Category: Public Health Law Research

Overdose Update: Celebrity Edition

Temple University Center for Public Health Law Research 1 Comment

By Scott Burris

You’ve probably heard about the good news/bad news experience of Stephanie Bongiovi, daughter of rocker Jon Bon Jovi. A college student, she ODed on heroin, but help was summoned and she’s going to be fine. The (temporary) bad news for her (and longer term for others in her plight) is that she and a companion were arrested IN SPITE of a recent New York Good Samaritan 911 law passed explicitly to encourage people to call for help.

There are some technicalities and prerequisites, so if you want to see the law it’s available on LawAtlas. But if she or her companion sought help, and absent a hyper-technical reading of the statute (it literally does not protect a victim unable to seek help), the charges should never have been filed and should be dropped. The problem for the rest of us is that these laws only work if people at an OD scene know about them and trust them. High profile arrests like this are — and for once I think there might be some truth to this claim — sending a message not to seek help.

Meanwhile, Leo Beletsky, Jody Rich and Alex Walley have a fine little piece in JAMA that thoroughly catalogues the removable barriers to OD prevention. The table alone is worth thousands of words, which is nice because JAMA’s editors were pretty tight on the word limit despite the importance of the topic.

The Prescription Drug Abuse and Overdose Crisis: Focus on the Supply Chain

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By Scott Burris

There’s so much we still don’t know about the prescription opioid problem. The partial remedies advanced so far reflect this:

  • Prescription Drug Monitoring Programs, which in essence define the problem as doctor-shopping patients;
  • treatment guidelines, which define the problem as doctors without expertise; and
  • crackdowns on “pill-mills,” which see the issue as physician corruption. Each of these diagnoses has an element of truth, but not necessarily enough to make the treatments effective.

One huge part of the problem has gotten far too little attention: the pharmaceutical supply chain where all these drugs start and along which they are distributed. Now, John Coleman, a former DEA officer, has given us a thorough and compelling primer on the supply chain, describing it and showing where the pressure points are for action. He is not happy about what he sees: DEA is overwhelmed, and too secretive with its data;  and the distributors are too interested in profits and far too unwilling to police paying customers. But he also sees room for action and even hope. This article is well worth a read if you are interested in the overdose problem and how to solve it:

Coleman, John J. “The Supply Chain of Medicinal Controlled Substances: Addressing the Achilles Heel of Drug Diversion.” Journal of Pain and Palliative Care Pharmacotherapy 26, no. 3 (2012): 233-50.

P.S. — One of the hopeful signs he sees was Florida’s legislation beefing up state-level monitoring and controls. This takes me back to the successful Wisconsin Cancer Pain Initiative in the 70s and 80s, which articulated the Principle of Balance in drug control and demonstrated that it was possible to have good access to pain medicine and effective control. In those days, David Joranson, the state drug controller, worked closely with DEA, using state regulatory authority to shut down docs and pharmacies who were acting outside the law. The possibility of history repeating itself is a ray of sunlight in the cloudy skies of this issue. (If you are interested in the story, here’s one place to start: Joranson, D., and J. L. Dahl. “Achieving Balance in Drug Policy: The Wisconsin Model.” In Advances in Pain Research and Therapy, edited by CS Hill Jr. and WS Fields. 197-204. New York: Raven Press, 1989.)

An International Meeting of Public Health and Law Enforcement

Temple University Center for Public Health Law Research 1 Comment

By Scott Burris

We know, and now most people acknowledge, that police activity has some clear, and in some instances intentional, effects on health.  To start with the obvious, police are instrumental in reducing the number of people who are murdered, assaulted, raped, or otherwise terrorized. Policing – like any form of social intervention – can also have unintended consequences. There is, for example, considerable evidence that criminal law and legal practices can increase risks of HIV and other harms among drug users.

These facts are well-established and pretty well recognized. So now the question is not whether policing has health consequences, but rather whether social and health work is to be seen as an integral element of law enforcement in the 21st century.  In much of their day to day work, police are engaged in far more than the prevention of crime or the maintenance of social order.  This is something we all know, something that has probably always been true of police work, something that is shaping a lot of programs around the world, and yet something we need to talk more openly about.

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Dispatches from APHA 2012

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By Scott Burris

Two thoughts for the Friday following the 2012 APHA Annual Meeting:

(1) This is a public service message for public health lawyers and their extra-disciplinary significant others.

The American Public Health Association now has a Health Law Section. This is a big step up, in organizational terms. Until this year, health lawyers and those interested in public health law were just a special primary interest group (really, that’s what they called them at APHA – a SPIG.)  As a section, we have more opportunities to recruit members and fill presentation slots, and a greater voice in association governance.

That’s not the best part. The best part is that the officers behind the section and its elevation are all dynamic and mostly young. They’ve got energy and vision, which is going to make this section an exciting one to belong to.  They are making the case within the association and beyond for the importance of law to health, and they are taking a multi-disciplinary view. The section is bringing together legal practitioners in public health, normative legal scholars, and empirical public health law researchers.

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Occupy Public Health? A Social Determinants Tea Party?

Temple University Center for Public Health Law Research 4 Comments

By Scott Burris

Kathy Ward is a veteran public health worker in Nebraska. She has a neat idea, which I summarize here in mostly her words:

Public health policy needs more proponents who are knowledgeable and able to express their positions freely. The shortage of advocates presents a danger for public health in a time of anti-government attitudes, uninformed public health policies, deficit reduction efforts, and looming budget cuts to the public health programs that protect our country.
A 2008 study by the Association of Schools of Public Health indicated that 23% of the current public health work force–almost 110,000 workers–will be eligible to retire by 2012. This generation of baby boomer public health workers has a high level of expertise in public health; passion for improving the public’s health; and strong partnerships with nonprofit, government, and private health organizations. They have the credibility to be effective spokespersons for public health and to influence its partners.
Why not use these assets to build a movement of public health advocates?

• Enlist national public health organizations such as ASTHO, the Chronic Disease Directors Association, and the Association of Maternal and Child Health Programs in finding and enlisting public health advocates.
• Find advocates through similar organizations at state and local levels, such as state public health associations and nonprofits such as the American Cancer Society and the American Heart Association.
• Build linkages with other national associations such as AARP. Consider public health in the broader sense, including in this effort retired Medicaid professionals who can knowledgeably describe the losses that will occur to the public from cutting Medicaid programs.
• Provide training in advocacy through webinars conducted with public interest lobbyists and health associations that employ advocacy staff

Sounds like a sensible idea to me. Mobilizing a lot of effective volunteers at a low cost. What do you think?

How About a Clean-Air Shave?

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By Scott Burris

Somewhere along the way, environmental law and public health law got separated.  Despite the importance of clean air and water to public health – not to mention parks, recreation, salubrious zoning – the two fields developed independently in the law. That’s changing in a lot of ways, and one very good example is a study proceeding now in New York City.

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Preventing Teen Crashes with Stickers

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By Scott Burris

Graduated Drivers’ License Laws have apparently been a major success in reducing crashes among novice drivers. (A couple of studies have suggested the laws might just be postponing crashes, but so far that hypothesis remains unproved, and the weight of expert opinion seems to be that the association is spurious.)  There has been a weak link in enforcement, though, which is that in the dark of night and flow of traffic, police officers can’t always spot an underage driver out past the curfew or chauffeuring too many passengers.

Enter the decal.  A number of European and Asian countries require new drivers to decorate their car with a special decal indicating probationary status. That way it is easy for police to detect possible GDL violations.

In 2010, New Jersey became the first state to require the decal, and this week a PHLR study published in the American Journal of Preventive Medicine found robust evidence of seriously positive impact.

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NIH + NFL = PHLR

Temple University Center for Public Health Law Research 1 Comment

By Scott Burris, JD

The National Football League has given the National Institutes of Health $30 million for research on traumatic brain injury. There is much we don’t know about the causes, effects, prevention and treatment of sports-related brain injury – but that doesn’t mean that we should put all our eggs into the basket of biomedical research. Since Washington state pioneered its youth-sports brain injury prevention model-law in 2009, 40 states have passed laws setting out rules aimed at the problem (We’re tracking these on LawAtlas, the new PHLR policy surveillance portal). Most of these laws work by promoting identification of concussions, regulating the athlete’s return to play, and educating parents and coaches.

To put it another way, the nation, through a majority of its state legislatures, has embarked on a major initiative to reduce sports-related injuries. Tens of millions of people will be affected in some way – athletes, parents and coaches. Limited school-based resources will be consumed to comply with these laws. And, most importantly, people worried about the problem will, to some extent, rely on implementation of these laws to protect student athletes.

If this public health intervention were a drug or a new technique for changing behavior, its efficacy would be rigorously tested by government-funded research. Why should things be different because this possibly magic bullet happens to be based in the law? So far, the CDC has funded implementation case studies of youth sports concussion laws in Washington and Massachusetts. PHLR is funding a more in-depth study in Washington, with results expected next year.

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Using the Taxing Power for Public Health

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By Scott Burris

In a Perspective in this week’s New England Journal of Medicine, Michelle Mello and Glenn Cohen, both professors at Harvard, write about the prospects for using the constitutional Taxing Power to adopt innovative laws to advance public health objectives.  Cueing off the Supreme Court’s decision in the Affordable Care Act litigation, Mello — who is also a member of PHLR’s Methods Core — and Cohen write that the Court appears to have opened the door for “more targeted, assertive interventions to promote public health” under the Taxing Power than Congress has previously pursued. “For example, instead of merely taxing tobacco sales, the federal government could require individuals to pay a tax penalty unless they declare that they haven’t used tobacco products during the year. It could give a tax credit to people who submit documentation that their bodymass index is in the normal range or has decreased during the year or to diabetic persons who document that their glycated hemoglobin levels are controlled. It could tax individuals who fail to purchase gym memberships. …These strategies depart from traditional uses of taxes by targeting omissions and noncommercial activities that are important drivers of chronic disease.”  Read the full article online at the New England Journal of Medicine online.

Early Warning on Heroin and Syringe Exchange?

Temple University Center for Public Health Law Research 2 Comments

By Scott Burris

It’s hard to believe that after all these years, all the evidence, and all the reductions in HIV among injection drug users, we still only have 15 states that explicitly authorize syringe exchange programs (SEPs). (See LawAtlas for an interactive map.)  CDC estimates we still have around 4,000 new cases a year by injection, so that’s reason enough to keep the SEPs we have open and start new ones where drug users are not now being reached.

Now another factor could be in play. Harm reductionists are reporting an upsurge in SEP users in places where efforts to crack down on illicit pill use have started to bite.  A lot of these users are reportedly young, under 25, and at serious risk of getting HIV or HCV.

So far we only have anecdotal reports. It could be coincidence, or overblown.  But we should be worried: there is nothing strange about pharmaceutical opioid users moving on to heroin when pills get scarce. It would be prudent as a matter of health policy to make sure that syringe access services are available in every community where opioid users are injecting, and to make sure these programs have surge capacity.  That’s prudent policy: here on planet earth we are cutting health budgets and, I fear, ignoring the effect of pill control on heroin use.

All this reminds us how important it is to be closely evaluating the consequences of new laws and policies that are intended to reduce illicit pill use.  Their success in reducing consumption is only part of the picture: the ultimate issue of concern is that we protect the health of people who are using until they can reach a safer place in their lives.