Iowa’s Opioid Epidemic

needle and opioid pillsThe college is tackling Iowa’s increasingly deadly opioid crisis with a multidisciplinary response.

Despite its relatively small population, Iowa is not immune from the opioid epidemic. While prescription drug overdose deaths and rates of opioid prescribing are low in Iowa compared to other states, rates of prescription opioid deaths since 1999 have quadrupled in Iowa, making it only one of four states with such a dramatic increase. Reflecting national trends, the state is also seeing rising rates of heroin deaths.

“Heroin overdose death rates in Iowa have increased more than nine-fold in the past 15 years,” says CPH Associate Professor Carri Casteel, associate director of the UI Injury Prevention Research Center (IPRC). “The rapid growth of heroin death rates in Iowa is two to three times higher than the national average.”

A SECOND CHANCE

Laura McCaughey of Davenport, Iowa, was almost one of those overdose death statistics. McCaughey was introduced to heroin at age 16 by a boyfriend and was soon hooked. “Drug dependency gets out from under your feet before you know it,” she says.

She barely graduated from high school and dropped out of college after one semester. She job-hopped and acquired a criminal record, finding herself stuck in the same cycle for four years even though she sought treatment several times. “Nothing would stick,” McCaughey says.

Heroin addiction nearly took her life. “I OD’ed five times,” she says, recalling how she’d wake up in hospitals throughout eastern Iowa. “Every time my record got worse because I was found with drug paraphernalia.”

In October 2012, at the age of 20, McCaughey was jailed for possession of heroin and drug paraphernalia after being pulled over by Davenport police. “My parents wouldn’t bail me out because they knew I was safe there,” McCaughey says. “I had no stability, I didn’t have anything. I was just defeated.”

McCaughey credits the judge who heard her case for giving her a second chance. “She told my parents, ‘She’s not a criminal, she needs help.’ The judge let me out on the condition that my dad immediately drive me six hours to a treatment facility in Sioux City.”

The treatment stuck, and in 2013 McCaughey returned to Davenport to restart her life. Now 25, McCaughey is working full-time, pursuing a degree in psychology, and raising her two-year-old daughter. “She’s the light of my life,” McCaughey says.

PARTNERING ON A RESPONSE

Laura McCaughey
Laura McCaughey

McCaughey’s story underscores the complexity of opioid abuse and the importance of involving many partners and resources in responding to the crisis.

In November 2015, IPRC co-sponsored the summit “Heroin and Opioids: A Community Crisis.” The event, hosted at the College of Public Health, brought together more than 200 experts to discuss the heroin and prescription opioid epidemic plaguing eastern Iowa.

IPRC also has conducted research on prescription opioid and heroin overdoses and overdose deaths in Iowa using state death certificate records (2002–2014) and insurance claims data (2003–2014). Among the key findings:

  • The rate of prescription opioid overdoses in Iowa increased from 2.1 /100,000 in 2003 to 8.8 /100,000 in 2009. This rate declined to 5.1/ 100,000 in 2014.
  • In Iowa, prescription opioid overdoses and overdose deaths are decreasing, while heroin overdoses and overdose deaths are increasing.
  • Those ages 25 to 49 make up the majority of all opioid-involved overdose deaths in Iowa.
  • Males make up the majority of deaths from both prescription opioids and heroin.

IPRC also met with key stakeholders in Iowa to identify priorities to address this growing crisis in the state (see page 6).

MULTIDISCIPLINARY APPROACHES

College of Public Health researchers are taking a multidisciplinary approach to addressing opioid use and addiction in Iowa.

“We’re doing work on risk factors for overdose and dependence, and thinking about patterns of use,” says Ryan Carnahan, CPH associate professor of epidemiology. Investigators are also looking at patterns of long-term prescription opioid use, especially in conditions unlikely to benefit from it. Future work may involve in-depth evaluations of prescribing patterns for different health conditions.

Natalie Langenfeld, a doctoral student in biostatistics, is conducting research that applies infectious disease modeling to study the path of opioid addiction in communities over time (monthly) and space (Iowa’s 99 counties). The model incorporates data on prescription rates, demographics, overdose death records, possession arrests, distribution and manufacturing arrests, and treatment data. Ultimately, the model can be used to evaluate interventions as new data are made available.

The Iowa Institute of Public Health Research and Policy (IIPHRP) and the CPH Research Office have convened a broad group of researchers from across the university, including public health, pharmacy, and medicine, to identify teams interested in opioid research.

“Bringing together multidisciplinary teams generates new ideas and initiatives that will inform practices and policies related to this important topic,” says Vickie Miene, IIPHRP interim director.

OPEN CONVERSATIONS

McCaughey encourages more open conversations about opioid use. “If five people are in a room, probably three know someone who is affected by addiction,” she says. “The more we talk about it, the quicker we’ll find solutions and save someone’s life.”

McCaughey is vice president of Quad Cities Harm Reduction, a nonprofit organization working to save the lives of those struggling with substance use disorders. She remains strongly motivated to help others caught in drug dependency.

“I want to be a source for people to come to if they’re ready to be clean, or whatever is going on with them. Addicts are so alone,” McCaughey says. “I didn’t die for a reason. I want my daughter to be proud of me. I want to have a good ending to my story.”

Related stories:

The Growing Opioid Crisis
Reversing the Tide

This story originally appeared in the fall 2017 issue of InSight.

The Growing Opioid Crisis

Both urban and rural areas are awash in opioids.

The United States is struggling with a worsening opioid epidemic. Since 1999, the number of overdose deaths involving opioids (including prescription painkillers and heroin) quadrupled. Every day, 91 Americans die from an opioid overdose and more than 1,000 people are treated in emergency departments for misusing prescription opioids, the Centers for Disease Control and Prevention reports. The numbers continue to trend upward. In 2015, there were more than 52,000 drug overdose deaths in the United States. That number grew to an estimated 64,000 overdose deaths in 2016, according to provisional data compiled by the National Center for Health Statistics.

The current epidemic of drug overdoses began in the 1990s, driven by increasing deaths from prescription opioids that paralleled a dramatic increase in the prescribing of such drugs for chronic pain, according to a CDC report. In recent years, as health care providers have become more cautious in prescribing opioids, other illicit drugs—including heroin and synthetic opioids such as fentanyl—are driving sharp increases in overdoses and deaths.

“This issue affects all of Iowa,” emphasizes Carri Casteel, associate director of the University of Iowa Injury Prevention Research Center, which is taking part in a CDC-funded project on preventing overdoses. “Our research shows deaths from prescription opioid overdoses are concerns in both urban and rural counties in Iowa. We also found high doses of prescription opioids are dispensed in both rural and urban parts of the state. It crosses all borders.”

College of Public Health researchers from across disciplines are collaborating to provide data about the opioid crisis in Iowa and develop policy and program recommendations to prevent overdoses.

“There’s a lot of interest in Iowa around prescription opioids, heroin, and fentanyl,” says Casteel. “We have many stakeholders—law enforcement, physicians, and others— looking for better ways to communicate ongoing efforts and share data to address the crisis.”

Related stories:

Iowa’s Opioid Epidemic
Reversing the Tide

This story originally appeared in the fall 2017 issue of InSight.

 

UI report addresses prescription opioid, heroin epidemic in Iowa

A new report from the University of Iowa includes several policy and program recommendations to address the state’s opioid crisis after a review process involving dozens of stakeholders from across the state.

A portrait of Carri Casteel, professor in the Department of Occupational and Environmental Health at the University of Iowa College of Public Health.
Carri Casteel

Carri Casteel, associate professor of occupational and environmental health in the UI College of Public Health and report co-author, says the epidemic is affecting all Iowans, whether they live in rural or urban counties. She points to data that show more than 700,000 opioid prescription pain relievers (OPRs) were dispensed by pharmacists to new OPR users between 2003 and 2014.

Meanwhile, heroin deaths have increased more than ninefold in Iowa in the past 15 years, three times higher than the national average. In addition, prescription opioid overdose deaths in Iowa have quadrupled since 1999.

“While the rates of prescription opioid overdose deaths are lower in Iowa than in many states, these are disturbing and tragic trends that mirror the national prescription opioid epidemic,” says Casteel.

The report was compiled with a grant from the United States Centers for Disease Control and Prevention to the university’s Injury Prevention Research Center (IPRC), one of four injury research centers in the country to participate in the grant. The centers gathered hundreds of opioid experts in their states to recommend methods for preventing prescription opioid misuse, overdose, and overdose deaths.

In Iowa, the IPRC convened 33 stakeholders in Des Moines in April to identify public policy and program priorities for addressing the opioid epidemic in the state. The group included representatives from law enforcement, substance abuse treatment, medicine, psychiatry, nursing, public health, nonprofit/advocacy, poison control, insurance, state and local drug-control policy, and pharmacy, as well as elected officials or their representatives. Their top five priorities include:

  • Providing evidence-based physician training in pain management and opioid prescription in medical school. For current licensed professionals, developing a presentation that will provide a historical perspective with up-to-date data focusing on evidence-based solutions to alter the course of the epidemic.
  • Educating physicians, nurses, pharmacists, and other practitioners to ensure a strong knowledge base in recognizing patients at high risk for opioid abuse and addiction.
  • Making the Iowa Prescription Monitoring Program (PMP), a database of all prescriptions of certain types of controlled substances filled by pharmacies in the state, an accurate and effective clinical tool for all prescribers. Stakeholders need to work together to identify and enact measures that will eliminate current barriers preventing Iowa’s PMP from reaching maximum use and effectiveness.
  • Strengthening capacity to conduct opioid drug overdose surveillance and prescription opioid monitoring among multiple organizations and agencies.
  • Ensuring that Medicaid and other state health programs adequately cover all FDA-approved medication-assisted treatment prescriptions, such as methadone, as well as behavioral interventions. Encouraging or requiring commercial health plans to adopt similar policies.

The committee will discuss the report with the interim study committee tasked with evaluating Iowa’s response to the opioid epidemic on Monday, Oct. 16. The committee wants input from various relevant agencies and entities and plans to submit a report with its findings and recommendations to Iowa Governor Kim Reynolds and the general assembly by Nov. 15, in time for possible action during the next legislative session.

The report also highlights successful initiatives in communities across Iowa. For instance, the Eastern Iowa Heroin Initiative has placed prescription drug drop boxes in nearly every county and trains law enforcement agencies around the state on methods for successful investigation of heroin overdoses. The report also features the Alliance of Coalitions for Change and Iowa Pharmacy Association, which organizes community discussions around the state targeting physicians, pharmacists, dentists, nurses, chiropractors, social workers and representatives from treatment programs to discuss opioid trends and look for collaborative ways to address the issue.

The report is online at www.uiiprc.org.

This article originally appeared in Iowa Now

Additional Media Coverage

Iowa Public Radio
http://iowapublicradio.org/post/new-report-recommends-policies-addressing-iowas-opioid-crisis#stream/0

Associated Press
http://www.sfchronicle.com/news/article/Iowa-lawmakers-to-discuss-opioids-though-policy-12246802.php

KCRG, WGEM , KTIV, KEYC
http://www.kcrg.com/content/news/Iowa-lawmakers-to-discuss-opioids-though-policy-unclear-449139753.html

Radio Iowa
http://www.radioiowa.com/2017/10/03/effort-continues-to-cut-prescription-painkiller-abuse/

Business Record
http://www.businessrecord.com/Content/Default/All-Latest-News/Article/New-UI-report-weighs-Iowa-opioid-crisis-handling-best-strategies-/-3/248/79735

USAgNet
http://www.usagnet.com/state_headlines/state_story.php?tble=IA2017&ID=1105

Preventing workplace violence

crime scene for vehicle search protect by yellow caution tapeInjury of death on the job is often associated with machinery in the agricultural and manufacturing sectors. What doesn’t come as readily to mind is workplace violence—bullying by a colleague or assault by an angry client are just two examples of violence on the job. And yet American workers experience nearly two million incidents of workplace violence every year.

Researching the causes and prevention of such violence, and then working in the field to establish consistent and affordable practices is at the heart of the work of the University of Iowa’s Injury Prevention Research Center (IPRC).

Established in 1991 with core funding from the Centers for Disease Control and Prevention, the center is multidisciplinary in its scope, and has been involved in bringing together research, policy, and practice to address everything from bullying by school kids to the recent heroin and opioid crisis and from drowsy driving to tractor injuries.

Preventing Armed Robbery 

Some of the center’s current work can be traced back to the early 1990s at the University of California, Los Angeles where then assistant professor Corinne Peek-Asa was directing a graduate student named Carri Casteel. As epidemiologists interested in the high rate of fatalities associated with armed robberies, the two women created a study focused on small, independently owned businesses, including convenience stores, motels, late-night restaurants, and liquor stores.

“At the time, armed robbery was responsible for 84 percent of workplace violence,” says Casteel. Casteel and Peek-Asa’s primary goal was to identify affordable prevention measures and to educate business owners about them.

Prevention strategies varied. They discovered that business owners were willing to devote resources to security equipment such as surveillance cameras, but owners were unaware of less expensive and more effective approaches such as cash control, increased visibility and lighting, and employee training. Lack of implementation of the less expensive but more effective strategies clued Casteel and Peek-Asa into the need for research that translated evidence-based practices into small business settings.

For example, they discovered that blocking access to a business after hours via window grates and other structural enhancements reduces visibility and actually leads robbers to prey on the establishment when it is open, putting more people—both employees and customers— in harm’s way. Keeping too much cash on the premises also attracts robbers, whereas announcing that a minimal amount of money is in the register and maintaining a regular deposit schedule also prevents robberies.

Extending the Study

Peek-Asa and Casteel successfully tested the effectiveness of their prevention program with liquor stores in Santa Monica, Calif., before embarking on a larger study of nearly 500 “mom and pop” grocery stores throughout Los Angeles. Tracking businesses for a full year and partnering with the Los Angeles Police Department to receive outcomes of robbery-related injuries, they found that their strategies significantly reduced employees-related assaults.

In 2008, the director of safety and research for the National Institute of Occupational Safety and Health (NIOSH), an agency of the Centers for Disease Control, reached out to the pair to pilot a variation of their program. This time, the program would be delivered by police officers rather than by researchers. Peek-Asa had recently joined the faculty of the University of Iowa College of Public Health, where she is now a professor of occupational and environmental health. Working in conjunction with the International Crime Free Association, she and Casteel — now an associate professor in the same department at the UI — piloted the program in six communities nationally, including Iowa City, Cedar Rapids, and Coralville.

Peek-Asa says the program was a success in that, “we learned a lot about dissemination and working with law enforcement. This is important because after a robbery, one of small businesses’ point of connection is with the police.”

However, the rapid turnover of personnel on police forces also made it difficult to maintain consistency in delivering the material. The project continues and is now disseminated online, with a community leader gathering an advisory team to help identify partners.

Types of Workplace Violence

Robbery is but one example of workplace violence. Casteel and Peek-Asa have created a well-respected and recognized topology of workplace violence. They identify four different kinds of workplace violence:

  • the perpetrator has criminal intent against the business, such as in a robbery;
  • the main relationship is a service relationship between the perpetrator and the business, such as when a patient becomes angry at his or her treatment in a hospital;
  • the perpetrator is a current or former worker who is disgruntled at the business;
  • the perpetrator has a personal relationship with a worker, such as in a domestic violence situation.

One industry that has notoriously high rates of assault against workers by clients is health care. Unlike small, independent businesses, however, it is an industry that benefits from strong advocacy groups. One such group, the Emergency Nursing Association, worked with California’s Office of Occupational Safety to create the nation’s first hospital security act in 1995.

To study the effectiveness of this new law, Peek-Asa and Casteel compared security measures and violent event rates in California’s hospitals to those in New Jersey, which did not then have a similar law. They found a 48 percent reduction in assault rates among emergency department and psychiatric unit workers. Based on the success of the California law, the pair worked closely with stakeholders to help advocate for a similar law in New Jersey.

“Seeing our research culminate in policy change was very satisfying,” says Casteel.

Protecting Employees

IPRC has more recently been involved in a project with one of the world’s largest corporations— The Boeing Company. “Boeing is very proactive in recognizing and responding to the threat of workplace violence,” says Casteel, “particularly in the form of worker-on-worker violence.”

They partnered with Boeing’s threat assessment team to run simulations and assess how important such organized teams and clear protocol are to mitigating workplace violence. The answer? Very. The only scenario that proved challenging despite the protocols was one involving stalking. This is an area that Peek-Asa and Casteel believe most workplaces underestimate as potentially dangerous, and yet it’s also an area where businesses have a surprising degree of ability to help control and diminish potential risk.

“When someone is being stalked or is the victim of domestic violence, they still have to go to work,” notes Peek-Asa. This puts them in danger as the would-be perpetrators know when and where to find them. But what many businesses don’t fully appreciate is that they can control the environment by providing the employee with an escort or working with the police. In some cases, businesses can even take out a restraining order when the individual cannot.

“We really want to take the lessons we learned with Boeing,” says Peek-Asa, “and apply them to mid-size and smaller businesses. We want these lessons to be applicable to the kinds of businesses we have here in Iowa.”

This story originally appeared in the Fall 2016 issue of InSight