Breaking the Cycle of Overdose and Death in Rhode Island’s Opioid Crisis

In 1995, Oxycontin was introduced by Purdue Pharma and aggressively lobbied as a “safe” pain pill. Since that time, Oxycontin and many other opioids have been the cause of countless deaths in the United States with over 67,000 drug-related deaths in 2018. Deaths from prescription drugs such as Oxycontin alone are more frequent than both cocaine and methamphetamine combined.  

One of the states most affected by this crisis is Rhode Island. Despite only having a population of ~1 million, the number of opioid deaths per capita is 20% higher than the national average. In most cases of any drug-related death, the victim had previously overdosed multiple times. Overdose victims are sent to the hospital, which will only provide them with treatment for their physical overdose and not their addiction. Aproximately 46% of those who enter drug rehabilitation remain sober while another 16% check themselves into rehab again later on. Even without remaining sober, the risk of death from overdoses drops even further. So, how can we ensure those who are hospitalized with an overdose and survive receive the life-saving treatment they need?

The best option is through referrals. The hospital system in Rhode Island operates on a fee-for-service budget. For every person who comes in, their insurance is billed, and the hospital is paid. States like Maryland, for example, operate on a fixed budget system where they save money the fewer patients they treat. Both systems have benefits and drawbacks but a major drawback of the R.I. system is that hospitals have no incentive to refer overdoses to rehabilitation centers. Everytime someone overdoses it adds to the number of services the hospital has provided and increases their budget. The challenge, then, is getting hospitals to refer patients to rehabilitation centers even when it is not in their best interests. Additionally, pharmaceutical companies have been known to lobby against any change that might disrupt the flow of opioids sales despite the countless deaths they are responsible for. 

In order to enact this type of policy the support of other important stakeholders is key. The Drug Overdose Prevention and Rescue Coalition (DOPRC), for example, was established by the Rhode Island department of health in 2012 to fight the opioid crisis by developing evidence-based policy to prevent opioid addiction and death. Enacting a policy of automatic rehab referrals in RI hospitals could not only prevent deaths, but also put many victims of the opioid crisis on the path to recovery. 

Opioid Substitution Therapy: An Evidence-Based Approach to Afghanistan’s Opioid Epidemic

Opioid use continues to rise in Afghanistan despite $50 million of US funded substance abuse treatment programs. Image by Andrew Quilty.

In light of two decades of war and environmental disaster in Afghanistan, the country has seen an explosion in opioid use as Afghans struggle to cope with the world around them. In response, tens of millions of dollars have been poured into substance abuse treatment. The bulk of funding has come from the United States, which provides largely abstinence based therapy through contracts with the NGO Colombo Plan (CP). Despite these efforts, the opioid situation has not improved.

Opioid substitution therapy (OST) is a treatment that involves the use of prescribed opioids to wean patients off opioid dependence. OST has been backed by years of research and is supported by the United Nations Office of Drugs and Crime. The practice is associated with reduced risks of illicit opioid use, disease transmission, crime, adverse effects of withdrawal, and mortality. In 2010, the French NGO Médecins du Monde (MdM) opened the first OST clinic in Afghanistan. Not only was the OST successful, but MdM was able to operate at a reduced cost.

Despite its success, the MdM clinic met strong opposition and today there are only 8 OST clinics in the country. While the Afghan Ministry of Counter Narcotics (MoCN) supports OST on paper, the ministry has blocked methadone to OST clinics. CP has not been helpful either. The NGO was accused of warning the MoCN against the use of buprenorphine-based OST, and promoting the use of abstinence devoid of harm reduction programs. At the same time, the US Bureau of International Narcotics and Law Enforcement Affairs (INL) has spent over $50 million contracting CP to oversee treatment programs with no evidence of efficacy and over $23 million of unaccountable costs.

Additional OST programs are needed, but will require pressure on stakeholders. To start, the INL needs to be held accountable for its neglected oversight of mismanaged funds by the CP. Instead of supporting an organization that advocates against evidenced-based practices, the INL should be requiring all treatment programs to be evidence-based. If the US taxpayer is going to be paying the bill, the INL should be able to have something to show for it.

Prohibiting the sale of menthol-flavored e-cigarettes in the United States

Electronic cigarettes (e-cigarettes) produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other tobacco constituents that is then inhaled.  Many young people incorrectly believe that e-cigarettes are safe, and some do not even realize that these devices contain nicotine. However, e-cigarettes can deliver much higher concentrations of the drug than combustible tobacco products. Moreover, studies have shown that exposure to nicotine during adolescence can cause addiction and harm the developing brain.[4] For example, “smoking during adolescence increases the risk of developing psychiatric disorders and cognitive impairment in later life. In addition, adolescent smokers suffer from attention deficits, which aggravate with the years of smoking.”[1]

Young people are heavily targeted by the tobacco industry’s marketing efforts, and since 2011 youth e-cigarette use has increased dramatically, with 3.6 million youth reporting currently using e-cigarettes in 2020.[3] There is also growing evidence that menthol flavoring in tobacco products increases smoking initiation and reduces cessation by them. More than 80% of youth who have used tobacco report that they began with a flavored product, and 37% of high school students and 23.5% of middle school students who used any type of flavored e-cigarettes in 2020 used menthol.[4] These rising rates of use and the high rates of daily use of e-cigarettes suggest that many young people are addicted to nicotine.

Use of flavored e-cigarettes among youth in 2020; Source: https://www.fda.gov/tobacco-products/youth-and-tobacco/get-latest-facts-teen-tobacco-use

The U.S. Food and Drug Administration (FDA) has the authority under the 2009 Family Smoking Prevention and Tobacco Control Act to regulate all substances in tobacco products, including flavoring chemicals. In January 2020, the FDA issued guidance that prohibited the sale of e-cigarettes in any flavor other than tobacco or menthol. While menthol was previously not as popular an e-cigarette flavoring as mint in youth and young adults, by March 2020 menthol-flavored e-cigarette sales had risen to 58% market share, and by September sales of menthol-flavored cigarettes had increased by almost $60 million and its market share more than doubled.[5]

Over 20 state and local jurisdictions have already restricted menthol-flavored e-cigarette sales.[4] Such bans have been found to reduce sales and increase smoking cessation. It is reasonable to conclude that a national ban would help promote smoking cessation and reduce initiation in youth and young adults and could improve public health by reducing smoking-attributable diseases.[2] For these reasons, the FDA should prohibit the sale of menthol-flavored e-cigarettes.

The Need For Greater Access to Healthcare in the United States and the Impact of COVID-19

With the rise of the COVID-19 pandemic, the discrepancies of healthcare treatment between populations that have access to care and those that face barriers have been exacerbated. By the middle of 2020, around 3.3 million people lost employer-sponsored health insurance. While programs like the ACA, insurance marketplaces, and Medicaid expansions prevented more Americans from losing coverage compared to the Great Recession, the pandemic continued to highlight large barriers in accessing healthcare. 

After the passage of the Affordable Care Act in 2010, 20 million Americans gained health insurance coverage, especially with the expansion of Medicaid and the opening of insurance marketplaces. Although this coverage greatly expanded the number of Americans accessing affordable healthcare, affordability continues to be a major issue in American healthcare. In 2020, ⅓ of adults could not afford their healthcare plans. Before the pandemic, around 1/10 Americans reported delaying care due to the high cost of care. During the pandemic, factors up to 30/40% of adults delayed getting care. Populations with high barriers to care, including black Americans and low-income households were more likely to forgo care due to cost. 

Several policy solutions can be implemented to address inaccessibility to care in the United States. Firstly, the remaining states that have not expanded Medicaid in the US, can implement Medicaid expansion to improve accessibility for low and middle-income populations. Furthermore, the American Rescue Plan passed by Joe Biden, increases the number of citizens eligible for health insurance subsidy market exchanges as well as increases the subsidy amounts per healthcare plan. Additionally, COVID-19 measures such as covering the cost of disease treatment regardless of income or insurance status have increased healthcare accessibility in the US.

Source: SSRS

food and nutrition security in  schools Colombia

South America has been a reflex of socio economic contrast in the most recent years. This constrast can be observed in children nutrition as well. In 2015 was reported 11.3% of children is  chronically malnourished in South America, approximately 3.3 million children. Affecting most commonly the population in poverty and rural areas. These are the target scenarios for nutriotion plan at schools.

In the other hand, overweight has increased to 7.2% in children at scholar age 5-14 years of age, approximately 2.5 million children.

Policies in Latin America to improve nutrition among children:

• Increase taxes for drinks that contain sugar in Barbados, Dominica and Mexico.
• Regulate publicity and labeling in Ecuador, Bolivia, Chile and Peru

In Colombia the school nutrition program has the goal not only to impact the percentage of students graduating from elementary and high school but also their performance. Implement by. The ministry of education in national wide territory applied this strategy from 2010-2014, right before the stats shown emerged (2015).

According to panamerican health organization the agriculture production, storage and transformation need to be improved in order to guarantee equative access to these resources.

Improvements for the program:

• Despite reaching the calories per day in the nutrition plan, the diets are poor in proteins and rich in sugar, this aspect could favor the overweight and hyperactivity among students.
• The sources of food are influenced by the benefit of companies that provide low quality ingredients for lower prices.
• Good source of nutrient products (Agro products) such as vegetables and fruits are not being included and could support the agriculture in Colombia

Conclusion:

Modifications need to be performed in the diet nutrition plan provided from schools to children at scholar age in order provide better quality products that provide nutrients necessary for a healthy diet with good quality of ingredients and distribution of macronutrients (protein, fat and carbohydrates).

Based on diet plan distribution of macronutrients might be modified to include more protein and fats, still providing the carbohydrates and diminish the sugar added products such as sodas trough. Policies that increase taxes for these products. Also provide access to potable water and protect agriculture products.

The improvement should be applied for the period 2022-2026

• References for graphics and images
• https://iris.paho.org/bitstream/handle/10665.2/33680/9789253096084-spa.pdf?sequence=1&isAllowed=y

Importance of Universal Screening for Autism Spectrum Disorder to Minimize Racial Disparities in Early Intervention

Autism Spectrum Disorder (ASD) is a developmental disability that causes social, communication, and behavioral challenges for children and adults. Currently 1 in 54 children in the United States has ASD, and it can be diagnosed in children 18 months and younger. This is important because there is no cure for ASD. However, early intervention, which occurs before the age of 3, has been proven to dramatically improve development. This is a critical time to intervene and set the child up for long term success.

Source: https://www.autismspeaks.org/press-release/cdc-estimate-autism-prevalence-increases-nearly-10-percent-1-54-children-us

In the United States, non-Hispanic white children are diagnosed with ASD at higher rates and earlier than African American children. In 2018, 1.2 white children were diagnosed with ASD for every 1 African American child. These differences in prevalence are likely not a true difference but rather a difference in diagnosis rates. In African American children, the average age of ASD diagnosis was 64.9 month, which was on average 42.3 months after parents’ first concerns about their children’s development.

This data indicates that African American children are being diagnosed later and less frequently than their white counterparts. Given the importance of early intervention, universal screening programs are a central way to screen all children for ASD to ensure they are connected to early intervention as soon as possible. These screening programs are especially important because late diagnosis disproportionately impacts African American children. By screening all children for ASD, we will reduce disparities in occurrence and timeliness of diagnosis, which will result in better outcomes for African American children with ASD.

Currently, the United States Preventative Services Task Force (USPSTF) does not recommend universal screening for all children based on insufficient evidence and has called for more research. However, many expert organizations who work directly with individuals with ASD strongly support universal screening, including Autism Speaks, the American Academy of Pediatrics, and Autism Research Institute. As a public health practitioner, I believe USPSTF should recommend universal screening for ASD given the disproportionate impact late diagnosis has on African American children. Early intervention has been demonstrated to be the most effective way to support individuals with ASD, and screening all children is the best way to implement this intervention.

Making the Contraceptive Pill Accessible Over-the-Counter (OTC) in the United States

 Image from healthline.org

There are 72.2 million American women of reproductive age, of which 64.9% use a contraceptive. Of those, 9.1 million (12.6% of contraceptive users) rely on pills, which is the second most common contraception method in the US after female sterilization. Unlike in about 100 other countries where the pill is available OTC and the fact that the Birth Control (BC) is one of the safest and best-studied medication, the US still requires a prescription from a doctor or pharmacist to access the pill, which has led to a debate on whether to make BC accessible OTC. 

Representative surveys of women consistently reveal over half are in favor of OTC BC pills, with over one-third of respondents stating they’d likely use OTC pill if one were available. Making OTC pill accessible is strongly supported by major organizations that provide evidence-based clinical practice guidelines, such as the American College of Obstetricians and Gynecology and the American Academy of Family Physicians, etc. Research has shown that prescription requirements make it more difficult for women to obtain and consistently use BC pills and disproportionately impacts people who already face barriers to care. Providing OTC access to BC pills would help more people control their reproductive health needs without unnecessary barriers, thus reducing unintended pregnancy, unsafe abortions, and other adverse impacts. 

However, organizations like Planned Parenthood are strongly against this saying it would increase women’s costs because they would now have to pay for previously covered forms of contraception out of pocket. Some other opponents, such as Dr. Donna Harrison, executive director for the American Association of Pro-Life Obstetricians and Gynecologists say they are worried about side effects, women missing out on necessary screenings, and other benefits of regular counseling with the doctor if the pill is accessible OTC.

All the proponents of OTC BC agree that insurance must cover the cost of contraceptives both with and without prescription, but still, even if it doesn’t, women who are uninsured and cannot see a doctor would be able to have access to contraception. Additionally, Affordability Is Access Act would make sure it’s covered on a federal level. The first step towards making BC available OTC would be getting FDA approval on the drug. Ibis Reproductive Health is currently partnering with pharmaceutical company HRA Pharma to ensure the FDA has all the research it needs to decide. While this is in process, policymakers must ensure that all insurance must cover OTC BC’s cost when approved.

From Mother-to-Child Transmission to Mother-to-Child Protection

Credit: UNICEF/Egypt 2005/Giacomo Pirrozi

Written by: Rachelle Ciulla and Kalai Willis

Egypt is among the countries with the highest rates of mother-to-child transmission (MTCT) in the world (40.09 884). Ninety (90%) of new HIV infections among infants and young children occur through MTCT. Although the Ministry of Health provides ARV to all detected cases of pregnant women living with HIV, testing rates are low, and many women neither know that they are HIV positive during their pregnancy nor while breastfeeding. Without this knowledge and due to deep stigmatization towards HIV/AIDS, women cannot take the necessary precautions that are provided by the government. If these necessary precautions were implemented, women could reduce the chance of MTCT from 20-45% down to 2%.

What needs to happen? All pregnant persons should be (1) offered rapid HIV testing, (2) counseled on HIV risks, risks during pregnancy, risks to child from MTCT, and (3) provided the option for treatment regimen and counseling for positive tests at the first antenatal care visit. Testing should be completed with patient’s consent at the first and third trimester antenatal care visits. However, if a patient tests positive for HIV at any time during their pregnancy, labor, and delivery, they shall be provided with the proper ARV treatment upon their consent, and counseled on treatment long term, including ARV and testing for themselves and their child, as well as safe practices for breastfeeding. Specifically, birthing persons should be provided with ARV prior to receiving the results of the confirmatory test if a rapid HIV test during labor and delivery is positive.

Who should be involved? Data shows that antenatal care visits were at 83% in 2014, which gives a touchpoint for providers to take the necessary precautions. The National AIDS Program (NAP) and the Global Fund on HIV, TB, and Malaria (GFATM), with procurement support from UNICEF are currently making strides to support the reduction of MTCT in Egypt. To support these interventions, we call on the local governments to use this report to develop and pass policy.

What can you do? The call to action is to continue to support national and community efforts to address MTCT of HIV in Egypt. Together, we can advocate for “the right of people living with HIV/AIDS to receive stigma and discrimination free quality health care services.” It starts with knowledge and ends with action!

Uganda Motivated to Reopen Schools during COVID-19 Pandemic

Let’s play a quick word association game. What words come to your mind when you see the word “school”? Is it “textbook”, “backpack”, or “classmates”? These days, it wouldn’t be surprising if one of the associated words was “reopening” given current pandemic conditions.

Last year, many places closed down because of COVID-19. Schools were no exception. But now, the world is adapting to the new normal to begin reopening. Given the global impact, many countries had to take stock of what are the necessary parts of their society which should reopen sooner rather than later. As a result, it does not come as a surprise that various countries consider reopening schools a priority.

One such country is Uganda, where education is a focus area in the country. Additionally, various organizations highlight the role schools have to help protect children from exposure to violence and exploitation. As such, the wellbeing of children is at the center of Uganda’s actions to reopen their schools.

UNICEF Uganda/2020 – A school in Uganda

Uganda started taking steps to reopen their schools very early on. In fact, the Ugandan Ministry of Education and Sports had a game plan last year. Though, such plans at that point in time were a bit premature by the Uganda National Teachers’ Union’s standards. So, schooling in Uganda continued from a distance with help from the international support organization, UNICEF.

UNICEF/UNI324473/Sadurni/AFP Image – A Ugandan teacher supported by UNICEF efforts.

During this period of remote learning, various parties remained motivated to reopen schools once Uganda was ready. This included international support organizations such as ZOA and UNICEF, certain Ugandan districts, and teachers and parents.  Now, with the current turning point in the pandemic, Uganda is moving forward with reopening. Some steps forward are before they’re actually ready or are still clarifying appropriate guidelines and safety protocols. But, overall, it is important for the county to continue planning how to reopen schools because schools provide more than education, they are a place of community support for children.

Biden (Partially) Repeals Trump’s Attack on Reproductive Rights

In 2019, the Trump Administration passed a revision to the Title X family planning program. The policy was a gag rule on counseling and abortion referrals, prohibiting comprehensive counseling. The rule stated that there must be a “clear financial and physical separation” between Title X funded facilities and facilities that provide abortions. It also removed the requirement that Title X providers offer abortion counseling and referrals. Instead, the Title X providers were required to provide a list of health care providers, where some, but not a majority, could include providers that perform abortions. Those facilities could not be marked on the list, and the Title X providers could not tell patients which facilities on the list provide abortions.

Understandably, this raised many ethical concerns among healthcare providers. The American College of OBGYNs (ACOG) spoke out against the policy, saying that prohibiting providers from giving “complete and accurate medical information” will exacerbate health inequities, and increase rates of “unplanned pregnancy, pregnancy complications, and undiagnosed medical conditions.”

Conversely, some anti-choice groups supported the policy, especially those who receive Title X federal funding. The Obria Group operates a network of crisis pregnancy centers (CPCs), which do not provide comprehensive counseling options to pregnant people, and do not provide hormonal birth control. They mislead their patients and coerce them into not seeking abortions. Obria’s website provides medically inaccurate information about reproductive care, including referring to the emergency contraception pill (a.k.a Plan B) an “abortion pill.” Obria’s CPCs received $1.7 million in Title X funding 2019, and there are over 2500 CPCs in the U.S.

The American Public Health Association published a policy statement on the ruling in 2020, and found no scientifically-backed arguments that supported the policy, all being morally or religiously based—which cannot take precedence over scientific evidence in a medical setting.

President Biden signing the executive order. Image from https://www.medpagetoday.com/publichealthpolicy/healthpolicy/90936

President Biden signed an executive order repealing the Mexico City Policy, which is related to the the Title X ruling, in January 2021. Part of the executive order encourages the DHHS to reconsider the ruling. His action was a step forward for reproductive rights, but they are still being attacked. The ACLU has published a list of action steps to protect reproductive rights, and we encourage readers to hold their elected officials and health care providers accountable.