Introduction to Public Health (HBEH 700) Shauna Ayres-1 Paper: Individual and Population Approaches to Health October 30, 2015

Reducing opioid abuse in the Appalachia region Description of nonmedical use of prescription drugs and its public health significance.

In 2013, an estimated 6.5 million Americans engaged in nonmedical use of prescription drugs, constituting more users than cocaine, inhalants, hallucinogens, and heroin combined. (SAMHSA, 2014) The recent increased use of nonmedical prescription drugs has been associated with an increase in overall drug overdose deaths which have now surpassed deaths from motor vehicle crashes (CDC, 2013; Paulozzi, 2011). In fact, prescription drugs accounted for approximately 60% of drug overdose deaths in 2010 (CDC, 2013). Pain relievers accounted for approximately 70% of nonmedical prescription drug use (SAMHSA, 2014) and increased deaths from and abuse of prescription drugs is primarily attributed to the proliferation of opioid pain relievers (Paulozzi, 2011).

The economic cost of prescription drug abuse amounted to nearly $181 billion in 2002. Furthermore, the total annual cost per patient for an opioid abuser was approximately $15,884 as compared to $1,830 for a nonabuser (White, 2005). One study estimated that the total U.S. societal costs of prescription opioid abuse alone cost $55.7 billion in 2007(up from an adjusted $11.8 in 2001) (Birnbaum, 2004); however, indirect expenditures are difficult to measure and this number is likely an underestimate. Other costs include the waste of healthcare resources due to unnecessary or fraudulent doctors’ visits; loss of productivity and wages due to doctors’ appointments, incapacitation effects of prescription drugs, or death; surge in drug-related theft, violence, and other criminal activity; and increases in law enforcement at the community and administration levels (Manchikanti, 2006). As if that weren’t burdensome enough, prescription drug use and abuse has immeasurably devastating emotional and psychological consequences within families and communities.

The demographics of the opioid abuse problem in the U.S. is not entirely understood due to the stigma and secrecy that is innate to any substance abuse disorder. More research is needed, however the literature reveals some notable trends. According to the U.S. Drug Abuse Warning Network, people who abuse prescription drugs tend to be white, younger, and female (ACPM, 2011). Yet more fatalities occur among whites, males, people aged 18-54, with a mean and median age of 39 years old, and those who have divorced or never married (Hall, 2008). Comorbidity of mental illness or physical pain also put people at greater risk for substance abuse (John, 2010; SAMHSA, 2014). In addition, greater numbers of overdose deaths tend to occur in areas with lower educational attainment and higher poverty (Hall, 2008) and recently, rural areas have experienced an increase in prescription overdose deaths, most notably in the Appalachian region (Cicero, 2007; Hall, 2008; The White House, 2015)

It is not difficult to see why the Appalachian region is suffering from a substance abuse epidemic as well as a range of other health problems. Traditionally the region was known for mining, manufacturing, textiles, and paper and wood products, but global competition and the 2008 recession have caused a decline in growth and employment (ARC, 2011). The Appalachian region suffers from the greatest disparities in income, job rates, education, and health (ARC 2011, Lane, 2012). In 2009 it had an average per capita personal income of $15,964 (68% of the national average) and had an unemployment rate of 11.1 (19.6% higher than the national average) (ARC, 2011; BLS, 2015). In addition, 42.1% of Appalachian counties have lower than normal access to health resources, higher Medicaid and Medicare recipients, and lower cost per capita on healthcare when compared to the nation as a whole (Lane, 2012).

Description of a social determinant for nonmedical prescription drug abuse. It is apparent that the Appalachian region has a plethora of risk factors for prescription drug

abuse including the primarily white population, high poverty, and poor education. However, the overarching social determinant of the prescription drug problem is undoubtedly the access and availability of healthcare resources. The Appalachian region lacks the entire array of healthcare professionals including primary care physicians, non-primary care physicians, and dentists.

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(Lane, 2012) Simply due to the terrain and distance between towns and people, transportation and exchange of goods and services is challenging (Lane, 2012). Despite transportation improvements, many Appalachians are isolated because of the monetary expense of travel and/or the time requirement to travel which may entail taking off work and missing wages. Additionally, new healthcare professionals with large student loans avoid working in higher poverty areas because of low base salary as well as inadequate Medicare and Medicaid reimbursement (Jackson, 2003; Lane, 2012).

In the context of nonmedical prescription drug use, there are numerous plausible instances which could easily lead to abuse. For example an average middle-aged mine worker struggling to support his family of four severely injures his back and goes to the only doctor in his remote community for relief. It’s noteworthy that this doctor is likely overworked and underpaid due to the area’s high number of low income laborers and the percentage of them on Medicare and Medicaid assistance programs. The doctor prescribes Vicodin, a cheap, common opioid pain reliever, and the man begins taking the prescribed dose, however to continue doing the same job and ensure a steady income he slowly increases his dosage of Vicodin over time.

Eventually, his back no longer hurts, but he still takes the medication because he suffers withdraw symptoms and can’t function without it. He realizes he has become dependent on his medication, but doesn’t really perceive it as a problem because most of his coworkers are also using pain medication regularly too. Even if he did want to get substance abuse help, he can’t afford to take an unpaid absence from work to go the nearest substance abuse treatment center 80 miles away which is uncovered by his insurance anyway. In fact, he can hardly make arrangements to see his own physician every six months to get his prescription renewed and will occasionally use some of his wife’s pain medication that she got after dental surgery last year, but never used or buy some pills from a friend at work.

Sadly, one morning the man’s wife finds him unresponsive and the medics pronounce him dead on the scene due to opioid overdose. Now his family is left with no father, husband, or income. Although not all prescription drug abuse is as dramatic and innocent, this illustrates how the social determinate of inadequate availability and access of resources can significantly impact a person’s life beyond his control. Justification for a population approach.

Rose states in The Strategy of Preventive Medicine that the strong attraction to the high-risk preventive strategy is that the intervention matches the needs of the individual (Rose, 1992). While it seems logical to target and treat only individuals at-risk or suffering from prescription opioid abuse in the Appalachian region, due to the lack of resources for advice and long-term care, one of Roses policy guidelines for screening to assess risk, it is unrealistic to expect meaningful change using such a strategy. Some of the appealing strengths of the high-risk approach for the Appalachian region include how the intervention could be tailored for each individual and would avoid introducing the concept of prescription opioid abuse to people who are at low risk.

However the weaknesses of the high-risk approach for this region are overbearing. The primary concern is that the strategy is “palliative and temporary” and will not address the substance abuse issues for future generations. In addition, it is contingent on predictive testing and could potentially overlooking individuals who are considered low risk, but later develop problems (Rose, 1992). It is likely that the longer Appalachian residents live in their current living conditions with current social constructs that they will develop poor health behaviors, including prescription drug abuse, in response to physical, social, or emotional stressors (Barr, 2008). Lastly the contribution to overall control of the issue would likely be small due to the number of individuals who would be treated compared to the vastness of the region (Rose, 1992). Thus, the expenditures, including funding, travel, time, and manpower, versus the overall long-term impact discourages a high-risk approach.

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A powerful line in Rose’s The Strategy of Preventive Medicine is “the ‘normal’ majority defines what is ‘abnormal’” (Rose, 1992). This applies well to the Appalachian region due to the high prevalence of prescription opioid abuse. The norm maybe be shifting in favor of using more medication to treat more injuries and illnesses which puts more people at risk for abuse and addiction. Although Rose names monetary cost as a limitation to successfully utilizing the population approach, I think a more comprehensive approach in the Appalachian region that targets communities, established social networks, and social norms would be less expensive, or at least more cost effective than a high-risk approach. This also contrasts with a weakness of the high-risk approach concerning overlooking individuals currently at low-risk because it would include the entire population in an intervention or program.

The feasibility of either a population or high-risk approach to changing any health issue in this region is difficult because of the geography, limited resources, and vast health disparities. Because either approach will be difficult, I feel the population approach to addressing opioid drug abuse in the Appalachian region is the logical method due to its ability to promote lasting change for the entire area. A population approach is also supported by the Theory of Fundamental Causes in that finding ways to break the correlation between low socioeconomic status and lack of access to health resources has the most profound effects on a range of health disparities, this would include reducing opioid abuse in low resource areas like Appalachia (Phelan, 2010). Description of a relevant intervention that reflects the selected approach.

In 1974, Physician Shortage Area Program (PSAP), was established at Jefferson Medical College (JMC) located in Philadelphia, Pennsylvania and was established to assist in the recruitment and retention of physicians in rural areas. The PSAP recruits and selectively admits medical school applicants who are from rural areas and show interest in practicing family medicine in rural and underserved areas, particularly in Pennsylvania. About 15 PSAP students per year service their third-year family medicine clerkship in a rural location, take their senior outpatient internship in family medicine (typically at a rural preceptorship), and receive some financial aid. After graduation PSAP students are expected to complete a residency in family practice, and to practice family medicine in a rural and underserved area, but compliance is not enforced (Rabinowitz, 1999).

A retrospective cohort study of 206 PSAP graduates from the classes between 1978 to 1991 were examined to understand rural physician shortages and find effective ways to increase the number of physicians in rural Pennsylvania. Reports concluded that PSAP graduates accounted for 1% of graduates from one of the state’s seven medical schools, but 21% of family physicians practicing in rural Pennsylvania. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the US (34% vs 11%), to practice in an underserved area (30% vs 9%), to practice family medicine (52% vs 13%), and to practice family medicine in a rural area (21% vs 2%). Retention was high with 87% of PSAP graduates were currently practicing rural family medicine and had been doing so for longer than five years and similarly 94% in underserved areas (Rabinowitz, 1999).

The study concluded that PSAP had a substantial impact on increasing the number of rural physicians in Pennsylvania. Authors stressed that policymakers and medical schools must collaborate to further ameliorate the physician shortages by recruiting individuals from rural areas to attend medical school, providing students with more attractive funding packages, and including specialist exposure and training in rural communities into medical school curriculum (Rabinowitz, 1999). It is important to recognize that PSAP is not only addressing the physician shortages, but taking a population approach to improving the overall rural healthcare system and consequently reducing many health disparities in this population. Critique of selected approach.

In the context of prescription opioid abuse, PSAP would not be helpful if it just increased the number of doctors prescribing medication. The essential components in this program are PSAP graduates are native to these areas and take greater ownership of improving their clients’ well-

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being, they understand the social context of the region, and they are specially trained in rural medicine. Thus, PSAP graduates would need to be acutely aware of the prescription opioid abuse problems in rural areas, be cognizant of their own prescribing habits, understand the risks, signs, and symptoms of abuse, and be able to adequately counsel individuals with problems. This resembles a more of a high-risk approach however, when examining it more broadly, by changing medical school curriculum to address these issues before placing graduates in rural environments, it is actually a larger population approach. Changing school curriculum is not simple and it may be unproductive to add more rural focused curriculum to a medical student’s course load when he/she is not interested in working with this demographic.

Likewise, simply increasing the number of rural physicians may not change Appalachian culture or norms around healthcare and prescription opioid use. Thus residents may not prioritize seeing a doctor regularly or may not value the advice of a more educated “outsider.” However, this may be mitigated if a doctor is originally from the area and returning to practice because the community will likely be more responsive to a native resident as compared to someone from an urban or higher socioeconomic background.

Individuals living in rural areas often have a demanding lifestyle marked by high poverty and low education. They may not have adequate health insurance through their employer or may be unemployed and therefore, going to the doctor may be financially unviable. In addition to increasing the number of physicians in rural Appalachia, it would be important to ensure that affordable services are being offered. Although the Affordable Healthcare Act is attempting to solve this issue, gaps still persist. Therefore part of this population approach would have to include providing subsidizes for residents or adequate reimbursement for doctors to provide the needed care for disadvantaged residents in the Appalachia region. Redistribution of monetary funding in the government is never easy and takes considerable amounts of persistence, time, and resources.

On the same note, recruiting medical students to practice in rural area of Appalachia is an obstacle. With the recent increased cost of higher education and decreased financial assistance provided by schools and state and federal governments, funding programs like PSAP is more challenging. Potential medical students coming from rural backgrounds would likely need full-ride scholarships to attend any higher education not just medical school. This means that a student would need funding for school and cost of living for at least 11 years (four years of undergraduate, four years of medical school, and three years of residency). This is a weighty and risky investment. Loan repayment programs are also a possibility and are contingent on completion of service in rural areas, however the worry is that this will not increase retention rates for continued practice in rural areas and is not a long-term solution. Other incentive programs such as receiving yearly awards based on continued service in rural areas are another option, however the monetary value for current programs is inadequate. Debt-ridden graduating physicians will undoubtedly opt to practice where they are best compensated and the same issues of lack of resources for funding arise, like with scholarships. Until medical schools and the government place a higher demand on reducing physician shortages and addressing rural health disparities, the funding for programs like PSAP will be not be sufficient and we will continue to see a shortage of physicians in rural communities in the Appalachian region (Jackson, 2003; Lane, 2012; Rabinowitz, 1999).

Although current funding, support, and awareness is lacking in reducing physician shortages in rural areas and the resulting health disparities like prescription opioid abuse, it is encouraging to see more political attention on the issue. In fact, President Barack Obama recently gave a speech in West Virginia about the opioid and heroin epidemic and released a his own comprehensive plan to mitigate this issue (The White House, 2015). In conclusion, to fully understand and reduce prescription opioid abuse in the Appalachia, health professionals must take a population approach and do more research, demand additional funding, and advocate for policy change at the local, state, and national levels.

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References American College of Preventive Medicine (ACPM). (Copyright 2011). Use, abuse, misuse &

disposal of prescription pain medication clinical reference. http://www.acpm.org/?UseAbuseRxClinRef

Appalachian Regional Commission (ARC). (2011). Economic overview of Appalachia- 2011 Barr, D. (2008). Race/Ethnicity, socioeconomic status and health: Which is more important in

affecting health status? Health disparities in the United States: Social class, race, ethnicity, and health (1st ed., pp. 134-168). Baltimore, Maryland: The John Hopkins University Press.

Birnbaum, H. (2004). Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine, 12(4)

Bureau of Labor Statistics (BLS). (2015). Data tools: Databases, tables & calculators by subject: Unemployment rate No. LNS14000000. United States Department of Labor.

Centers for Disease Control and Prevention (CDC). (2013). Addressing prescription drug abuse in the united states: Current activities and future opportunities. US Department of Health and Human Services,

Cicero, T. (04). Multiple determinants of specific modes of prescription opioid diversion. Journal of Drug Issues, 41(2), 283; 283-304; 304.

Hall, A., Logan, J., Toblin, R., et al. (2008). Patterns of abuse among unintentional pharmaceutical overdose fatalities. Jama, 300(22), 2613-2620.

Jackson, J., Shannon, C., Pathman, D., Mason, E., & Nemitz, J. (2003). A comparative assessment of west virginia's financial incentive programs for rural physicians. The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association, 19 Suppl, 329-339.

John, M., Trout, R., Nicholson, B., Cunningham, M., Williams, C., & Davis, E. (2010). Cocaine abuse among patients: A study at the Charleston area medical center. West Virginia Medical Journal, 106(4), 82-85.

Lane, N., Lutz, A., Baker, K., Konrad, T., Ricketts, T., Randolph, R., et al. (2012). Chapter 3: Appalachian health disparities. PDA, Inc. & The Cecil B. Sheps Center for Health Services Research University of North Carolina – Chapel Hill, Health care costs and access disparities in Appalachia (pp. 19-52)

Lane, N., Lutz, A., Baker, K., Konrad, T., Ricketts, T., Randolph, R., et al. (2012). Chapter 5: Policy issues for ARC. PDA, Inc. & The Cecil B. Sheps Center for Health Services Research University of North Carolina – Chapel Hill, Health care costs and access disparities in Appalachia (pp. 63-80)

Manchikanti, L. (2006). Prescription drug abuse: What is being done to address this new drug epidemic? Testimony before the subcommittee on criminal justice, drug policy and human resources. Pain Physician, 9(4), 287-321.

Paulozzi, L., Jones, C., Mack, K., Rudd, R., & Centers for Disease Control and Prevention (CDC). (2011). Vital signs: Overdoses of prescription opioid analgesics—United states, 1999-2008. MMWR Morb Mortal Wkly Rep, 60(43), 1487- 1492.

Phelan, J., Link, B., & Tehranifar, P. (2010). Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications. Journal of Health and Social Behavior, 51 Suppl, S28-40.

Rabinowitz, H., Diamond, J., Markham, F., & Hazelwood, C. (1999). A program to increase the number of family physicians in rural and underserved areas: Impact after 22 years. JAMA, 281(3), 255-260.

Rose, G. (1992). The strategy of preventive medicine. New York, New York: Oxford University Press.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Substance use and mental health estimates from the 2013 national survey on drug use and health: Overview of findings. Center for Behavioral Health Statistics and Quality.

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The White House. (October 21, 2005). FACT SHEET: Obama administration announces public and private sector efforts to address prescription drug abuse and heroin use, from Office of the press secretary. https://www-whitehouse-gov.libproxy.lib.unc.edu/the-press-office/2015/10/21/fact-sheet-obama-administration-announces-public-and-private-sector

White, A., Birnbaum, H., Mareva, M., & et al. (2005). Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm, 11(6), 469-479.