews of drug overdose deaths in Rhode Island. Rhode Island had the 11th highest unintentional drug overdose deaths in the nation in 2017. Illicit fentanyl was involved in the majority of these deaths. The RI Department of Health piloted in-depth, multidisciplinary and multiagency team reviews of drug overdose deaths. The goal was to develop recommendations to prevent future deaths. The pilot team generated 78 recommendations and distributed 31 minigrants to advance these recommendations. In 2018, state legislation was passed enabling the continuance of these reviews.
“Delivering Opioid Overdose Prevention in Bars and Nightclubs: A Public Awareness Pilot in New York City,” authored by Bennett Allen and colleagues, describes a program to raise awareness of fentanyl overdose risk among people who use cocaine. The presence of fentanyl in the cocaine supply greatly increases the risk of overdose in individuals who use drugs. This pilot tested an awareness campaign in 23 NYC nightlife venues. The study demonstrated that opioid prevention education can be disseminated successfully to people in this setting.
Simone Singh, Karalyn Kiessling and Jordan Rhodes, in their article analyzing the community health needs assessments (CHNAs) of 140 non-profit hospitals, explore strategies initiated by these providers to address the opioid epidemic in urban communities most affected by the opioid epidemic. Almost 70% of CHNAs identified opioid use as a community health need, and 63% of the resulting implementation strategies included at least 1 hospital-initiated activity to address this need. The authors conclude that non-profit hospitals are taking action with respect to the opioid epidemic but most likely this represents additional treatment capacity. While an important contribution, hospitals need to mount more comprehensive approaches addressing the determinants and prevention of this epidemic.
Beginning with this issue, the ASTHO column “State of Health” will closely align with the issue focus. The column for this issue, titled “Opioid and Suicide: Opportunities for Comprehensive Prevention,” calls for strengthening the partnerships between state health agency leadership and behavioral health. A recommendation is made for forming an interagency overdose and suicide council or workgroup that promotes collaboration among these stakeholders and coordinates funding from different sources.
Lloyd F. Novick, MD, MPH is Professor Emeritus of the Department of Public Health at the Brody School of Medicine, East Carolina University. Previously, he was chair of this Department. He has served as the Commissioner of Health and Secretary for Human Services of Vermont, Director of Health Services for Arizona, and Director of the Office of Public Health for New York State. Previous academic positions include Professor and Director of the Preventive Medicine Program for SUNY Upstate Medical University, Professor and Chair of Epidemiology at the University of Albany School of Public Health, and Clinical Professor and Director of the Teaching Program in Epidemiology and Public Health at the University of Vermont, College of Medicine. [Full bio]