The nation's opioid epidemic is increasingly in the news. In October, President Donald Trump labeled the opioid crisis a public health emergency.
Opioid crisis in Colorado
By Bill Radford
And yet, Mary Steiner with the Community Heath Partnership in Colorado Springs, Colorado, said one of the biggest issues in battling the emergency continues to be "a huge lack of awareness of the problem."
"Unless you're directly hit with it, people don't have that level of awareness that they need," said Steiner, who coordinates the Coalition for Prevention, Addiction, Education and Recovery in Colorado Springs.
She said among those likely to be "opioid naïve" are "high school students who may be taking medications out of parents' or grandparents' medicine cabinets. Over 50 percent of people who use opioid medications for non-medical reasons got them from a family member's medicine cabinet."
Falcon School District 49 works to educate students about opioids and other drugs.
"District 49 students learn about the dangers of drug use as part of their health curriculum in high school," according to a statement from the district. "All students, regardless of age or grade level, receive support on an individual basis from counselors, school psychologists and nurses as needed. This group of support staff receives annual training on the substances most likely to be used by local teenagers through partnerships with local law enforcement agencies."
That rummaging through a family member's medicine cabinet can have deadly consequences. Nationally, overdose deaths involving prescription opioids such as oxycodone and hydrocodone have quadrupled since 1999, according to the Centers for Disease Control and Prevention. A decline in U.S. life expectancy is blamed, at least in part, on the opioid crisis.
In 2015, 329 people died in Colorado from prescription opioid overdoses, according to numbers from the state Department of Public Health and Environment. While that number slipped to 300 in 2016, no one is saying the crisis is over. For one thing, heroin overdose deaths increased 23 percent that year; people hooked on prescription pain pills may switch to heroin, which is also an opioid, when their supply runs out or as a cheaper substitute. And preliminary numbers point to a possible increase in prescription opioid overdose deaths in 2017.
Deaths are only one measurement of the problem -– "just the tip of the iceberg,” Steiner said. There are the people who show up at the emergency room with an overdose, those who are in treatment, those who can't find treatment.
So how did we get here? Opioid prescriptions have skyrocketed in the past 20 years or so. Part of that stems from recognition of the under-treatment of pain and a push to label pain as a "fifth vital sign," gaining equal status with blood pressure, heart rate, respiratory rate and temperature.
"We said, 'Why aren't we using narcotics to get these pain levels down? They're safe.' With the knowledge we had, we thought they were," said Dr. William Lippert, a pain management specialist with Penrose-St. Francis Health Services.
With the "ballooning of prescription writing" came more narcotics development by drug companies and an expectation by the public to have their pain controlled without question, Lippert said. While doctors understood there was risk in prescribing opioids, that risk was "grossly underestimated," he added.
The battle against the opioid epidemic is being fought on several levels. The Coalition for Prevention, Addiction, Education and Recovery was formed in March 2016; it includes elected officials, first responders, representatives from hospitals, public health, law enforcement and the military — and more.
Among initial recommendations from coalition work groups: making naloxone, a medication that reverses the effects of opioids in the case of an overdose, more readily available; a needle exchange program; and provider and patient education. The results of a community readiness assessment, meant to identify what steps the community might be ready to take and a cost-benefit analysis of each of those steps, are expected in February. The El Paso County Board of Health has already squashed a proposal for a needle exchange, with a majority expressing opposition at a meeting in December.
The Coalition for Prevention, Addiction, Education and Recovery is affiliated with the Colorado Consortium for Prescription Drug Abuse Prevention, reflecting a coordinated attack on the problem, Steiner said. The state consortium is also involved with the work of the Opioid and Other Substance Use Disorders Interim Study Committee in the state Legislature, which has recommended six bills for consideration in the 2018 legislative session beginning this month, she said. Among the proposals: authorizing the creation of a supervised injection facility, based in Denver, for drug users as a pilot program; adding inpatient and residential treatment for opioid addiction under the state's Medicaid program, conditional upon federal approval; and generally limiting initial opioid prescriptions to seven days.
The emergency departments at UCHealth Memorial Hospital Central and Memorial Hospital North limit the duration of opioid prescriptions as part of an effort that began in 2015 to reduce such prescriptions. With an injury such as a bad ankle sprain, "We typically don't like to give them more than two to three days' worth," said Dr. Sean Donahue, a Memorial emergency physician. So a patient might be prescribed a half-dozen pills rather than the 30 or so that might have been prescribed a few years ago. The estimated reduction in opioid prescriptions from Memorial's effort adds up to more than a metric ton.
"It's just a real frank conversation with patients that we want to treat them safely, with non-narcotic alternatives," Donahue said, from anti-inflammatories to muscle relaxants to lidocaine patches.
The push to reduce opioid prescriptions came from recognizing the growing toll from abuse.
"We, as an institution, just said enough is enough," Donahue said. "We have to make a positive change here."
Steiner praises Memorial's effort, but notes the need for a shared philosophy among the medical community regarding opioids. Otherwise, she said, "If you squeeze one area, like the emergency rooms, the prescribing goes up in another area." (The number of controlled substance prescriptions, including opioids, dispensed to El Paso County residents in 2016 was 916,492, down from 918,592 in 2015 but up from 844,079 in 2014, according to the El Paso County Prescription Drug Profile, July 2017.)
There is no desire to let those who truly need the relief that opioids provide suffer, Steiner said. "That's not what this is about. It's simply about safe prescribing practices, especially for those who are opioid naïve and don't realize how addictive they are."
But Lippert worries about the pendulum swinging too far the other way. "I think people with chronic pain, legitimate pain, potentially are going to be somewhat under-treated for a while,” he said. “We're trying to keep that from happening, but that's a risk."
| || ||
According to a survey conducted by the Pew Research Center in 2015, 73 percent of teens age 13 to 17 have a smartphone. Additionally, 24 percent of those teens reported using the Internet on their cell phones “almost constantly,” and 56 percent reported going online several times a day. With teens spending so much time connected to their mobile devices, concerns arise about the effect it has in the classroom.|
At Falcon School District 49, in Falcon, Colorado, the policy on student use of cell phones and other personal technology devices determines appropriate uses for such devices. The policy states: “The Board of Education believes personal technology devices may be useful tools for students in the educational environment and can play a vital role during emergency situations.”
Peter Hilts, chief education officer for D 49, said the district is seeing an increase in the use of personal technology devices for medical and emotional support, something that was not possible for past generations. “There are multiple students in the district that rely on connectivity for medical monitoring such as glucose monitors or cardiac monitors,” he said. “There are other students for whom having access to a parent or other trusted person can help them regulate their behavior.
“While we recognize the potential for distraction with connected devices, we are increasingly supportive of the supportive uses of connective devices to help students stay healthy and high-performing.”
Andrea Anderson, a third-grade teacher in Colorado Springs School District 11, said she has a student in her class who has difficulty writing because she has weak muscles in her hands. “Having access to electronic devices, such as an iPad and a touchscreen monitor, allows her to participate and complete written assignments that would otherwise be difficult,” Anderson said. “She is able to type her responses instead of writing them in pencil.”
Rebecca Sims, a fourth-grade teacher in D 49, said she also has experience with students needing access to a personal technology device, most notably students with diabetes. “Because of technology, they can check their blood sugar in the classroom and treat their blood sugar accordingly, which allows for less time missed from the classroom.”
Those students are able to participate in more classroom activities, and they also help educate their peers on their health issues, Sims said.
Hilts said technological devices have really become the “norm” so the district strives to address their usage as they would anything else. “I think there is a normalization of connected devices; and, because it is normalized behavior, we have to manage it with our normal expectations,” he said.
Just like dealing with students talking inappropriately in class, the district responds to improper online activity by addressing each situation, Hilts said. The district must deal with the actual behavior and not jump to the conclusion that the device is the problem, he said.
“We are very intentional at teaching, at all levels of education, digital citizenship and character expectations to being a citizen in a digital age,” he said. “We also teach our staff and parents through training opportunities to detect and disrupt behavior that might be happening through social media and on connected devices.”
Sims said it is clear that technology will continue to be part of everyday activities, which means education needs to keep up with those trends. Students are practicing 21st century learning skills that they will eventually apply to real-world situations, she said.
“We would be doing a disservice to students if we were not incorporating devices into the classroom,” Sims said.
Next month: Effects of excessive cell use and related mental health issues.