Rates of drug-related deaths have risen steadily across America for nearly two decades, with more than half of the deaths being attributed to opiate overdose (National Institute on Drug Abuse, 2017). Due to the magnitude of this national health issue, various initiatives have been undertaken in attempts to reduce substance abuse and its negative subsequent consequences. This paper will discuss a few of these interventions, along with the organizations that are involved with each.
Healthy People 2020 defines substance abuse as a culmination of negative physical and behavioral impacts that are the result of consuming substances that alter the mind and a person’s behavior (Healthy People 2020, n.d.). The Centers for Disease Control and Prevention (CDC) defines drug-related deaths as all those that occur as a direct result of drug use and where drugs are the underlying cause, most commonly overdose (Paulozzi, 2011). This topic is of interest as clinicians from all practices will be forced to address this growing issue. Advanced practice nurses must educate patients on the dangers of substance abuse, offer evidence-based treatment when indicated, and work with a community of healthcare providers, health organizations, and policymakers to influence positive change.
Define the Federal Program Initiative
According to Healthy People 2020, 22 million people grappled with substance abuse (Healthy People 2020, n.d.). The U.S. Preventive Services Task Force (USPSTF) states that every day, 4300 adolescents are using drugs for the first time (U.S. Preventive Services Task Force, 2014). This is important as substance abuse is associated with tremendously negative impacts, some of which include suicide, homicide, violence, abuse, crime, and the spread of sexually transmitted diseases (Healthy People 2020, n.d.; U.S. Preventive Services Task Force, 2014).
Brief Overview of the Program
Healthy People 2020 have developed various strategies for reducing substance abuse including multiple efforts to decrease substance abuse among adolescent youth populations as a primary means of prevention. The program aims to see reductions in rates of adolescents struggling with substance abuse, as well as an overall decrease in substance abuse rates and incidence of mortality (Healthy People 2020, n.d.).
According to the Healthy People 2020 website, one primary objective is to see a decrease in the current statistics to obtain a target of 11.3 drug-induced deaths per 100,000 by the year 2020 (Healthy People 2020, 2017). However, the current statistical trend has seen an increase nearly every year since 1999, and the most current listed data displayed from 2015 states a drug-induced death rate of 17.2 per 100,000, which is well above the stated goal (Healthy People 2020, 2017).
Substance abuse and drug-induced deaths is a significant issue across the nation, with only a handful of states being at or below the Healthy People 2020 goals, and there is also little variance seen across population locations (urban versus non-urban) as well as between ethnicities (Healthy People 2020, 2017).
An important population to target for change is adolescents for several reasons. Ideal prevention involves adolescents, as this population offers a unique opportunity to stop substance abuse before it begins and research has shown that the start of addiction in most adults begins in teenage years (National Institute on Drug Abuse, 2014). If adolescents can be prevented from beginning substance abuse, then it follows that fewer adults should have substance abuse problems in the future. Age non-specific interventions that broadly target substance abuse can also sometimes be applied to the adolescent population.
Defining the Health Promotion Topic
With a complex issue such as substance abuse, a multifaceted approach is likely the best solution. Existing recommendations include primary care interventions that target adolescent populations, a collaborative public health approach promoting education to prescribers and legislation changes, and the increased utilization of medication-assisted therapies (MATs).
The Effects on the Community
The negative impacts of substance abuse are harmful to communities and individuals alike. The Substance Abuse and Mental Health Services Administration (SAMHSA) states that prescription drugs are the second most commonly abused drug group among the adolescent population (Substance Abuse and Mental Health Services Administration, 2017).
Healthy People 2020 has set up goals to see a decline in rates of substance abuse both in the adolescent population as well as overall (Healthy People 2020, n.d.). Along with rates of substance abuse, the Healthy People 2020 program aims to see a decline in mortality from substance abuse to 11.3 per 100,000 deaths (Healthy People 2020, 2017).
The Effects on the Health Care System
According to Downey and Zun (2010), the most common reason that patients visit the emergency room is due to pain. Kolodny et al. (2015) argue that over-prescription of opioids for pain relief has led to increased rates of addiction and consequently, overdose. This upward trend is alarming, as the number of drug overdose deaths has over doubled in a decade (National Institute on Drug Abuse, 2017). Kirschner, Ginsburg, and Sulmasy (2014) claim that substance abuse annually strains the health care system to the tune of $534 billion in preventable costs.
Some states have sounded the alarm and have begun rolling out programs to address this issue. Virginia, for example, has since launched an email campaign to health providers with ongoing updates and recommendations (Department of Health for the Commonwealth of Virginia, 2016). Other states have passed legislation requiring prescribers to complete mandatory education regarding the potential dangers of opioids (Kolodny et al., 2015). Some of the main health promotion initiatives being implemented are increasing availability and access to opiate reversal agents such as Naloxone, increased access to MATS, and increased access to rehabilitation programs (Volkow, Frieden, Hyde, & Cha, 2014).
Program Goals and Interventions
Healthy People 2020 states a goal of reducing substance abuse in a variety of metrics, with major focuses on decreasing rates of substance abuse among the adolescent population as well as reducing overall substance abuse and subsequent overdose deaths (Healthy People 2020, n.d.).
School-based interventions. A recommendation made by Healthy People 2020 involves school-based interventions in efforts to reduce substance abuse among adolescents. However, this recommendation is not supported by evidence, as it was found that such interventions did not significantly improve outcomes (Carney, Myers, Louw, & Okwundu, 2016). Furthermore, an overview of systematic reviews exploring various school-based interventions for substance abuse also found little benefit in such programs across multiple studies (Das, Salam, Arshad, Finkelstein, & Bhutta, 2016). An alternate goal for the adolescent population involves primary-care interventions. While the U.S. Preventive Services Task Force (USPSTF) states that current evidence is insufficient to claim that educational interventions were successful in reducing substance abuse, they still believe that primary care interventions should be focused on (US Preventive Services Task Force, 2014). Although the USPSTF claims that evidence was still insufficient to confirm a net benefit for primary care interventions, the organization stressed the importance and need for further research examining such practices in the adolescent population. The USPSTF also stated that primary care providers should still consider screening adolescent patients for substance abuse and offer available treatment (US Preventive Services Task Force, 2014).
A collaborative public health approach. On a separate front, research has been shown to support the use of a collaborative public health approach. A particularly alarming trend in healthcare is the increasing amount of over-prescription of opioids (Kolodny et al., 2015). Kolodny et al. believe this trend is correlated with opioid addiction rates and associated overdose fatalities. The authors recommend a coordinated public health approach including national and local government agencies, insurance companies, and healthcare providers (Kolodny et al., 2015). According to Kolodny et al., one of the greatest attempts at primary prevention exists by reducing medical exposure to opioids, and the authors claim that healthcare providers are one of the main sources of opioids that are abused. Moreover, the authors stressed the need for comprehensive educational programs for prescribers regarding appropriate use of opioids. Another important public health initiative that Kolodny et al. emphasized is the utilization of state prescription drug monitoring programs (PDMPs). The authors stated that the use of PDMPs could help to reduce the drug seeking practice of going from doctor to doctor for opioids (Kolodny et al., 2015).
Medication-assisted therapies. Another intervention that has shown promise for reducing substance abuse and associated mortality is the utilization of medication-assisted therapies (MATs) which are similar to typical opioids but prescribed for treating addiction. Volkow, Frieden, Hyde, and Cha (2014) claim that when prescribed appropriately, MATs aided recovery from opioid dependence and decreased mortality associated with opioid overdose. Volkow et al. state that in a study observing the impact of MATs over a decade, that mortality rates from opioid overdose decreased by half. Volkow et al. also believe some of the success associated with MATs is attributed to higher patient retention in programs that utilize them. Unfortunately, Volkow et al. claim that MATs have several barriers to overcome and are underutilized. The authors claim this is partially due to a common prescriber misconception that MATs are simply alternatives to other opioids that are abused and will cause similar addiction, but Volkow et al. state the literature does not support such claims. Another concern is limited cooperation in achieving accessibility of MATs due to inconsistencies from insurance companies (Volkow et al., 2014).
Increased access to opioid reversal agents. In another effort to decrease opioid overdose deaths, an intervention supplying the opioid reversal agent Naloxone directly to the population is starting to be implemented in many states across the country (Wheeler, Jones, Gilbert, & Davidson, 2015). According to Wheeler et al., the number of organizations that are providing Naloxone to communities are increasing, and their findings indicate that this practice is safe, and reduces mortality rates from opioid overdoses. In effect, Wermeling (2015) states that expanding access to Naloxone has allowed for medical care to begin even before emergency medical services can respond and provide professional health care. To provide more usable forms of Naloxone to communities, intranasal Naloxone was developed and results from multiple studies show its efficacy to be roughly equivalent to traditional parental routes (Wermeling, 2015). Both the treatment of intranasal Naloxone as well as the expanded access to Naloxone are fairly new developments. The early data looks promising, and hopefully, these interventions can help to decline the statistics towards the Healthy People 2020 goal.
How the Goals are Implemented
Both state and federal government agencies are funding various programs in attempts to reduce the breadth of substance abuse. Programs range from education to populations such as adolescents and other high-risk groups, as well as to health care providers who are prescribing opioids. Annual statistics are tracked by organizations such as the CDC and made available to organizations making recommendations such as the USPSTF. Furthermore, various state Departments of Health are considering the statistics and recommendations to influence legislation and policy changes that may make an impact.
According to Volkow et al. (2014), the National Institute on Drug Abuse (NIDA) is funding efforts to increase delivery of MATs as well as to make opioid reversal agents more accessible to the public. These efforts are also supported by the CDC and the Centers for Medicare and Medicaid Services (CMS). The CMS is also attempting to expand access to drug rehabilitation services (Volkow et al., 2014). The U.S. Food and Drug Administration (FDA) sponsors educational programs for prescribers regarding the potential dangers of opioids (Kolodny et al., 2015).
Assessment of Resources
Many organizations are involved in reducing substance abuse, some in a general sense, and others that specifically target the adolescent population. SAMHSA focuses on communities and has programs like Center for the Application of Prevention Technologies (CAPT) and Sober Truth on Preventing Underage Drinking Act (STOP Act) (Substance Abuse and Mental Health Services Administration, 2017).
State public health initiatives are aiming to increase accessibility to rehabilitation programs, make opioid reversal agents available over the counter instead of prescription only. One example of a state-run public health initiative is the one being undertaken in Virginia, where the Department of Health is tracking opioid statistics, providing updates and recommendations to healthcare providers, and changing policy to make treatment options more accessible (Department of Health for the Commonwealth of Virginia, 2016).
Accessibility of Resources
Education programs that target adolescent youth take place in public education which has a great amount of reach. Unfortunately, the success of such educational programs is not fully supported by evidence (Champion, Newton, Barrett, & Teesson, 2013). So, while resources for this intervention are accessible, they are not effective.
State public health initiatives are aiming to increase accessibility to rehabilitation programs, make opioid reversal agents available over the counter instead of prescription only (Department of Health for the Commonwealth of Virginia, 2016). Naloxone is now available in nasal spray form instead of only intravenous form which can help save lives outside of the medical environment and has shown great promise for reducing drug overdose deaths (Volkow et al., 2014; Wermeling, 2015; Wheeler et al., 2015).
The NIDA, the CDC, and the CMS are some of the organizations that are trying to increase prescription of MATs, especially for vulnerable populations (Volkow et al., 2014). There is some access now, but this remains a significant barrier. Volkow et al. state that even within programs that use MATs, they are only being prescribed to about a third of patients.
Barriers to Change
The trend of increasing amounts of substance abuse across the country has been growing steadily for decades (National Institute on Drug Abuse, 2017). Addiction is a difficult cycle to break as it has deep roots in individuals, families, communities. Fortunately, many large organizations have stepped forward to address this growing issue and look for solutions.
Literature is inconclusive regarding the impact of adolescent educational programs to prevent substance abuse (Carney et al., 2016). However, new research is promising to reduce adolescent substance abuse rates through the implementation of online prevention programs but still requires future research to confirm the findings (Champion et al., 2013).
The use of MATs is promising but such therapies have many barriers including a lack of prescriber approval and acceptance due to misconceptions, policy-related obstacles, and access issues with insurance companies (Volkow et al., 2014). However, MATs are still a relatively new treatment for opioid abuse, and awareness and approval among healthcare providers may increase if future research continues to favor their implementation.
The severity of the substance abuse epidemic requires a response of equal proportion. The statistical trend is dismaying and will require significant evidence-based interventions to see a positive change. Targeting adolescent populations through school/education as well as primary care interventions in efforts to reduce rates of substance abuse are unfortunately not well supported by research (Carney et al., 2016; US Preventive Services Task Force, 2014). It is reassuring that many organizations are taking a coordinated public health approach to increasing awareness. In addition, increased access to opioid reversal agents, utilization of MATs, and insurance coverage for rehabilitation programs all show great promise for reducing substance abuse and associated deaths (Volkow et al., 2014).
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