Pew Charitable Trusts

Drinking is more likely to be the cause of death in much of the Southwest than in other parts of the country. In parts of Appalachia and New England, it’s a drug overdose. Suicide by gun stands out as disproportionately lethal in parts of the Upper Midwest and Alaska.

Although the top causes of death are similar for most states, many states have their own peculiar hard cases —types of deaths whose rates are higher than the national norm, a Stateline analysis of 2014 data from the Centers for Disease Control and Prevention shows.

The analysis, which relies on a method similar to one used in a CDC journal, shows some understandable disparities in the causes of death in some regions. The South, the epicenter of the nation’s obesity epidemic, has high rates of heart-related deaths. New Mexico and Arizona, where American Indian reservations have struggled with alcohol for decades, have high rates of alcohol-related deaths.

Some are more puzzling. Why, for instance, are falls disproportionately killing people in Northern states such as Iowa, Minnesota and Wisconsin? Why is Alzheimer’s disease causing relatively more deaths in Washington state?

State and local health officials increasingly plumb such disparities for clues that may help them develop preventive programs and save lives.

For instance, Kentucky and New Hampshire have high rates of death by accidental poisoning, which includes drug overdose. In response, Kentucky has begun a program to monitor the prescribing of addictive painkillers. It has also expanded the availability of treatment for substance abuse.

New Hampshire Gov. Maggie Hassan, a Democrat, signed a bill in January calling for stiffer penalties for drug dealers and more tracking of prescription drugs, calling the epidemic of heroin and prescription painkillers “the most pressing public health and public safety issue facing our state.”

Sometimes states can only do so much about higher incidents of mortality. Take suicide, for example. Guns often are more available in some Western states, said Catherine Barber, who directs the Means Matter Campaign at Harvard University. Their prevalence can drive up suicide rates, she said, not because gun owners are more likely to be suicidal — but because guns are more lethal if a person decides to commit suicide.

Data Drives Action

After noticing a stubbornly high rate of liver disease, intoxicated-driving and other causes of alcohol-related deaths, New Mexico’s Health Department this year began an alcohol-awareness program that focuses on areas of the state where the problem is most acute.

“The rate was not improving over time,” said Rosa Isabel Lopez, health data dissemination coordinator for the state health agency. “The decision was made to create more data points for community audiences and get this information into the hands of our neighborhoods.”

The state also launched a public website last year that displays data on health issues in small areas of the state, which communities can use to understand problems and target them.

Local detail, plenty of data, and plain language for policymakers are important aspects of successful state efforts to prevent deaths, said Ross Brownson, an epidemiologist at Washington University in St. Louis who wrote a 2010 guide on the subject.

“We like to say, ‘What gets measured gets solved,’ ” Brownson said. Until recently, he said, communities often didn’t have enough details about health problems to make policy decisions.

In the last few years, he said, there’s been improvement nationally in collecting and distributing health data. The University of Wisconsin’s Population Health Institute, for instance, introduced county health rankings for Wisconsin in 2003, and then expanded them nationwide in 2010.

The rankings noted drug overdose deaths “reaching epidemic proportions” in some areas such as northern Appalachia, and rising 79 percent nationwide since 2002. TheStateline analysis also found high rates of accidental poisoning, which includes drug overdoses, in Massachusetts and New Hampshire.

Deadly Puzzles

In Wisconsin and nearby Iowa and Minnesota, there are disproportionate instances of accidental falls that are fatal. It’s a phenomenon that has puzzled researchers for years, said Patrick Remington, an associate dean at the School of Medicine and Public Health at the University of Wisconsin.

“We’ve supposed that it’s due to cloudy weather, no sun and so no vitamin D [which promotes bone health], but there’s not been a good answer yet,” Remington said. Wisconsin’s Health Department has a fall prevention program, which points out that the elderly are particularly susceptible to falling.

Elizabeth Stein, a preventive medicine resident at the University of Wisconsin medical school, said low vitamin D levels can lead to both fatal falls and dementia in older people, though studies have yet to confirm a link between those causes of death and the area’s cloudy weather.

Washington state prepared a plan to address Alzheimer’s disease last year after data indicated it was the state’s third leading cause of death, killing people at a rate two-thirds higher than the national average. Worse, Alzheimer’s was on the rise while other top killers like cancer and heart disease were in decline.

But the apparent rise could be attributed to better data. Washington has a more rigorous method of collecting and verifying death data than some other states. States’ totals for all deaths from dementia, which includes Alzheimer’s, suggests that many might not be reporting the disease as carefully as Washington.

Differences between the states in recognizing and coding the cause of death can muddy the picture, said Francis Boscoe, a research scientist at the New York State Cancer Registry who used differing death rates by state as a “conversation starter” about state-specific mortality issues.

“It seems entirely plausible that physicians or coroners in Washington could be coding as Alzheimer’s what other states might call pneumonia or something else,” Boscoe said. “There are explicit rules for all this, but that does not mean they are all being followed the same way.”

After Boscoe wrote last year about peculiar death patterns in states, he said he heard plenty of feedback about data-collection issues that can make for misleading numbers.

Flawed Death Certificates

As Stateline has reported, how the cause of death is recorded on death certificates, from which officials draw data, can vary widely even within a state.

In Kansas, for instance, what appeared to be the most distinctive cause of death — hardening of the arteries, or atherosclerosis, killing people there at seven times the national rate — was actually more of a data-recording problem than a medical one.

“This is a classification issue,” said Cassie Sparks, of the Kansas Department of Health and Environment. She said the state plans to emphasize better reporting and classification in training materials for medical examiners and others who sign death certificates.

But even if some data is flawed, cities and states can get life-saving or life-extending results by taking action on the evidence of health problems that do emerge. Brownson of Washington University in St. Louis points to New York City as an example.

The life expectancy in the city grew faster than the national average, paced by drops in heart disease, cancer and HIV from 2001 to 2010, a study published in the currentJournal of Public Health Management & Practice found.

New York has focused in recent years on using health trends to guide new, albeit sometimes controversial, public policy — from restrictions on trans fats and tobacco to unsuccessful bans on oversized portions of sweetened drinks.

“The city health department is really a prime example of evidence-based policy, of making the policy dependent on the data,” Brownson said.

Read original article
Where Drinking, Drugs and Alzheimer’s Are Disproportionately Fatal

California has a problem: Fifty-two percent of its managers in the state workforce could decide in the next five years that they’re tired of working, grab their retirement packages and go. Their departure would create a serious brain drain for the state, which has the largest number of state employees in the country — 220,000.

So Jeff Douglas, California’s chief of workforce development, is trying different tactics to keep senior workers on the job: offering a flexible work schedule, promoting work-life balance and creating the first government-wide employee management survey to assess the needs of workers. The idea is to find out who is leaving — and why.

Douglas knows that efforts to keep senior workers — especially managers, specialists, and highly educated and knowledgeable employees — on the job are at best stopgap measures. Eventually, the state will have to shore up its talent reserves as baby boomers age out of the state workforce. “Because people can walk right now, we have to be ready if they do,” he said.

Like California, nearly every state and locality faces the imminent departure of retirement-eligible employees. Anywhere from 30 to 40 percent of state workers are eligible for retirement, said Leslie Scott, executive director of the National Association of State Personnel Executives (NASPE). And states are scrambling to find ways to retain their most valuable seasoned employees.

Finding replacements won’t be easy. State employees are more educated than the rest of the nation’s workforce, including federal and local government employees, according to the Congressional Research Service.

So state personnel executives are experimenting with a variety of approaches to hang on to experience, including job-sharing and telecommuting, delayed retirement programs that pay lump sums to would-be retirees to keep working, training and development, and reward and recognition programs. They also are stepping up recruiting efforts to attract older employees who work in the private sector.

The idea, Douglas said, is to create a work environment “where you can stay longer and work longer.”

Retention Efforts

In Tennessee, where 32 percent of the state workforce is eligible for retirement, state workers can take advantage of the “temporary employment option.” The program allows retirees to work for up to 120 days during a 12-month period. This way, the state can “recruit” high-performing retirees to assist with special projects, said Rebecca Hunter, the state’s commissioner of human resources.

“This allows an agency to benefit from the transfer of institutional knowledge and is a nice transition to full retirement for the employee,” Hunter said.

In Ohio, state workers in the Office of Opportunities for Ohioans with Disabilities are allowed to schedule their work hours as they see fit, as long as they work somewhere between 6 a.m. and 6 p.m.

In Colorado, where 20 percent of the workforce in the state’s information technology division is eligible for retirement, the agency encourages retirement-age professionals to work with younger workers to ensure that knowledge is passed down to the next generation.

This is particularly important when it comes to dealing with older, “legacy” technology and other specialized fields, said Karen Wilcox, director of human resources in the Colorado governor’s information technology office. “Knowledge loss is the most critical issue,” Wilcox said.

In Virginia, where a quarter of state employees will be eligible to retire in the next five years, state human resources executives use “intense data” to predict who will be retiring and what is pushing them out, said Sara Redding Wilson, Virginia’s director of human resources.

“Only a small fraction is going, and we know why,” Redding Wilson said. Armed with data, she said, the state can tailor its retention efforts — while finding ways to recruit the next wave of talent.

The areas with the highest turnover rates are in corrections, juvenile justice and behavioral health, Redding Wilson said, fields with less flexibility in scheduling and that don’t pay as much.

Some states, such as Alabama and Arizona, and some localities, such as Los Angeles, Pinellas County, Florida, and St. Louis, let potential retirees take advantage of the Deferred Retirement Option Program (DROP). It works this way: public workers — such as police officers — who reach retirement age commit to continuing to work for a fixed period. They go on collecting their regular paycheck. And when they retire, they are paid a lump sum bonus of as much as 90 percent of the salaries they earned while continuing to work.

DROP programs can be an attractive incentive to keep talented employees on the job longer, while reducing costs for recruiting and training new employees, said Angela Curl, assistant professor of family studies and social work at Miami University in Oxford, Ohio.

But not all states have kept them going. In 2001, Missouri implemented a similar program, called BackDROP, which offered state workers more flexibility in the start and stop dates. (Roughly a quarter of Missouri’s state employees are eligible to retire this year.)

In a 2014 report, Missouri state employees said that the BackDROP program had been an incentive for them to stay on the job. Some used the money to pay off debt, while others put in savings for their children to inherit, something that they cannot do with traditional pension plans, Curl said.

But in 2010, legislators amended the program. Employees hired after Dec. 31, 2010, aren’t eligible to participate in the program.

Aging Out Will Continue

Public sector employees skew older than private workers. In 2013, 52 percent of full-time federal, state and local public employees were between ages 45 and 64, compared to 42 percent of full-time private sector workers, according to theCongressional Research Service. Fifty percent of state workers and 52 percent of local government workers were in that age group in 2013.

And states and local governments have already seen their workforces shrink in the past decade, thanks to budget cuts enacted during the Great Recession, according to the Center for State and Local Government Excellence.

State agencies also cut back on training and development programs, NASPE’s Scott said. As a result, younger employees aren’t prepared to step in to key management positions, she said. Meanwhile, many state workers — those who weren’t laid off in the midst of cutbacks — postponed retirement.

Some still are, which can give states some breathing room in which to plan to replace them. In Virginia, for instance, Redding Wilson said some younger boomers in their 50s are staying on the job to keep the state’s health care coverage.

But that won’t last long. As the economy continues to improve, more state workers are expected to retire, Scott said. And the remaining talent pool for top managers is much smaller. During the recession, many layoffs happened at the middle-manager level, she said.

The retirement wave will hit all sectors of government, from teachers to nurses to law enforcement. But finance, engineering and management, along with information technology, are areas that could see the biggest losses, according to Elizabeth Kellar, the center’s CEO. There are also big challenges to recruiting and retaining nurses, epidemiologists and doctors for public health jobs, she said.

“It’s a huge issue,” Kellar said. To maintain a strong workforce, she said, states need to focus on recruiting and retaining good people, develop talent through training, offer competitive compensation and have a succession plan for passing on duties to younger workers.

At the same time, states must adjust to the characteristics of a new generation of workers, who are more likely to hop from job to job, and between the private and public sectors.

“If they’re coming in [to work for the states], they’re not staying,” Scott said.

Planning for the Future

In Maine, where roughly a quarter of the state’s IT workforce is eligible for retirement in the next two years, “about 3,000 years of experience is going to be walking out the door,” said Jim Smith, Maine’s chief information officer.

“It’s going to be transformational. We’re going to need to do something radical to address this change.”

For the past couple of years, his agency has been focusing on how to keep seasoned employees on the job while attracting new talent. His agency allows retirement-age employees to work part-time. But, he said, “That’s a short-term solution.”

To attract millennials, his agency drastically streamlined its hiring process. Now, applicants can apply for jobs using a mobile app. Applications have increased 35 percent since the app launched, Smith said.

The state also launched an intern-mentor program, partnering with local universities and community colleges to identify potential hires and pair them with veteran workers. Since the program started in 2013, 70 percent of the interns have become full-time employees, he said.

But the state isn’t just focused on hiring young workers. It’s also recruiting seasoned professionals who’ve spent their careers in the private sector and don’t mind taking a pay cut to work in civil service.

One example of this: Smith. In 2012, after more than 30 years working in the private financial services sector, he decided, rather than retiring, he’d go to work for his home state. “I wanted an opportunity to give back,” Smith said.

Read original article
Beating the Brain Drain: States Focus on Retaining Older Workers

In the last couple of years, the number of sex offenders living on the streets of Milwaukee has skyrocketed, from 16 to 205. The sharp increase comes as no surprise to some. There are few places for them to live.

In October 2014, the City of Milwaukee began prohibiting violent and repeat sex offenders from living within 2,000 feet of any school, day care center or park. That left just 55 addresses where offenders can legally move within the 100-square-mile city. And their living options soon will become more limited across Wisconsin. Republican Gov. Scott Walker signed a bill in February that prohibits violent sex offenders from living within 1,500 feet of any school, day care, youth center, church or public park in the state.

Cities and states continue to enact laws that restrict where convicted sex offenders can live, applying the rules to violent offenders such as pedophiles and rapists, and, in some cases, those convicted of nonviolent sex crimes, such as indecent exposure. They are doing so despite studies that show the laws can make more offenders homeless, or make it more likely they will falsely report or not disclose where they are living. And though the laws are meant to protect children from being victimized by repeat offenders, they do not reduce the likelihood that sex offenders will be convicted again for sexual offenses, according to multiple studies, including one from the U.S. Department of Justice.

In all, 27 states have blanket rules restricting how close sex offenders can live to schools and other places where groups of children may gather, according to research by the Council of State Governments. Hundreds of cities also have restrictions, according to the Association for the Treatment of Sexual Abusers (ATSA). And many laws are becoming more restrictive — along with Wisconsin, they expanded last year in Arkansas, Montana, Oklahoma and Rhode Island.

The restrictions can make offenders’ lives less stable by severely limiting their housing options, and can push them away from family, jobs and social support — all of which make it more likely they will abuse again, according to researchers who have studied the laws, such as Kelly Socia, assistant professor of criminal justice at the University of Massachusetts, Lowell.

“If [the laws] don’t work, and they make life more difficult for sex offenders, you’re only shooting yourself in the foot,” Socia said.

Some state and local governments — in California, Florida, Iowa, Georgia and Texas — are finding the laws don’t work and are changing them or, more often than not, being told by the courts to do so. Many courts, such as in California and Michigan, have found the laws to be unconstitutional for being too vague or too restrictive in impeding where offenders can live.

False Perceptions

Psychologists who have treated sex offenders, such as Gerry Blasingame, chair of the California Coalition on Sexual Offending, say the impetus behind the laws — the belief that offenders who have been released will continue to seek out child victims who they do not know — is more perception than reality. Most perpetrators abuse children they know; just one in 10 perpetrators of child sex abuse is a stranger to the victim.

There may be merit in restricting housing for sex offenders who victimized a child they did not know, Socia said. But these laws often apply to all registered sex offenders, including anyone convicted of a sex crime, even nonviolent offenses such as indecent exposure and statutory rape.

Maia Christopher, executive director of the ATSA, said the laws are based on “the myth of the sex offender — that there is a stranger who is lurking in the bushes and grabbing people” and that they cannot be treated. Some treatment programs, such as one in Minnesota, have been found to reduce recidivism rates for sexual offenses, but researchers haven’t concluded that treatment is effective, according to the Justice Department’s Office of Justice Programs.

A U.S. Bureau of Justice Statistics study in 2003, the most recent available, found that 5.3 percent of inmates released from prison after being convicted of a sex offense are arrested for another sexual offense within three years. (Although researchersgenerally acknowledge that the recidivism rate may be low because these crimes are underreported.)

After studying housing restriction laws for about a decade, Socia said he hasn’t seen one that has been effective in reducing recidivism. Several studies, including one from Florida and another from Minnesota, have shown the laws have no effect.

What they can do is make offenders even greater outcasts. A U.S. Department of Justice report released in October 2014 said there is fairly clear evidence that residency restrictions are ineffective, and the laws cause a “loss of housing, loss of support systems, and financial hardship that may aggravate rather than mitigate offender risk.”

After California created new restrictions in November 2006, the number of homeless offenders on parole shot up from 88 to 1,986 in March 2011, according to a reportfrom the state’s Sex Offender Management Board. And the board soon will release a study that will show that, once homeless, a sex offender is more likely to reoffend.

“These guys that are homeless, they become desperate,” said Blasingame, a board member. “They look for opportunities.”

California stopped enforcing its blanket rule requiring offenders to stay 2,000 feet from schools and parks statewide last year, after the state Supreme Court ruled in March 2015 that the law imposed unconstitutional restrictions on paroled sex offenders in San Diego County. The restrictions made 97 percent of rental housing there unavailable to offenders. And, the court found, that contributed to homelessness, and hindered the parolees’ access to medical, drug and alcohol treatment, counseling and social services.

Following the court decision, the state started to enforce the rules on a case-by-case basis. As of October, a third of the 5,901 offenders in the state needed restrictions and the rest didn’t, the state found. From February 2015 to October 2015, the number of transient sex offenders without a permanent address fell by 20 percent, from 1,319 to 1,057.

Advocates — such as Christopher of the ATSA and Kurt Bumby, director of the Center for Sex Offender Management, a project run by the Center for Effective Public Policy that provides guidance on how to best manage sex offenders — are encouraged by efforts in some states. They point to Oregon, Vermont and Washington, where there is a more unified effort among state corrections and parole officials and nonprofits to provide a safe, structured re-entry for offenders, using monitoring, stable housing and access to treatment.

In a state-run program in Vermont, Circles of Support and Accountability, community volunteers meet regularly with high-risk sex offenders to offer support. Program participants have lower rates of recidivism.

‘A Dumping Ground’

In Milwaukee, most of the 55 places where offenders can move to are single-family houses, tucked in alcoves of pricy suburban areas. City officials there passed the 2014 law out of desperation, said Alderman Michael Murphy, who voted against the ordinance.

The city had become “a dumping ground” for sex offenders, he said, because most other cities in the county had passed residency restrictions, leaving nowhere else for the offenders to go. Sixty-three percent of county residents live in the city, but 2,269 sex offenders, or 82 percent of the county’s total, live there. The rules ended up pitting cities against each other, Murphy said.

But at least one state prohibits local government from creating the restrictions:Kansas passed a ban in 2006, and New Hampshire is thinking of doing the same.

Since Milwaukee enacted its law, Dereck McClendon, who works with prisoners being released from jail, said he has watched more sex offenders released onto the streets because they have no place to go. McClendon, a program director for Genesis in Milwaukee Inc., a Christian nonprofit that helps people find work after prison, said each ex-offender needs to be given an assessment, and then help re-entering the community. If not, he said, they will inevitably start to get into trouble.

“Man, I tell you, the lack of hope these men possess,” he said. “Oh man, it kills me.”

Murphy and others in Milwaukee are pleading with Walker for a statewide solution. The law the Legislature passed this year that establishes the 1,500-foot rule for violent sex offenders also requires the state to release prisoners only to the county where they lived before, and allows a judge to rule that an offender being released from jail can live within a restricted area if there are no other options. Murphy said that helps, but doesn’t solve the problem.

The new Wisconsin law also won’t address what Republican state Rep. Joel Kleefisch calls “a patchwork quilt of sex offender laws” across the state, because it does not supersede local rules.

He introduced a bill that would ban local restrictions and create a 1,000-foot restriction statewide — a smaller restriction than some cities have currently.

“Having a statewide, easily understandable residency requirement will mean we can watch them,” Kleefisch said. “If they are underground or off the grid, God only knows what they’re doing.”

Read original article
Despite Concerns, Sex Offenders Face New Restrictions

For more than a decade, doctors, dentists and nurse practitioners have liberally prescribed opioid painkillers despite mounting evidence that people were becoming addicted and overdosing on the powerful pain medications.

Now, in the face of a drug overdose epidemic that killed more than 28,000 people in 2014, a handful of states are insisting that health professionals do a little research before they write another prescription for highly addictive drugs like Percocet, Vicodin and OxyContin.

“We in the health care profession had a lot of years to police ourselves and clean this up, and we didn’t do it,” Kentucky physician Greg Jones, an anti-addiction specialist, said in an online training course he gives doctors in his state. “So the public got fed up with people dying from prescription drug abuse and they got together and they passed some laws and put some rules in place.”

By tapping into a database of opioid painkillers and other federally controlled substances dispensed in the state, physicians can check patients’ opioid medication history, as well as their use of other combinations of potentially harmful drugs, such as sedatives and muscle relaxants, to determine whether they are at risk of addiction or overdose death.

Prescribers also can determine whether patients are already receiving painkillers or other controlled substances from other sources, a practice known as doctor shopping. Patients with this type of history are at high risk for addiction and overdose and may be selling drugs illicitly.

In 2012, Kentucky became the first state to require doctors and other prescribers to search patients’ prescription drug histories on an electronic database called a prescription drug monitoring program (PDMP) before prescribing opioid painkillers, sedatives or other potentially harmful and addictive drugs.

Sixteen states have enacted similar laws, and experts, including the U.S. Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy, are encouraging other states to do the same thing.

Maryland Gov. Larry Hogan, a Republican, signed a law in April that requires certain prescribers to use the state’s monitoring system, and a similar bill is moving through the Legislature in California.

Prescribers can be required to check PDMP databases in 29 states, depending on conditions that vary from state to state, according to the National Alliance for Model State Drug Laws.

Although the American Medical Association supports physician use of drug tracking systems to identify potential addiction and drug diversion to the black market, state medical societies have argued against mandatory requirements they say interfere with the practice of medicine. Patients’ privacy and legitimate pain needs, they say, could be jeopardized by requiring busy physicians to investigate potential patient abuse of pain medications.

Despite these objections from some in the medical profession, more states are imposing the requirements. “Comprehensive mandates are the single most effective thing states have done to curb opioid prescribing, and it seems to have an almost instantaneous effect,” said John Eadie, who has evaluated state programs at Brandeis University’s Prescription Drug Monitoring Program Center of Excellence in Massachusetts.

In states where physicians are required to use monitoring systems, overall opioid prescribing has plummeted, as have drug-related hospitalizations and overdose deaths, Eadie said. States also are seeing a rise in addiction treatment as more doctors refer patients to treatment after discovering they are taking painkillers from multiple sources and are likely addicted to them.

In Kentucky, hydrocodone (Vicodin) prescribing dropped 13 percent, oxycodone (Percocet) dropped 12 percent, oxymorphone (Opana) dropped 36 percent and tramadol (Ultram) dropped 12 percent between 2012 and 2013, the first year the law was implemented, according to an analysis by the University of Kentucky’s College of Pharmacy.

Since the law was passed, overdose hospitalizations declined 26 percent, and prescription opioid deaths dropped 25 percent, the first reduction in nearly a decade, according to a March 2016 report by Shatterproof, a national advocacy organization that promotes prevention and treatment of drug addiction.

In another effort to stem overprescribing of opioid painkillers, which is widely blamed for the current epidemic, the CDC in March took the unprecedented step of issuing national opioid prescribing guidelines. Along with patient education, urine drug testing, and abuse-deterrent formulations of pain pills, the federal agency recommended prescribers check prescription databases before prescribing to reduce the risk of opioid overdose and addiction.

Vastly Underused

Prescription drug monitoring systems have existed in paper form since the 1930s, and every state except Missouri has some type of system. But the rules governing who has access, how quickly pharmacies must enter dispensing data, and which medications are included vary widely from state to state.

(The creation of a prescription drug monitoring system in Missouri has been blocked by a small group of legislators, led by state Sen. Rob Schaaf, a Republican and a doctor, who argue that allowing the government to keep prescription records violates patient privacy rights. In March, the opioid-plagued county of St. Louis adopted an ordinance to create a monitoring system, and advocates and some lawmakers continue to press for a statewide program.)

In general, state databases have been used effectively by law enforcement to track down so-called pill mills, where doctors indiscriminately prescribe opioid medications for cash. And a substantial number of pharmacists have consulted them before filling a prescription. But a relatively small percentage of medical professionals are signing on to the systems to detect patients who are at risk for addiction or overdose.

In most states, health care professionals who prescribe at least one controlled medication are encouraged to use PDMPs, but only on a voluntary basis. As a result, the typical state program in 2012 had only 35 percent of doctors signed up for access, according to the center at Brandeis. In 2014, 53 percent of doctors were signed up to one of the programs, according to a survey by Lainie Rutkow, an associate professor of public health at Johns Hopkins.

Most states require prescribers to obtain access to PDMPs and use them at their discretion when they suspect a patient is at high risk for addiction, drug diversion or overdose, according to the National Alliance for Model State Drug Laws.

The problem with that, said Van Ingram, Kentucky’s director of drug control policy, is “people think doctors can just look at a patient and recognize this disease of addiction, and it’s not that simple.”

“People with addictions can fool their spouses, their children and their employers. They can definitely conceal the disease from their physician in a 15-minute visit.”

A Diagnostic Tool

In Kentucky, doctors and some patients complained about the requirement when it was first adopted, Ingram said. But these days, he said, he mostly hears doctors saying, “Wow, I treated that patient for 20 years and had no idea he had a drug problem.

“If there’s a tool out there that takes 15 seconds to use and can diagnose a disease, why wouldn’t you want to use it? To me it’s a no brainer,” Ingram said.

Before Kentucky physicians were required to check the database, patients commonly visited multiple doctors to get prescriptions for opioid painkillers, the sedative Xanax, and the muscle relaxant Soma, according to the state’s PDMP director, David Hopkins. “The cocktail,” as it’s known in Kentucky, produces a high that is similar to heroin and just as deadly. It has become much less prevalent since the law was enacted.

“We cracked down on that big time,” Hopkins said. The number of people receiving the cocktail has dropped 30 percent since the law took effect and the number of doctor shoppers has dropped 52 percent, he said.

Kentucky is also trying to curtail dangerously high doses of prescribed painkillers by flagging the database when a patient is taking medications from multiple sources that add up to the equivalent of 100 milligrams or more of morphine per day. Last year, a calculator was added to the system so doctors wouldn’t have to add up the morphine equivalents on their own.

Hopkins said the state listened to doctors’ complaints and added some commonsense exceptions after the initial rules came out. Prescribers are no longer required to check the database in emergencies or for patients in hospice, long-term care or cancer treatment. They can also skip the step if a patient was originally prescribed a pain medication by a fellow doctor in their practice and needs a refill or a different pain medicine.

Kentucky’s prescriber rules, which were developed by the state Board of Medical Licensure, allow doctors to appoint a delegate to access the drug monitoring system and review patients’ drug profiles. Doctors typically ask their assistants to run prescription drug histories on all the patients they will see the next day and add the information to their electronic medical records, said Michael Rodman, director of Kentucky’s licensure board.

If a potential drug problem is detected, prescribers can query the database to determine how other physicians in the state are addressing the pain needs of similar patients and they can discuss an individual patient’s drug history with another prescriber, something that was forbidden under previous state privacy laws.

Another part of Kentucky’s 2012 opioid law requires prescribers to attend a certain number of free training sessions each year on addiction, pain management and use of the state’s prescription monitoring system. (Jones conducts some of those training programs.)

To increase the effectiveness of drug monitoring programs, Kentucky and other states use reciprocal agreements to allow interstate sharing of drug dispensing information for pharmacists, law enforcement and physicians in nearby states. Kentucky has agreements with at least 20 other states. New Jersey Gov. Chris Christie, a Republican, announced in April that New York had joined his state in sharing PDMP information, along with Connecticut, Delaware, Minnesota, Rhode Island, South Carolina and Virginia.

As for what happens when a physician discovers a patient is doctor shopping, Rodman said, they often dismiss patients and no longer treat them.

But Jones, who heads the Kentucky Physicians Health Foundation, which supports doctors who suffer from substance use disorders, tells doctors not to do that to patients.

“Maybe you don’t keep prescribing them 90 OxyContins with five refills,” he said, “but don’t throw them out. If you do, you’re missing an important opportunity to save a life.”

 

The relatively high percentage of American women who die as a result of pregnancy, which exceeds that of other developed nations, is prompting a new national prevention campaign that is relying on the states to take a leading role.

The key element in that effort is to encourage all states to go beyond the information provided on a typical death certificate by having mortality review panels investigate the causes behind every maternal death that occurs during pregnancy or in the year after delivery.

The hope is the investigations will reveal systemic causes for at least some of the deaths and lead to preventive measures to save the lives of more would-be or new mothers.

A number of studies suggest that one in three maternal deaths is preventable.

“It’s hard to do anything about a problem if you don’t have the problem fully defined,” said Cynthia Shellhaas, an associate professor in the division of maternal-fetal medicine at the Ohio State University Wexner Medical Center.

The campaign is led by the Association of Maternal & Child Health Programs (AMCHP), a public health advocacy group, and the U.S. Centers for Disease Control and Prevention.

AMCHP and the CDC want every state that doesn’t have one already to create a maternal mortality panel of medical and forensic experts. They want the panels to collect as much information as possible related to every maternal death, including matters related to prenatal care, other health conditions, use of medications, drug and alcohol abuse, violence and medical procedures performed.

They also are encouraging states to standardize the data they collect. And they will provide a digital application to help them collect it, to make it easier to analyze the data for possible trends and remedies.

About half the states — including California, New York and Texas — already have panels, although each currently devises its own ways of classifying information and determining which cases to investigate.

For example, some consider as maternal any death up to 42 days after a pregnancy. Others examine any death up to a year after delivery.

High U.S. Rate

In the U.S., there are 18.5 maternal deaths for every 100,000 live births, according to the Institute for Health Metrics and Evaluation at the University of Washington, which tracks mortality trends worldwide. (For African-American women, the rate is three times higher, according to the CDC.) The CDC says that about 700 maternal deaths occur in the U.S. every year.

The rate is down from a recent peak — in 2009, when it was 22 deaths per 100,000 — after rising steadily for more than a decade.

But preliminary numbers suggest that maternal deaths are again on the rise after 2013, the institute said. The death rate is significantly higher in the U.S. than in other developed countries. For example, the rate is 8.2 in Canada and 6.1 in the United Kingdom and Japan.

 

There are several possible reasons for the higher U.S. rate, including better reporting, mothers giving birth at older ages (increasing the odds of pregnancy-related complications) and the growing percentage of expectant mothers with untreated chronic conditions such as obesity, hypertension and diabetes. The upsurge in opioid overdoses also may be a factor.

Maternal deaths often signal broader health problems among expectant and new mothers.

The Joint Commission, a nonprofit that accredits health care organizations and programs, calls maternal deaths “sentinel” events. “For every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy, labor and delivery,” Dr. William Callaghan, a senior CDC scientist who studies maternal morbidity, said in the Joint Commission’s 2010 alert.

Renewed Effort

The notion of investigating the deaths of mothers to prevent them isn’t new.

Medical societies in some large cities and states began establishing maternal mortality panels in the 1930s, when the maternal mortality rate was more than 600 deaths for every 100,000 live births.

Even then, there was a strong sense that many of the deaths could be prevented through improved medical and hygienic practices.

The work of those panels, combined with the Social Security Act of 1935, the advent of antibiotics, advances in obstetrics and medicine in general, and the trend toward more hospital births, led to a precipitous drop in the mortality rate through the early 1960s.

Many of the review panels disappeared. But as rates started rising again the late 1990s, panels began to resurface. David Goodman, the senior scientist for the CDC’s Maternal and Child Health Epidemiology Program, estimates that at least 20 states have panels and another dozen are creating them. Some states, including Illinois, have additional maternal mortality panels that focus on violent deaths.

Most of the mortality panels are appendages to state health departments, although Goodman said most operate with little state revenue. They rely instead on the financial contributions and participation of its volunteer members, which usually includes doctors, coroners, lawyers and even police officers.

Some states also have mortality review panels for fetal, infant and child deaths.

Beyond Death Certificates

Although death certificates usually provide a cause of death, the quality of the information varies greatly from state to state.

The certificates lack the level of detail that would help hospitals and other providers make adjustments that could prevent recurrences, Goodman said.

For example, he said, a death certificate may indicate that a new mother might have died as a result of an infection. But a deeper examination of her case and similar ones could reveal deficiencies in the sterilization of surgical equipment in hospital obstetrics units.

Something like that happened in California. Evidence revealed by the California mortality review panel led to revised protocols in the handling of post-delivery hemorrhages in all California hospitals beginning in 2008.

Barbara O’Brien, program director of the Office of Perinatal Quality Improvement at the University of Oklahoma Health Sciences Center, said that evidence collected by her state’s mortality review panel has led to the use of compression devices for all pregnant women undergoing cesarean sections to reduce the risk of developing a deep vein thrombosis — a blood clot, usually in the leg, that can be fatal.

The panels turn to many sources of information, including autopsies, hospital and provider medical records, and, in some cases, records from police and social service agencies.

Some states have laws that give the panels access to those records, but not always. “If you want to go to the provider’s office who provided prenatal care [in Oklahoma] they aren’t required to give you the records,” O’Brien said.

Dr. Shellhaas of Ohio, who oversees her state’s maternal mortality panel, said it usually waits two years before delving into a case to allow any civil lawsuits to be resolved, which removes an impediment to getting the necessary documents.

AMCHP and the CDC are testing the new data collection system in a dozen states. Eventually it will be made available to all states, thanks in part to funding from the pharmaceutical giant Merck & Co. Inc., which is engaged in a $500 million, worldwide campaign to improve maternal health and reduce maternal deaths.

AMCHP also plans to create an internet portal to help states communicate with each other on issues related to maternal health and mortality, said Lori Tremmel Freeman, AMCHP’s CEO.

Read original article
States Urged to Reduce Pregnancy-Related Deaths

It’s been four months since anyone in Broward County, Florida, has died from an overdose of alpha-PVP, known as flakka, a crystal-like synthetic drug meant to imitate cocaine or methamphetamine. But the drug has already taken a deadly toll, and left health and law enforcement officials scrambling to stem a new public health crisis.

In small doses, flakka elicits euphoria. But just a little too much sends body temperatures rocketing to 105 degrees, causing a sense of delirium that often leads users to strip down and flee from paranoid hallucinations as their innards, quite literally, melt. If someone survives an overdose, they are often left with kidney failure and a life of dialysis.

Flakka is among a growing number of addictive and dangerous synthetic drugs being produced easily and cheaply with man-made chemicals in clandestine labs in China. But because the drugs were largely unregulated when they first hit the market, some states have struggled to combat them. Now legislators, health professionals and police are trying to eradicate the drugs by making it easier to qualify them as illegal and ramping up the criminal penalties for selling them.

Since 2010, when synthetic drugs started becoming popular in the U.S., 32 states have passed laws to make it easier to classify synthetic drugs as illegal. This year, the District of Columbia and Florida passed similar measures, and in at least 10 other states, changes to controlled substance laws took effect, according to the National Alliance for Model State Drug Laws (NAMSDL).

Among the most popular synthetic drugs in the U.S. are synthetic cathinones, known commonly as bath salts, and synthetic cannabinoids, essentially smokable imitation marijuana products, which are sold in stores using kid-friendly branding like Scooby Snax.

It had been difficult for states to classify synthetic drugs as illegal, a process known as scheduling, because drugs are typically banned based on the compounds they contain. Under that system, manufacturers can change a molecule of an illegal synthetic drug, essentially rendering it legal.

“It does seem to some extent that everybody’s a step behind what’s being produced,” said Jonathan Woodruff, an attorney with NAMSDL.

While the federal Drug Enforcement Administration is working to permanently add 10 synthetic cathinones, including alpha-PVP, to its list of scheduled drugs, some states have also been moving to modify how they schedule drugs.

This year, Florida and the District of Columbia enacted laws that change the way they schedule synthetic drugs. Rather than making the drugs unlawful based on their chemical makeup, the new laws classify drugs based on the type of drug and the reaction it causes.

The approach means that any drug that mimics an already illicit substance will automatically be illegal. The change will enable Florida to quickly prosecute drug cases and stomp outbreaks of new drugs, said James Hall, an epidemiologist with Nova Southeastern University.

“It bans substances before they appear or before we even know about them,” Hall said. “So it breaks this vicious cycle of a new drug appearing, finally getting it scheduled or banned and then another one rushing in to takes its place.”

These laws alone won’t stop the spread of synthetic drugs. But public health advocates are hopeful the Florida law will help prevent another flakka, from which 61 people in Broward County died between September 2014 and mid-December 2015.

In the District of Columbia, where in September 603 people were taken to the hospital after ingesting synthetic cannabinoids, the new law, which went into effect this month, is also expected to make it easier for police and prosecutors to charge and convict drug dealers.

Chasing Synthetics

In DeKalb, Illinois, one of the first places to adopt a similar law in 2012, City Attorney Dean Frieders said flakka and other synthetic cathinones like bath salts haven’t taken hold there. (A statewide law in the same vein was passed in 2015.)

But the city of almost 44,000 people, which is home to Northern Illinois University, did face a growing problem with retail sales of synthetic marijuana products, which are said to elevate mood and relax the user but have also been known to cause extreme anxiety, paranoia and hallucinations, as well as rapid heart rate, vomiting and violent behavior.

The ordinance not only banned the synthetic substances, but allowed city officials to suspend or revoke the tobacco and liquor licenses of businesses that sold the drugs, which Frieders said was effective.

“A business just can’t relocate to a different corner,” he said.

States are also sanctioning businesses for the sale of synthetic drugs to cut down on sales and adverse health reactions, Woodruff said.

The District of Columbia has shut down four stores that sold the fake marijuana products, which has led to a substantial decline in people needing medical attention after injecting them, said Robert Marcus, communications director for the District attorney general. The number of people transported to hospitals in the city after consuming synthetic marijuana dropped to 110 in February, down 82 percent in five months.

What’s Next?

Broward County officials say they expect the new scheduling of synthetic drugs to be helpful, but they relied on a different approach to largely eliminate flakka: working with the DEA to pressure the Chinese government, which last fall made it illegal to produce it and 115 other synthetic substances.

Heather Davidson, a prevention specialist for the United Way in Broward County, said officials in South Florida are at a “resting point” with flakka-related emergencies. But, she said, some dealers are passing off real methamphetamine and cocaine as the synthetic drug, even though those drugs are more expensive and have been around longer, because flakka has become so popular.

Broward’s flakka problem came to a head last year when county hospitals saw 360 cases related to the drug in one month. By December that number had dropped to 54, an 85 percent drop in five months.

“We still hear anecdotally that people are searching for flakka, that users are still wanting to find it,” Davidson said. “And I believe that another synthetic drug or synthetic compound will take its place.”

One of those compounds might be synthetic opioids, which are gaining popularity as it becomes more difficult to get prescription opioids like oxycodone and morphine in the wake of the nation’s painkiller- and heroin-addiction crisis. Those drugs, largely produced in Mexican labs, are made with fentanyl, a synthetic drug that is a hundred times more powerful than morphine and 50 times stronger than heroin. Davidson and others worry they will be behind the next epidemic.

Already nine people have died from fentanyl-based drugs this year in Pinellas County, Florida.

“Heroin you need to cultivate. You need fields, you need workers, you need labor,” Davidson said. “With something like a synthetic drug, you just need a laboratory and chemical compound and a base and you’re able to create it very cheaply.”

Read original article
Synthetic Drugs Send States Scrambling