Category Archives: Addiction

How to keep kids safe with the legalization of marijuana


Cannabis_leaf_marijuana_potFrom Seattle Children’s On the Pulse blog
Feb 24, 2014

The legalization of marijuana in the state of Washington, along with the impending legalization of marijuana sales this spring, has sparked concern among many parents who have questions on what this means for their children.

Leslie Walker, MD, division chief of Adolescent Medicine at Seattle Children’s Hospital, recently co-authored a guide for parents about preventing underage marijuana use. Walker says that it’s important for parents to know the facts, learn how to talk about marijuana and be aware of the messages that their children may see.  Continue reading

lesson one

Oregon schools use ‘behavioral vaccine’ to reduce smoking

Blackboard with "Lesson one" written on it.

Photo: Krzysztof “Kriss” Szkurlatowski

By Kristian Foden-Vencil
Oregon Public Broadcasting

Behaving well in elementary school could reduce smoking in later life. At least, that’s what Trillium Community Health Plan hopes, and it’s putting money behind the idea.

Danebo Elementary in Eugene, Ore., is one of 50 schools receiving money to teach classes while integrating something called the “Good Behavior Game.”

Teacher Cami Railey sits at a small table, surrounded by four kids. She’s about to teach them the “s” sound and the “a” sound. But first, as she does every day, she goes over the rules.

“You’re going to earn your stars today by sitting in the learning position,” she says. “That means your bottom is on your seat, backs on the back of your seat. Excellent job, just like that.”

For good learning behavior, like sitting quietly, keeping their eyes on the teacher and working hard, kids get a star and some stickers.

Railey says the game keeps the kids plugged in and therefore learning more. That in turn makes them better educated teens and adults who’re less likely to pick up a dangerous habit, like smoking.

The Washington, D.C., nonprofit Coalition for Evidence Based Policy says it works. It did a study that found that by age 13, the game had reduced the number of kids who had started to smoke by 26 percent — and reduced the number of kids who had started to take hard drugs by more than half.

The fact that a teacher is playing the Good Behavior Game isn’t unusual. What is unusual is that Trillium is paying for it. Part of the Affordable Care Act involves the federal government giving money to states to figure out new ways to prevent people from getting sick in the first place.

So Trillium is setting aside nearly $900,000 a year for disease prevention strategies, like this one. Jennifer Webster is the disease prevention coordinator for Trillium Community Health, and she thinks it’s a good investment.

“The Good Behavior Game is more than just a game that you play in the classroom. It’s actually been called a behavioral vaccine,” she says. “This is really what needs to be done. What we really need to focus on is prevention.”

Trillium is paying the poorer schools of Eugene’s Bethel School District to adopt the strategy in 50 classrooms.

Trillium CEO Terry Coplin says changes to Oregon and federal law mean that instead of paying for each Medicaid recipient to get treatment, Trillium gets a fixed amount of money for each of its 56,000 Medicaid recipients. That way Trillium can pay for disease prevention efforts that benefit the whole Medicaid population, not just person by person as they need it.

“I think the return on investment for the Good Behavior Game is going to be somewhere in the neighborhood of 10 to one,” Coplin says.

So, for each dollar spent on playing the game, the health agency expects to save $10 by not having to pay to treat these kids later in life for lung cancer because they took up smoking.

Coplin concedes that some of Trillium’s Medicaid recipients will leave the system each year. But he says prevention still makes medical and financial sense.

“All the incentives are really aligned in the right direction. The healthier that we can make the population, the bigger the financial reward,” he says.

The Oregon Health Authority estimates that each pack of cigarettes smoked costs Oregonians about $13 in medical expenses and productivity losses.

Not all the money Trillium is spending goes for the Good Behavior Game. Some of it is earmarked to pay pregnant smokers cold, hard cash to give up the habit. There’s also a plan to have kids try to buy cigarettes at local stores, then give money to store owners who refuse to sell.

This story is part of a reporting partnership that includes NPROregon Public Broadcasting and Kaiser Health News

Photo courtesy of Krzysztof “Kriss” Szkurlatowski

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


As Washington delays, states move on e-cigarettes


eBy Jake Grovum
Stateline Staff Writer

Money grab, health concerns, or both? Absent guidance from Washington, states are pressing ahead with their own agendas on electronic cigarettes.

Heading into legislative sessions next year, policymakers, industry representatives, health advocates and tax wonks expect electronic cigarettes — or e-cigarettes for short — to be among the top issues at state capitols.

Legislatures are expected to tackle how to classify, regulate and, perhaps most importantly, tax the relatively new products.

The debates in states come as the federal government considers its own answers to similar questions. The Food and Drug Administration is considering classifying e-cigarettes as “tobacco products,” which would extend its reach and potentially subject e-cigarettes to a host of rules and regulations that apply to tobacco cigarettes.

“States are scrambling to figure out how to deal with this,” Ohio Attorney General Mike DeWine said in an interview. “It’s going to be fought out in 50 states; it’s going to be fought out in one jurisdiction after another.”

DeWine was a lead author of an Oct. 23 letter sent by 40 attorneys general to the FDA pushing for federal rules and for e-cigarettes to be treated as “tobacco products” for regulatory purposes.

So far, Washington hasn’t decided how to proceed with e-cigarettes. A proposed rule, expected to be released for public comment in November, was delayed by the government shutdown and is still pending.

That has left a patchwork of rules, regulations and product definitions across the nation, often at the urging of anti-tobacco advocates. “We think it’s really important that states act,” said Danny McGoldrick, vice president of research at the Campaign for Tobacco-Free Kids.

More than half the states, for example, have banned the sale of e-cigarettes to minors, but others have no restrictions. Currently four states — Utah, North Dakota, Arkansas and New Jersey — have lumped the products in with tobacco under indoor smoking bans, even as research about possible ill-effects from second-hand vapor smoke, if there even are any, remains limited.

Some local governments have taken similar steps on their own, enacting rules for e-cigarettes that sometimes go beyond those in place at the state level.

The intensity of the debate illustrates both the lack of good research on e-cigarettes as well as the money at stake. Often, those considering limits don’t even agree on whether applying tobacco regulations is appropriate, given how different the products are. Like tobacco cigarettes, nicotine levels in the “cartridges” that are loaded into the e-cigarette device can vary widely, complicating efforts to agree on a standard approach to regulation and taxation.

E-cigarettes first appeared about a decade ago, and sales have grown exponentially in recent years. The number of American adults who said they have tried them doubled to one in five in just one year (from 2010 to 2011), according to a Centers for Disease Control survey.

Use among middle and high school students also doubled from 2011 to 2012, according to the CDC, with nearly 1.8 million students saying they’ve used them.

E-Cig Revenue

In an era of revenue-hungry state governments — some still dealing with declining revenue from traditional tobacco taxes and recovering from the Great Recession — taxing e-cigarettes seems likely to get the most attention from state lawmakers in 2014. Questions of advertising limits, health claims and ingredient disclosure will likely remain federal issues.

So far, only Minnesota has put in place a specific state tax policy for e-cigarettes, a decision reached in 2012. The products are subject to a 95 percent tax that functions like a sales tax, tacked onto the wholesale cost of the product.

That generally means they are taxed at a higher rate than traditional cigarettes, which are subject to a $1.29-per-pack levy. The state expects to collect $1.16 billion from all tobacco taxes in the 2014-2015 fiscal year.

For now, most other states apply only a sales tax – if they have one – to e-cigarettes. But at least 30 others are considering e-cigarette taxes of some kind next year.

“I will be watching to see if more proposals like Minnesota are replicated in the states,” said Scott Drenkard of the Tax Foundation, an anti-tax research group, “But I hope they are not.”

What this is is a money grab.

As tax experts see it, there’s little rationale aside from simply raising revenue for taxing e-cigarettes as traditional cigarettes. Tobacco, they say, is taxed because it produces negative health consequences that cost the public. For now, there’s little research that shows similar effects from e-cigarettes.

“There is zero, emphasis on zero, justification for taxing e-cigarettes right now,” said David Brunori of the group Tax Analysts, a nonprofit tax analysis group that provides insight to private firms and government agencies. “What this is is a money grab. It’s a way of trying to find revenue to replace lost tobacco taxes.”

According to the nonpartisan Tax Policy Center, state and local tax revenues have somewhat leveled off in recent years as smoking has declined. Collections grew from $7.7 billion in 1997 to $15.8 billion in 2007, but reached just $17.6 billion in 2011, the most recent year available.

Tobacco companies that don’t produce e-cigarettes have often pushed tax parity so their own products are not at a disadvantage. In Minnesota’s case, the state simply said that under its laws, the tax must apply.

But the most popular argument is deterrence—higher taxes might make the product less attractive and less affordable to young people looking for nicotine.

“It has nothing to do with revenue,” Ohio’s DeWine said. “It has everything to do with discouraging use.”

An Alternative to Tobacco

Discouraging use, however, is exactly the opposite goal lawmakers should have, said Ray Story of the Tobacco Vapor Electronic Cigarette Association. It’s an opinion shared by some outside of the industry as well, especially with regard to those already smoking.

“Cigarettes are sold everywhere in the world, and we want to make sure that the e-cigarette is sold as a less-harmful alternative right there next to it,” Story said.

“We should expand the use, not restrict it,” he added, saying that if e-cigarettes can greatly reduce cigarette use the industry “will have made the greatest impact on humanity ever.”

The contrasting approach reflects two key differences in thinking about e-cigarettes: as a new recreational product similar to tobacco cigarettes, or as a potentially less-unhealthy alternative that could even help smokers quit entirely.

E-cigarette producers themselves are divided. Some welcome traditional cigarette-style regulations to a degree, content to play by similar rules as tobacco producers, especially if it saves them from more onerous limits applied to drug manufacturers, for example. Others argue that even thinking about e-cigarettes through the same frame of reference as tobacco is a flawed approach.

Federal officials in Washington will likely be the ones to eventually settle the dispute, and that decision could still be months away. Meanwhile, debates in the states over two key issues within their control – taxes and sales to minors – are likely to rage in 2014.

But the eventual decision from the FDA is sure to affect those debates. “If the FDA says these are essentially tobacco products,” said Brunori of Tax Analysts, “that will give all kinds of cover to state politicians.”

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.


Addressing a dangerous epidemic: Abuse of Painkillers and other prescription drugs


Tablet Thumb BlueBy Ankita Rao

About 50 Americans die every day from a prescription drug overdose — a tally that, in most states, turns out to be more than deaths from car accidents.

In a new report, “Prescription Drug Abuse: Strategies to Stop the Epidemic,” researchers at the Trust for America’s Health found that rates of overdose and addiction doubled since 1999 in most states.

In West Virginia — the state with the highest number of drug overdose deaths — the rate was six times higher than fourteen years ago.

During a conference call on Monday, the researchers said the emergence of prescription drugs like oxycodone has benefitted many people but is also marked by a corresponding rise in misuse.

“Working on this report, we were overwhelmed by the number of sad stories of tragedies that could have been averted,” said Jeff Levi, executive director of the Trust for America’s Health.

He said intervention strategies — ranging from the education of health providers to the correct disposal of unused medications — are proven solutions.

The Trust for America’s Health, along with other public health and law enforcement experts, reviewed national recommendations and examined a set of 10 indicators that were having a positive impact, including certain laws and educational initiatives.

But most states had in place six or less of the indicators that help curb the issue. Only New Mexico and Vermont had all 10 strategies touted by the report. South Dakota had the lowest number: two.

Levi also said a Medicaid expansion in the 24 states and District of Columbia that are expanding the federal-state health insurance program for low-income people will lead to expanded coverage of substance abuse and treatment.

Meghan Andreae, a senior case manager at the addiction services and consulting firm Southworth Associates, said many clients become addicted to painkillers first through legitimate prescriptions for a health concern but later seek out new doctors and methods to obtain the drugs.

This issue highlights the need for more awareness among physicians — one of the strategies outlined in the report — since only 22 states have laws that require or recommend continuing education for doctors and other health providers who prescribe prescription pain meds.

“I would certainly say that’s something that’s lacking,” Andreae said. “A small amount of their training is spent on this issue.”

While the report highlights the shortcomings of prescription drug abuse prevention, it also recognizes that many states are taking steps to address the issue.

Almost all state Medicaid programs have in place a pharmacy “lock-in” program that requires patients to use a single prescriber or pharmacy if they are suspected of abusing drugs.

And, in 44 states, health providers have to conduct a physical exam and screen for substance abuse before prescribing medication.

Other recommendations include:

  • Good Samaritan Laws — Measures that protect individuals from criminal charges for helping themselves or others experiencing an overdose.
  • ID Requirements — Laws requiring or permitting a pharmacist to require an ID before dispensing a controlled substance.
  • Rescue drug laws — Laws to expand access to the use of naloxone, a drug that can be effective in counteracting an overdose.

“Given the extraordinarily rapid growth of the problem, we’re also impressed by how quickly policies have emerged to get a handle on it, and how quickly many of these are showing signs of progress,” said Andrea Gielen, director of the Johns Hopkins Center for Injury Research and Policy, who was a reviewer of the report.

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.


Medicaid limiting access to meds for painkiller addiction


pills-spill-out-of-bottleBy Michael Ollove, Staff Writer

To Mark Publicker, a doctor in Portland, Maine, who practices addiction medicine, it’s a clear case of discrimination. You wouldn’t deprive a diabetic of insulin.

You wouldn’t stop giving hypertension drugs to a patient with high blood pressure after successful treatment. You wouldn’t hold back a statin from a patient with high cholesterol.

Yet Publicker’s patients face severe limitations on the amount and duration of medicines they take to fight their addictions to pain pills.

And the consequences of those policies by Medicaid and private insurers are at least as dire as they would be for those with other serious ailments if they were denied proven treatments, he said.

“People will die,” Publicker said.

Many private insurance companies and state Medicaid agencies across the country impose sharp limitations on access to medications used in the treatment of the addiction to prescription painkillers known as opioids.

A report commissioned by the American Society of Addiction Medicine found that Medicaid agencies in just 28 states cover all three of medications that the Food and Drug Administration has approved for opioid addiction treatment: methadone, buprenorphine and naltrexone.

The study also found that most state Medicaid agencies, even those that cover all three medications, place restrictions on getting them by requiring prior authorization and re-authorization, imposing lifetime limitations and tapering dosage strengths. The study was done by the substance abuse research firm Avisa Group.

“Now that we finally have medications that are shown to be effective and cost-effective it is shameful to throw up roadblocks to their use,” said Mady Chalk, director of the Center for Policy Research and Analysis at the Treatment Research Institute, which researches all aspects of substance abuse.

By any measure, there is an epidemic in the misuse of prescription drugs, most of it involving abuse of opioid painkillers such as OxyContin or Percocet. The Centers for Disease Control and Prevention reported that 12 million Americans acknowledged using prescription painkillers for nonmedical reasons in 2010.

While opioid addiction is on the rise in the United States, so too are the opportunities for treatment. In January, when major provisions of the Affordable Care Act go into effect, 37 million currently uninsured Americans will be enrolled in health insurance plans, an estimated 11.2 million of them in Medicaid.

Among those newly insured will be many with an opioid addiction. (One study showed a higher rate of opioid addiction among current Medicaid beneficiaries than among those on other forms of insurance.)

Yet even though the ACA holds out the possibility of new treatment options for many, restrictions on the medicines used in treating opioid addicts clouds the chances of successful recovery, treatment experts say.

The CDC says that the number of overdose deaths from opioids tripled between 1999 and 2008, when it reached 14,800 deaths. That is more than the number of overdoses from heroin and cocaine combined.

Prescription painkillers bind receptors in the brain to decrease the perception of pain. But they can also produce a feeling of euphoria, cause physical dependence and lead to addiction. These opioids can also cause sedation and slow breathing, sometimes to the point of stopping it altogether.

History of Addiction

Opioid addiction has existed in the United States at least as far back as the Civil War when opioids were given to wounded soldiers to relieve pain.

Later in the century, it was common for women to become addicted to the laudanum, opium and morphine they were prescribed for the discomforts caused by menstruation or menopause.

By 1900, 300,000 Americans were addicted to opioids, according to the federal Substance Abuse and Mental Health Services Administration.

Early in the 20th century there were aborted attempts to detoxify addicts with decreasing doses of heroin and morphine, but it wasn’t until the 1960s that an effective drug was developed for the treatment of opioid addiction. T

hat medicine was methadone, itself an opioid that has to be taken daily but doesn’t create the euphoria of other opioids and also provides relief from the craving for opioids.

Eventually, two other drugs were developed and proved effective for opioid addiction, buprenorphine and naltrexone, the latter of which can be injected and is effective for a month. Both of these drugs can be prescribed by a doctor and filled at pharmacies.

Research has shown successful treatment reduces the rates of disease associated with illicit drug use, including HIV/AIDS and hepatitis. It also reduces crime while enabling addicts to join the workforce and resume their roles within families.

Research also shows that detoxification without continued medicinal treatment results in a high rate of relapse. Without the medicine, addicts return to drug use.

Yet, most state Medicaid agencies have found ways to reduce access to these drugs in an effort to cut costs. “For these limitations to be imposed by the government is particularly odious and would not be accepted by any other disease,” said Publicker, who waged a losing battle in the Maine legislature in 2011 to fend off a two-year limitation on treatment drugs to Medicaid patients.

Maine state Rep. Elizabeth Dickerson, a Democrat who introduced a bill this year to continue lifetime restrictions on methadone, denied that she was targeting addicts.

Methadone is an expensive program for the state, she said, and it concerned her that addicts were simply replacing one addictive drug for another. She said addicts should be able to achieve a drug-free existence. She pegged the cost in Maine at $15 million a year.

“Maybe they should have to pay for it themselves,” Dickerson told Stateline.

“A Stigmatized Illness”

“The reality is that government exists to live within a lot of parameters,” said Matt Salo, executive director of the National Association of Medicaid Directors. “That’s the nature of government and health care. Decisions have to be made.”

Carol McDaid, co-founder of Capitol Decisions, a consulting firm that specializes in substance abuse policy, said it’s common to those who draft state budgets to target this treatment first “because it is a voiceless, under-represented constituency.”

“This is a stigmatized illness,” McDaid said. “It’s a chronic illness just like diabetes and asthma, but people with those diseases often don’t commit crimes. But that’s another reason why these treatment drugs need to be fully funded. Unlike those other illnesses, with this one there is a public safety issue.”

Addiction experts are hopeful that the federal Mental Health Parity and Addiction Equity Act will even the playing field between opioid treatment drugs and other medications. The law says that patients with mental illness and substance abuse issues are entitled to the same level of care as those with other illnesses or conditions.

But even though the act was passed in 2008, the federal government has yet to write specific rules that would make it enforceable.

It could take years – and lawsuits – before the law removes the restrictive policies on medicines used in opioid treatments.  In the meantime, addiction specialists are focusing on making the case that these medicines work, and limiting their usage makes no sense.

“This just hasn’t been thought out well enough,” said Mark L. Kraus, who practices addiction medicine in Connecticut. “They think they are saving money, but that isn’t true. The cost for not treating is far higher to the state than treating.”

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Prescription painkiller overdoses soar among women


Pills-red-and-whitePrescription Painkiller Overdoses

A growing epidemic, especially among women

Vital Signs, a publication of the US Centers for Disease Control and Prevention

The numbers

48,000: Nearly 48,000 women died of prescription painkiller* overdoses between 1999 and 2010

400%: Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men.

30: For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse.

About 18 women die every day of a prescription painkiller overdose in the US, more than 6,600 deaths in 2010. Prescription painkiller overdoses are an under-recognized and growing problem for women.

Although men are still more likely to die of prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing.

Deaths from prescription painkiller overdose among women have risen more sharply than among men; since 1999 the percentage increase in deaths was more than 400% among women compared to 265% in men.

This rise relates closely to increased prescribing of these drugs during the past decade. Health care providers can help improve the way painkillers are prescribed while making sure women have access to safe, effective pain treatment.

When prescribing painkillers, health care providers can

  • Recognize that women are at risk of prescription painkiller overdose.
  • Follow guidelines for responsible prescribing, including screening and monitoring for substance abuse and mental health problems.
  • Use prescription drug monitoring programs to identify patients who may be improperly obtaining or using prescription painkillers and other drugs.

*”Prescription painkillers” refers to opioid or narcotic pain relievers, including drugs such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone.


Prescription painkiller overdoses are a serious and growing problem among women.

  • More than 5 times as many women died from prescription painkiller overdoses in 2010 as in 1999.
  • Women between the ages of 25 and 54 are more likely than other age groups to go to the emergency department from prescription painkiller misuse or abuse. Women ages 45 to 54 have the highest risk of dying from a prescription painkiller overdose.*
  • Non-Hispanic white and American Indian or Alaska Native women have the highest risk of dying from a prescription painkiller overdose.
  • Prescription painkillers are involved in 1 in 10 suicides among women.

*Death data include unintentional, suicide, and other deaths. Emergency department visits only include suicide attempts if an illicit drug was involved in the attempt.

More than 5 times as many women died from prescription painkiller overdoses in 2010 as in 1999.

  • Women are more likely to have chronic pain, be prescribed prescription painkillers, be given higher doses, and use them for longer time periods than men.
  • Women may become dependent on prescription painkillers more quickly than men.
  • Women may be more likely than men to engage in “doctor shopping” (obtaining prescriptions from multiple prescribers).
  • Abuse of prescription painkillers by pregnant women can put an infant at risk. Cases of neonatal abstinence syndrome (NAS)—which is a group of problems that can occur in newborns exposed to prescription painkillers or other drugs while in the womb—grew by almost 300% in the US between 2000 and 2009.
If you take mental health drugs and prescription painkillers, discuss the combination with your health care provider.

Prescription painkiller overdose deaths are a growing problem among women.

Prescription painkiller overdose deaths are a growing problem among women.
SOURCE: National Vital Statistics System, 1999-2010 (deaths include suicides)Every 3 minutes, a woman goes to the emergency department for prescription painkiller misuse or abuse.

SOURCE: Drug Abuse Warning Network, 2010. (Suicide attempts are included for the cases (.03% of total) where opioids were combined with illicit drugs in the attempt.)

What Can Be Done

Icon: Federal government

The US government is:

  • Tracking prescription drug overdose trends to better understand the epidemic.
  • Educating health care providers and the public about prescription drug misuse, abuse, suicide, and overdose, and the risks for women.
  • Developing and evaluating programs and policies that prevent and treat prescription drug abuse and overdose, while making sure patients have access to safe, effective pain treatment.
  • Working to improve access to mental health and substance abuse treatment through implementation of the Affordable Care Act.

Icon: Health care providers

Health care providers can:

  • Recognize that women can be at risk of prescription drug overdose.
  • Discuss pain treatment options, including ones that do not involve prescription drugs.
  • Discuss the risks and benefits of taking prescription painkillers, especially during pregnancy. This includes when painkillers are taken for chronic conditions.
  • Follow guidelines for responsible painkiller prescribing, including:
    • Screening and monitoring for substance abuse and mental health problems.
    • Prescribing only the quantity needed based on appropriate pain diagnosis.
    • Using patient-provider agreements combined with urine drug tests for people using prescription painkillers long term.
    • Teaching patients how to safely use, store, and dispose of drugs.
  • Avoiding combinations of prescription painkillers and benzodiazepines (such as Xanax and Valium) unless there is a specific medical indication.
  • Talk with pregnant women who are dependent on prescription painkillers about treatment options, such as opioid agonist therapy.
  • Use prescription drug monitoring programs (PDMPs)—electronic databases that track all controlled substance prescriptions in the state—to identify patients who may be improperly using prescription painkillers and other drugs.

Icon: Building

States can:

  • Take steps to improve PDMPs, such as real time data reporting and access, integration with electronic health records, proactive unsolicited reporting, incentives for provider use, and interoperability with other states.
  • Identify improper prescribing of painkillers and other prescription drugs by using PDMPs and other data.
  • Increase access to substance abuse treatment, including getting immediate treatment help for pregnant women.
  • Consider steps that can reduce barriers (such as lack of childcare) to substance abuse treatment for women.

Icon: Women

Women can:

  • Discuss all medications they are taking (including over-the-counter) with their health care provider.
  • Use prescription drugs only as directed by a health care provider, and store them in a secure place.
  • Dispose of medications properly, as soon as the course of treatment is done. Do not keep prescription medications around “just in case.” (
  • Help prevent misuse and abuse by not selling or sharing prescription drugs. Never use another person’s prescription drugs.
  • Discuss pregnancy plans with their health care provider before taking prescription painkillers.
  • Get help for substance abuse problems (1-800- 662-HELP); call Poison Help (1-800-222-1222) for questions about medicines.

Science Behind this Issue

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Attorneys general seek warning label cautioning pregnant women against using pain pills


Illustration showing two pill bottlesBy Maggie Clark
Stateline Staff Writer

Forty-three state attorneys general, including Washington state Attorney General Bob Ferguson, are calling for new “black box” warning labels on prescription painkillers that can harm unborn children.

In a letter sent Monday to the U.S. Food and Drug Administration, the attorneys general point to an alarming spike in the number of babies born with “neonatal abstinence syndrome,” or drug withdrawal symptoms experienced by babies when they are cut off from the opioid drugs ingested by their mothers. The symptoms include tremors, seizures, poor weight gain and fever.

“We believe that a ‘black box warning’ for these medications would help ensure that women of childbearing age – as well as their health care providers – are aware of the serious risks associated with narcotic use during pregnancy,” the attorneys general wrote in the letter addressed to FDA Commissioner Margaret Hamburg.

The targeted medications include popular painkillers such as OxyContin, Vicodin, codeine, morphine and methadone, which are part of the same opioid family of drugs as the illegal drug heroin.

Nationally, about 13,500 infants were born with drug withdrawal symptoms in 2009, about one baby each hour, according to a 2012 study from the Journal of the American Medical Association.

The problem is particularly pronounced in certain states. In Kentucky, for example, instances of neonatal abstinence syndrome have increased 2500 percent over 10 years, from 29 cases in 2001 to 730 cases in 2011, according to the attorney general’s office in that state.

Babies born with neonatal abstinence syndrome require more care and risk lifelong health problems. Medicaid, a joint state-federal program, bears much of the cost: In Florida, where seven of every 1,000 infants born in 2011 experienced opioid withdrawal symptoms,

Medicaid paid for treatment for 77 percent of those babies, at a total cost of about $32 million, according to a report on prescription drug abuse and newborns. The rate of opioid-exposed babies born in Florida more than tripled between 2007 and 2011, from 2.3 to 7.5 per 1,000 live births.

In Tennessee, the average cost to the state Medicaid program of a baby born with neonatal abstinence syndrome was $40,931 in 2010. That compares with $7,258 in Medicaid benefits for a healthy birth, according to the Tennessee Department of Health.

The state ranked second in the country for number of retail prescriptions filled per person, at 17.6 prescriptions filled per person in 2011.

The black box labels the attorneys general are calling for are found on prescriptions which cause the most serious side effects, including anti-depressants or heart medications.

The new warning labels would be added to any existing black box labels on the drugs. For instance, OxyContin already comes with a black box label warning about its potential for abuse.

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.


Are tax revenue estimates from legal marijuana a pipe dream?


Cannabis_leaf_marijuana_potBy Elaine S. Povich
Stateline Staff Writer

When Colorado and Washington voted to legalize marijuana for recreational use, supporters sold the idea partially based on new tax revenue estimates that ranged as high as $2 billion over five years.

But recent reports and analyses offer some advice: Don’t spend that money yet.

“Nobody has any idea (about revenue),” said Jeffrey Miron, a Harvard economist and analyst at the libertarian Cato Institute. “There’s only one good way to find out what the revenue would be, and that would be for all levels of government to legalize it and then we see what happens.”

While many states have legalized marijuana for medical use, nationwide recreational legalization is not likely anytime soon. Meantime, economic studies in both Colorado and Washington — the first two states to legalize marijuana for purely recreational use — have ventured predictions that played into the successful efforts to legalize the drug.

In a widely cited study of the Colorado law, the Colorado Center on Law and Policy predicted that marijuana legalization would produce $60 million annually in new revenue and savings for the state each year until 2017.

The taxes on marijuana sales include a 15 percent excise tax (dedicated to school construction) and a 10 percent sales tax, for a total of 25 percent. According to the study, those levies would bring in $32 million for the state budget, $14 million for local governments and would result in a savings of more than $12 million in state and local law enforcement spending.

The first $40 million of the excise tax revenue is dedicated to school construction. Extrapolating from there, the study projected economic development based on anticipated tax revenue — counting on 372 new construction jobs to build schools.

Last week, Colorado lawmakers approved the taxes and set other regulations. Gov. John Hickenlooper, a Democrat, is expected to sign the bill. The taxes then go before the voters in a November referendum. If approved, the regulations would take effect in January.

Unrealistic Expectations?

The $60 million estimate is still being discussed, but a more recent study tempered expectations. The Colorado Futures Center at Colorado State University concluded that while revenue will be raised, it may not meet the state’s expectations, particularly the 15 percent tax targeted for school construction.

The report concluded that for the tax to raise the $40 million anticipated for schools, given current consumption estimates, the cost to grow a pound of marijuana would be in the range of $1,100 a pound, almost twice earlier estimates. That level risks raising the price of retail marijuana so high that it could send users back to the black market.

“Our overall conclusion was while there is some revenue here, this is not a panacea for fiscal imbalance going forward,” said Phyllis Resnick, lead analyst and author of the report. “Our conclusion at the end was there is at least a risk, even with a high revenue number, once you take all this into account, there is not going to be a significant amount left over relative to the size of the (state’s budget) gap,” which is anticipated to be $3 billion to $3.5 billion by 2025.

In Washington, a state government estimate predicted revenue could reach $1.9 billion over five years, “assuming a fully functioning marijuana market.”

Brian Smith, spokesman for the Washington State Liquor Control board, which will regulate legal marijuana sales, said licenses to sell pot will be issued beginning in December. Taxes of 25 percent will be imposed at three levels — producer, processor, and retail.

Smith said it will take time for money to make its way to state treasury. “Until you start those initial sales between producers to processor, you won’t begin the flow of revenue,” he said.

While noting the lucrative tax estimates, Smith said the state is being cautious and hasn’t “banked” any of the revenue for the next two-year budget cycle, which begins in July. “It’s too unknown,” he said. “We’re operating as if we are going to implement this (tax) system, but the future is unknown.”

The Marketplace

Both states have made assumptions about consumption of marijuana in order to set their revenue estimates. For example, the Washington state study used the U.S. Department of Health and Human Services national drug survey from 2008-2009, which estimated that 17.2 percent of Washington residents aged 18 to 25 used marijuana, plus 5.6 percent of those over 26.

From those figures, the study estimated 363,000 Washington marijuana users in 2013, plus a 3 percent increase in 2015 to account for population growth and inflation. (Colorado and Washington will restrict recreational use to those over 21.)

“My intuition tells me there will be a cross border effect,” said Scott Drenkard, an economist with the Tax Foundation who has studied the issue. “It will be cheap and available. That’s something to consider. There is going to be a tourism boom of some sort. It won’t be illicit.”

But he added, “It’s hard to know because it’s an entirely new product on the legal market.”

Another wrinkle: Taxes may be harder to collect because pot sales are a cash-only business. It is cash at the medical marijuana stores open in many states and it will be cash at the new recreational marijuana stores. That’s because no bank will knowingly approve credit card sales for the drug, nor knowingly take deposits from the transactions, since marijuana is still illegal under federal law.  A financial institution could be fined or reprimanded if it handled marijuana money, even in states where it is legal.

“The short answer is we don’t (deal with marijuana business) said Don Childears, president of the Colorado Bankers Association. “I don’t know how the state regulates or taxes an industry when it can’t follow the money. No financial institution ­— bank or credit union or anything — may handle any kind of marijuana business, medicinal or recreational, because it is illegal under federal law so we can’t touch that business.”

There have been anecdotal reports out of both states that medical marijuana shops have underground relationships with banks that wink at the source of cash, or title their businesses as something innocuous, like “Suzie’s Cookies,” so a bank won’t guess the source of the deposits.

But there is a bit of a problem in cash deposits, according to Childears, because marijuana has a distinct odor which can be picked up on currency.

“An easy way to detect these businesses is literally by the smell of the currency,” he said. And if that’s the case, banks are obligated to report it to authorities.

Meg Sanders, CEO of Gaia Plant-based Medicine, a medical marijuana company in Denver, is all too familiar with the banking hassles. Determined to pay her taxes, Sanders takes cash to a post office and gets a money order.  Or, she uses funds from another business she owns to get a cashier’s check from a bank and then uses that check to pay the Gaia company’s taxes.

“It gets done, but it’s not easy,” she said. “It’s challenging because we can’t have a bank account. It takes extra steps in an already arduous process to make sure we get our taxes paid.”

The Colorado Department of Finance reported collecting $5.4 million in taxes on medical marijuana in 2012.  Sanders maintains that those who are already in the medical marijuana business, and pay their taxes, will continue to do so if they operate a recreational marijuana store. But she said, “There’s always that element” who will try to evade the tax law.

“I want the state to collect money,” she added, “but I don’t want to see the taxation so high we encourage the black market. We have to participate as partners with the state so everyone wins.”

U.S. Rep. Jared Polis, D-Colo., who has called for a federal marijuana legalization bill, expects the black market to go up in smoke after pot is legalized in Colorado.

“The black market would cost more,” he said. “If some state taxed marijuana at 100 percent or 200 percent, there would be a black market, but as long as the tax is reasonable, there’s no black market.”
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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.


National Prescription Drug Take-Back Day – April 27


Web Button-round-400x400pxThe Drug Enforcement Administration (DEA) has scheduled another National Prescription Drug Take-Back Day which will take place on Saturday, April 27, 2013, from 10:00 a.m. to 2:00 p.m.

This is a great opportunity for those who missed the previous events, or who have subsequently accumulated unwanted, unused prescription drugs, to safely dispose of those medications.

In the five previous Take-Back events, DEA in conjunction with our state, local, and tribal law enforcement partners have collected more than 2 million pounds (1,018 tons) of prescription medications were removed from circulation.

The National Prescription Drug Take-Back Day aims to provide a safe, convenient, and responsible means of disposal, while also educating the general public about the potential for abuse of these medications.

To find a Take-Back center near you go here.

Chain Saw

What will the impact of sequestration be on Washington health programs?


In an effort to pressure Congress to come up with a deal to prevent the $85 billion in across-the-board spending cuts required by the sequestration agreement, the White House has released a list of programs that will be hit should the cuts go through.

Here is the White House’s list of cuts that will likely hit health-related programs in Washington state.

Protections for Clean Air and Clean Water:

Washington would lose about $3,301,000 in environmental funding to ensure clean water and air quality, as well as prevent pollution from pesticides and hazardous waste. In addition, Washington could lose another $924,000 in grants for fish and wildlife protection.

Vaccines for Children:

In Washington around 2,850 fewer children will receive vaccines for diseases such as measles, mumps, rubella, tetanus, whooping cough, influenza, and Hepatitis B due to reduced funding for vaccinations of about $195,000.

Public Health:

Washington will lose approximately $642,000 in funds to help upgrade its ability to respond to public health threats including infectious diseases, natural disasters, and biological, chemical, nuclear, and radiological events. In addition, Washington will lose about $1,740,000 in grants to help prevent and treat substance abuse, resulting in around 3800 fewer admissions to substance abuse programs. And the Washington State Department of Health will lose about $174,000 resulting in around 4,300 fewer HIV tests.

Nutrition Assistance for Seniors:

Washington would lose approximately $1,053,000 in funds that provide meals for seniors.

Education for Children with Disabilities:

In addition, Washington will lose approximately $11,251,000 in funds for about 140 teachers, aides, and staff who help children with disabilities.

To learn more:

  • Read the full list of programs the White House says will be affected here.
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Binge Drinking: a serious, under-recognized problem among women and girls – CDC


From the U.S. Centers for Disease Control and Prevention

Binge drinking is a dangerous behavior but is not widely recognized as a women’s health problem.

Drinking too much – including binge drinking – results in about 23,000 deaths in women and girls each year.

[Binge drinking for women is defined as consuming 4 or more alcohol drinks (beer, wine, or liquor) on an occasion.]

Binge drinking increases the chances of breast cancer, heart disease, sexually transmitted diseases, unintended pregnancy, and many other health problems.

Drinking during pregnancy can lead to sudden infant death syndrome and fetal alcohol spectrum disorders.

About 1 in 8 women aged 18 years and older and 1 in 5 high school girls binge drink. Women who binge drink do so frequently – about 3 times a month – and have about 6 drinks per binge. There are effective actions communities can take to prevent binge drinking among women and girls.

Binge drinking infographic


For a PDF of this infographic go here.


Drinking too much can seriously affect the health of women and girls.

Drinking too much can seriously affect the health of women and girls.

  • Women’s and girls’ bodies respond to alcohol differently than men’s. It takes less alcohol for women to get intoxicated because of their size and how they process alcohol.
  • Binge drinking can lead to unintended pregnancies. It is not safe to drink at any time during pregnancy.
  • If women binge drink while pregnant, they risk exposing their developing baby to high levels of alcohol, increasing the chances the baby will be harmed by the mother’s alcohol use.

Drinking is influenced by your community and your relationships.

  • Alcohol use in a community is affected by alcohol’s price and availability.
  • Underage drinking is affected by exposure to alcohol marketing.
  • Underage drinking is also influenced by adult drinking, and youth often obtain alcohol from adults.

What Can Be Done

Federal agencies and national partners are:

  • Recognizing that binge drinking is an important women’s health issue.
  • Working with states and communities to support Community Guide recommendations to reduce binge drinking.
  • Informing people about the US Dietary Guidelines on alcohol consumption (see box).
  • Helping states and communities to report on how many people binge drink, how often and how much they drink when they binge, and whether health care providers are screening and counseling for excessive alcohol use.
  • Reporting on youth exposure to alcohol marketing because it influences underage drinking.

We know what works

The Guide to Community Preventive Services(Community Guide) recommends effective policies to prevent binge drinking. Learn more at:

States and communities can:

  • Follow Community Guide recommendations to reduce binge drinking. The same approaches that work in the population as a whole can work for women and girls.
  • Increase enforcement of laws on the sale and consumption of alcohol.
  • Develop partnerships with a variety of groups, including schools, women’s and girls’ organizations, law enforcement, and public health agencies to reduce binge drinking.
  • Report on how many people binge drink, how often, and how much they drink when they binge.

Key Points on Alcohol Consumption from the 2010 US Dietary Guidelines for Americans

  • Don’t begin drinking or drink more frequently on the basis of potential health benefits.
  • If you do choose to drink, do so in moderation. This is defined as up to 1 drink a day for women or 2 for men.
  • Don’t drink at all if you are under age 21, pregnant or may be pregnant, or have health problems that could be made worse by drinking.

Doctors, nurses, and others who treat patients can:

  • Ask women about binge drinking and counsel those who do to drink less (see Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse). This screening and counseling can also be effectively done using the internet, telephone, or other electronic methods, as recommended by the Community Guide.
  • Advise women who are pregnant or might be pregnant not to drink at all.
  • Recognize that most binge drinkers are not alcohol dependent or alcoholics, but may need counseling.
  • Support effective policies to prevent binge drinking such as those recommended by the Community Guide.

Women and girls can:

  • Avoid binge drinking. If you choose to drink alcohol, follow the US Dietary Guidelines.
  • Choose not to drink alcohol if you are underage or if there is any chance you could be pregnant.
  • Be cautious about consuming drinks if the alcohol content is unknown to you.

To learn more:

Read the CDC’s WMMR article: Vital Signs: Binge Drinking Among Women and High School Girls — United States, 2011.

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Washington state moves to address epidemic of prescription painkiller overdose deaths – BMJ


A feature article on efforts in Washington state to address the epidemic of prescription painkiller overdose deaths by LocalHealthGuide editor Michael McCarthy appears this week in the BMJ, the journal of the British Medical Society.

Containing the opioid overdose epidemic

In the late 1990s, Washington State began to relax its rules regulating the prescription of opioids. Shortly thereafter, overdose deaths began to climb.

“We saw the deaths increase within a year,” says Gary Franklin, medical director for the Washington Department of Labor and Industries, which administers compensation for job related injuries and illnesses for more than 3.2 million workers in the state.

“These were productive people who were working the day they came into the system with a back sprain or whatever, and three years later they were dead from an accidental overdose of opioids,” Franklin says. “I had never seen anything so sad.” . . .

Read the full article on the BMJ website.

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Blue and white capsules spilling out of a pill bottle

Turn in your unwanted and expired prescription drugs on Saturday


King County residents can dispose of their unwanted and expired medicines anonymously and at no cost at a nationwide drug “take-back” day on Saturday, Sept. 29 from 10 a.m. to 2 p.m.

There are 22 take-back collection sites in King County currently with more expected by the day of the event.

To find a location go to:

Blue and white capsules spilling out of a pill bottle

Photo courtesy of Pawel Kryj

This one-day event is coordinated by the federal Drug Enforcement Administration and participating local law enforcement agencies.

About 30 percent of prescription and over-the-counter medicines sold go unused.  Unused prescription drugs too often fall into the hands of children and teens, where they cause poisonings and deaths.

Drug facts:

  • Prescription drug abuse is the fastest-growing drug problem in the country.
  • Drug overdoses have surpassed car crashes as the leading cause of accidental deaths in Washington – the majority involved prescription pain killers.
  • In Washington state 11 percent of teens use prescription medicines for non-medical reasons – a rate among the highest in the nation.
  • Over half of the 37,000 calls to the Washington Poison Center in 2009 were for young children poisoned by medicines found at home, and the elderly are also at risk of accidental poisonings.
  • Human medications are the leading cause of pet poisoning.
Photo courtesy of Pawel Kryj

To learn more:

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Cigarette thumb

Washington State Tobacco Quitline resumes service for all residents


New funding from the Washington State Legislature and the Centers for Disease Control and Prevention means the Department of Health can once again provide help quitting to all adult tobacco users in the state.

Funding cuts in 2011 eliminated free quitline help for many, including people without health insurance.

Starting immediately, all adults in Washington regardless of insurance status can call the toll-free Washington State Tobacco Quitline for support to quit using tobacco.

The quitline (1-800-QUIT-NOW, 1-877-2NO-FUME in Spanish) provides free counseling, a personal quit plan, a quit kit, and referrals to local resources.

Eligible callers can also get a supply of nicotine patches or gum.

In the past year, more than 6,500 people called the quitline for help but didn’t qualify for service. The quitline has a long list of people who asked to be called back if services were restored.

Benefits of quitting include lower the risk of lung cancer, heart attack, stroke, chronic lung disease, and other cancers.

Calling a quitline significantly increases a person’s chances of kicking the habit, health officials said.

The quitline is part of Washington’s tobacco prevention and control efforts that health officials say have contributed to a 30 percent drop in adult smoking since 2000.

More than 170,000 people have received help from the quitline since it opened for business in 2000. Today, there are many more former smokers in Washington than there are current smokers.

The estimated 329,000 fewer smokers in the state represents an overall savings of $3 billion in future health care costs, officials say.

While Washington has made significant headway in lowering smoking rates, prevention and cessation services have been drastically reduced due to budget cuts, state health officials say.

At the same time, the tobacco industry spends more than $122 million each year to attract new smokers, and about 50 youth in Washington start smoking each day and about 7,900 people die every year from tobacco-related diseases.

Web link: Washington’s Tobacco Quitline: Free Help for Tobacco Users.

Other local resources:

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Tobacco Thumb

Decline in smoking stalls in King County


The decline in the number of adults who smoke in Kind County has stalled, Public Health – Seattle & King County finds in a new report

Today, an estimated 155,000 King County adults continue to be cigarette smokers and an additional 26,000 use smokeless tobacco, according to the county’s new “Tobacco use in King County” Data Watch Report.

Tobacco remains the leading preventable cause of death nationally, and in King County it accounts for 1 in 5 deaths and $343 million annually in health care expenses and lost wages, the report finds.

Other highlights from the report:

  • After a nearly 50% decline from 1996 to 2007, smoking rates among adults flattened in the most recent 5 year period of 2007-2011. About 10% of King County adults smoke, plus an additional 2% use smokeless tobacco products.
  • More than 15,000 students (including 1 in 4 12th graders) used cigarettes or other tobacco products in the past month.
  • Adult smoking rates are highest among African-Americans, low-income residents and lesbian, gay, bisexual and transsexual (LGBT) groups.
  • For youth, the highest smoking rates are among American Indian/Alaska Native, Native Hawaiian/ Pacific Islander and Latino youth.
  • Youth also use alternative tobacco products such as chewing tobacco, snuff, dip, cigars, cigarillos and little cigars – many of which are flavored to taste like fruit, candy, or alcohol.
  • In all, 50% of female and 67% of male tobacco users reported using multiple tobacco types.

Though King County has an overall smoking rate that is among the lowest in the country, the county has the most extreme smoking gap between communities with low smoking rates and those that have high smoking rates of the 15 largest metropolitan counties in the United States.

To learn more, visit:

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