Category Archives: Drug Abuse

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.


Study doubles estimate of pot use in Washington state


Cannabis_leaf_marijuana_potMarijuana consumption in Washington state is about twice as large as previously estimated, according to a new RAND Corporation study.

Washington voters approved Initiative 502 in November 2012 that legalized recreational use of marijuana for those aged 21 and older, and requires the state to regulate and tax a new marijuana market.

Commercial marijuana stores and associated supply chains are scheduled to begin operating in 2014.

In the study, researchers used data from the federal government as well as data from a survey of marijuana users in the state to estimate that state’s annual consumption of marijuana.

They conclude consumption will likely range between 134 metric tons to 225 metric tons this year, with a median of 175 metric tons, or about 385,809 pounds.

The state’s three most-populous counties (King, Snohomish and Pierce) account for about half of all use. King County accounts for about 30 percent of the marijuana users, while Snohomish and Pierce counties have roughly 11 percent each, the report found.

The Washington Office of Financial Management previously had estimated that marijuana consumption in Washington would be 85 metric tons in 2013.

The analysis was done as a part of efforts to help the Washington State Liquor Control Board prepare for commercial sales of marijuana

The RAND report, “Before the Grand Opening: Measuring Washington State’s Marijuana Market in the Last Year Before Legalized Commercial Sales,” is available at


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.

Stopwatch public domain cdc

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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Teens have unsupervised access to prescription drugs


By Stephanie Stephens, HBNS Contributing Writer
Research Source: Journal of Adolescent Health

A new study in the Journal of Adolescent Health found that 83.4 percent of teens had unsupervised access to their prescription medications at home including 73.7 percent taking pain relief, anti-anxiety, stimulant and sedative medications that have the potential for abuse.


“It was surprising to me that parents were not storing medications securely because I expected them to be locked up and for parents to administer the medications,” said Paula Ross-Derow, Ph.D., of the University of Michigan’s Institute for Research on Women and Gender.

She and her colleagues explored the supervision of prescribed medications among 230 adolescents in 8th and 9th grade, using an online survey and in-person interview.

Emergency room visits for non-medical use of prescription narcotic pain relievers are increasing in people under age 21, and death by poisoning due to prescription overdoses is up 91 percent in less than a decade among adolescents ages 15 to 19, note the researchers.

They acknowledge that it is possible that parents and guardians may not believe that their children would engage in non-medical use or give away their prescription medications and therefore do not take steps to secure them.

“Dr. Ross-Durow’s paper shows that the majority of adolescents who are prescribed controlled medications have easy, unsupervised access to them,” said Silvia Martins, M.D., Ph.D., associate professor of epidemiology at Columbia University. “This is of great concern, since it not only can lead to the possibility of overdose of medications with potential abuse liability, but also can contribute to diversion of these medications and nonmedical use by their peers.”

“Parents don’t recognize that other kids come into their homes and can open a cabinet or see meds on the kitchen counter and take them,” Ross-Durow explained. “Teenagers may give them away—thinking they’re helping a friend—and they don’t see this as a risky behavior, or some may sell the medications. Visitors in the home may simply steal them.”

The researchers admit they don’t know whether providers are adequately educating parents and encourage more studies around this topic. “Plus, what we did not ask, but realized when examining our findings, is about other medications prescribed to parents and how those are stored. What we want to know is when medications are readily available in the home; does that lead to nonmedical use? We believe unsupervised access lays the groundwork for that,” said Ross-Durow.

Journal of Adolescent

Paula Lynn Ross-Durow, Ph.D., Sean Esteban McCabe, Ph.D., and Carol J. Boyd, Ph.D. (2013). Adolescents’ Access to Their Own Prescription Medications in the Home, Journal of Adolescent Health.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.


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.


Teens and Sexual Assault, Part 8: The Media’s Response to the Steubenville Convictions

Photo by Brainloc

Photo by Brainloc

This article first appeared on Seattle Children’s Teenology 101 blog.

I thought Part 7 was my last post in the series, but the media response to the sentencing of the two rapists in the Steubenville case has been so outrageous that I’m going to tack on a postscript here.

One of the first news reports to come out after the conviction was from CNN, and it spent much more time sympathizing with the rapists than the victim- in fact, the victim was not mentioned. You can watch the video here.

A concerned Poppy Harlow states, ”It was incredibly emotional, incredibly difficult even for an outsider like me, to watch what happened, as these two young men, that had such promising futures, star football players, very good students, literally watched as they believed their life fell apart…”

She then goes on to describe said emotion in the courtroom, and the offenders’ sadness. Later on, another reporter asked a legal correspondent, “What’s the lasting effect of two young men being found guilty in juvenile court of rape, essentially?”

There is so much wrong there: the concern over the rapists, the “essentially” tacked on to “rape”, the complete and utter absence of any thoughts of the victim. Just as people were beginning to criticize CNN, it turned out that the problem was not just with them.

NBC kept talking about the rapists’ “promising football careers.” I’m not sure why that’s relevant.

ABC News ran a piece on Ma’lik Richmond that talked extensively about his athletic prowess and difficult childhood. And yet, many athletes with difficult childhoods have refrained from raping someone.

Good Morning America mentions that “A juvenile judge will decide the fates of Trent Mays and Ma’lik Richmond, who face incarceration in a detention center until their 21st birthdays and the almost-certain demise of their dreams of playing football.” Perhaps if you dream of playing football, it’s best not to commit a sex crime.

The Associated Press opens a story with “Two members of Steubenville’s celebrated high school football team were found guilty Sunday of raping a drunken 16-year-old girl.” They are celebrated high school football players, the victim is left with the epithet “drunken.”

What none of these major media outlets seem to be addressing is that (ideally) if you rape someone, you pay the consequences for it. None of them are lamenting the long-term effects on a young women of being raped by two young men (and having pictures of it sent to peers). None of them are pointing out that this situation wouldn’t have happened if the two offenders had made the choice not to rape someone. Their promising football careers would be continuing untouched, they might have gone to great universities, and enjoyed all the opportunities and rewards given to people who have chosen not to commit rape.

What are our teens supposed to think when the mainstream media’s treatment of rapists is not full of revulsion, fear, or condemnation, but seems almost… affectionate? At the least, they feel very bad for them.

And they fail to mention concern over the fate of the rape victim. In fact, if she’s mentioned at all, it’s to point out that she was intoxicated. As Henry Rollins (yes, thatHenry Rollins) said in a piece in Raw Story, “It is ironic and sad that the person who is going to do a life sentence is her.”

I spoke earlier in this series about how important it is to talk to your teen about issues regarding sexual consent. It’s also important for you to talk to your teen about rape culture, how they can make sure they’re not a part of it, and what they can do to change it.

About Jen Brown, RN, BSN

Jen Brown, RN, BSN Teens never cease to amaze me with their strength, creativity, and new perspectives! Throughout my career, I’ve enjoyed helping teens and their parents tackle health concerns and navigate social issues. Nursing is my second career; my first degree was in biology from Carleton College, and a few years later I went to the University of Virginia for their Second Degree Nursing Program. Recently I began a graduate program at the University of Washington.

Picture of a table after a party with wine and beer bottles

Teens and Sexual Assault, Part 2: Drinking and Drugs


By  This article first appeared on Seattle Children’s Teenology 101 blog.

Picture of a table after a party with wine and beer bottlesIn this post, and posts to come, I’m going to talk about safety measures that teens can take to try and lower their risk of sexual assault. However, that comes with two important caveats.

The first is that, unfortunately, there is nothing a teen can do to keep themselves 100% safe from sexual assault.

The second is that if a sexual assault occurs, the blame is 100% on the perpetrator. It does not matter how the victim was acting, or what risks they took, or whether or not they showed good judgment in the situations leading up to the assault; a person who sexually assaults another person is the only one who bears responsibility for that assault.

The tips I am giving in the next few posts are ways to possibly lower risk, but someone who chooses to ignore all of them should never be blamed if they are attacked.

Sometimes I wonder if we spend time teaching our teens to take safety measures and then forget to teach our teens to not sexually assault people.

Like I mentioned in my last post, take the time to discuss with your teen, no matter what their gender, what is and is not acceptable.

Again, I’m not implying your teen is the type of person to victimize someone, but they might be able to speak up to help someone else.

If one teen had chosen to call the police when they saw what was happening during the Steubenville incident, the victim’s assaults- or at least some of them- might never have happened.

Let’s discuss ways to talk to your teen about increasing their safety, and possibly decreasing their risk of being seen as an “easy target” (again, there are unfortunately no guarantees.) And we’ll start by talking about drinking and drugs.

When someone is intoxicated or under the influence of drugs, their judgment and decision-making capacity is lowered and sometimes nonexistent.

This means that they may not be able to assess risk like somebody sober. They may decide to spend time with someone who, were they sober, their gut instinct would warn them away from.

They may be unable to see the danger of a situation that would normally set off alarm bells. If the effects of alcohol or drugs are visible, someone who is seeking a vulnerable person may be drawn to them. Or, if their impulse control is lowered, they may act aggressively towards somebody else.

If your teen decides to drink- hopefully once they are over 21, but the majority of teens do experiment with alcohol before then- they can avoid drinking to the point of severe impairment, especially when in large groups (keeping in mind, however, that most sexual assaults involve someone known to the victim).

When I was in college, we usually had a friend who agreed to be the “lookout” for an evening of parties, someone to avoid intoxication and make sure that nobody was taken advantage of, and that everyone got back to their dorm room safely. Groups of friends can rotate this responsibility among them.

This is obviously not a sure thing- the designated lookout can be drunk him or herself, they can assume one of their charges is having a good time when really they are quite incapacitated… etc.

But it’s never a bad idea for teens to look out for each other in party or group settings, and speak up if they are concerned that someone is being taken advantage of.

Sometimes teens can become incapacitated without having the chance to consider whether or not they want to drink or take drugs. Another important thing for teens to consider is the possibility that someone might slip a drug into their drink to render them less able to respond to or remember incidents.

When possible, teens should get their own drinks, or at least watch them being poured from a previously unopened container, and never leave their drink unattended. You and your teen can find out more about “date-rape drugs”, and ways to avoid them, here.

There are, of course, many other risks to drinking and drugs, many of which are discussed in the “Drug Use Among Teens” post by Dr. Evans.

But encourage your teen to think about drinking and drugs in terms of sexual assault as well. This may help them increase their own safety, or be able to help a friend when they need it most.

About Jen Brown, RN, BSN

Jen Brown, RN, BSN Teens never cease to amaze me with their strength, creativity, and new perspectives! Throughout my career, I’ve enjoyed helping teens and their parents tackle health concerns and navigate social issues. Nursing is my second career; my first degree was in biology from Carleton College, and a few years later I went to the University of Virginia for their Second Degree Nursing Program. Recently I began a graduate program at the University of Washington.


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Teens and Sexual Assault, Part 1: The Steubenville Incident


Seattle Children's Whale LogoBy

This article first appeared on Seattle Children’s Teenology 101 blog.

The small town of Steubenville, Ohio, has suddenly become reluctantly but internationally famous, and events there have made headlines around the world.

The story of a teen girl, dragged unconscious from party to party, her repeated assaults known of and even witnessed by peers, is a nightmare.

It chills any parent’s heart, for multiple reasons: the young woman’s vulnerability, the callous nature of the assault, the youth and former promise of the young men who committed it, and the small town politics that many allege obstructed the initial investigation (the mother of one of the accused is the town’s prosecuting attorney).

I want to go over how to talk to your teens about sexual assault and consent. I touch on this in item number three of “10 Tips For Talking to Your Teen About Sex“, but it deserves further discussion.

It’s vital that you have a frank discussion with your teen about sexual assault, and the media coverage of the Steubenville incident gives parents a perfect opportunity to bring it up.

Your teen needs to know the importance of taking “no” for an answer.

First of all, nobody wants to think their child is capable of sexually assaulting someone else. I’m not trying to imply that your child is a budding sexual predator who would perform the acts the young men are accused of in the Steubenville case.

However, bringing up the topic of sexual assault and sexual consent can help your teen with situations that some teens don’t know how to handle, or where others have made the wrong decision.

You can also hear what your teen thinks, both about Steubenville and sexual assault among teenagers.

Rape and sexual assault are terms that apply to a wide variety of circumstances, not just a man forcing sex on a resisting woman. A woman can sexually assault a man, and same-sex sexual assault occurs all too frequently.

Some victims are temporarily incapacitated by drugs or alcohol (or permanently incapacitated by disabilities, which is beyond my scope here), and under these conditions, cannot consent.

Having sex with a partner who is much younger than the other partner is also a form of sexual assault, and can be prosecuted as such.

Your teen needs to know the importance of taking “no” for an answer- you can’t really be too firm on this point- but that also that consent goes deeper than that.

If someone is intoxicated or their thinking is altered by drugs, they do not have the capacity to choose whether or not they want to have sex.

The one extreme of this is the victim of the Steubenville incident, who either was intoxicated to the point of unconsciousness, or was drugged by her aggressors; reports are unclear.

However, people can be awake and still too intoxicated to consent. Someone who is obviously under the influence is not someone that anyone should be physically intimate with.

Encourage your teen to seek consent from their partner, as opposed to just assuming it. Sometimes when a person perceives that a situation is getting out of control, they may “freeze” instead of fighting back.

This happened to someone I knew in college; in the boy’s mind, she was going along and didn’t say “no,” and in the girl’s mind she had frozen on perceiving danger, and he had continued anyway.

Instead of waiting for “no,” talk to your teen about the important of a “yes.” A simple “Is this okay?” shows not only respect for their partner, but helps a teen know that they are with someone who is truly willing, and is enjoying the experience as much as they are.

Make sure your teen knows that sexual activity with someone younger than them, even if that person gives a resounding “yes,” may be illegal. If they have detailed questions, direct them here to see the specifics.

Have you tried to talk to your teen about this? How did it go? Did they say anything that surprised (or impressed) you? Are teens watching the Steubenville incident unfold, and what do they think about it?

About Jen Brown, RN, BSN

Jen Brown, RN, BSN Teens never cease to amaze me with their strength, creativity, and new perspectives! Throughout my career, I’ve enjoyed helping teens and their parents tackle health concerns and navigate social issues. Nursing is my second career; my first degree was in biology from Carleton College, and a few years later I went to the University of Virginia for their Second Degree Nursing Program. Recently I began a graduate program at the University of Washington.



Fewer students smoking and drinking alcohol in Washington state


Picture of a table after a party with wine and beer bottlesFewer students in Washington state are smoking cigarettes or drinking alcohol, according to the state’s latest Healthy Youth Survey.

The survey is taken every two years by students in grades 6, 8, 10, and 12 in more than 1,000 Washington public schools.


Among the findings:


  • Cigarette smoking is down in all grades. About 10 percent of 10th graders reported smoking a cigarette at least once in the past 30 days —  down from nearly 13 percent in 2010 and from 25 percent in 1999.
  • Nearly as many 10th graders smoked tobacco from a hookah pipe as from a cigarette, and about 7 percent said that they smoked a cigar in the last month.
  • Statewide, about 50,000 youth smoke – and 40 start smoking every day.


  • Nearly 11,000 fewer students are using alcohol compared to 2010. Still, more than 115,000 youth currently drink.  Twelve percent of 8th graders, 23 percent of 10th graders, and 36 percent of 12th graders used alcohol in the past 30 days.


  • The  number of secondary school students who believe using marijuana is risky dropped to the lowest level since the state started collecting data and the percentage of Washington 10th and 12th graders who smoke marijuana is nearly double the percentage of cigarette smokers.

Suicide and Depression:

  • About 8 percent of 8th and 10th graders attempted suicide in the past year.
  • Over 100,000 youth, ages 12-17, seriously considered suicide – about one in every six students.
  • More than one in four teens surveyed said they felt so sad or hopeless for two weeks in a row that they stopped doing usual activities: 26 percent in 8th grade, 31 percent in 10th grade, and 30 percent in 12th grade.
  • These numbers haven’t changed much over the past 10 years.


  • Nearly one third (32 percent) of 10th graders and more than half (55 percent) of 12th graders reported having ever had sexual intercourse.
  • About 7 percent of 10th graders and 16 percent of 12th graders reported they had four or more sexual partners.
  • About 6 percent of 10th graders and 5 percent of 12th graders reported having sex for the first time at age 12 or younger.

To learn more:

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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Accidental poisonings leading cause of deaths at home

A jumble of pill bottles

Photo by Erin DeMay via Flickr

By Stephanie Stephens, HBNS Contributing Writer
Research Source: American Journal of Preventive Medicine

An increasing number of people are dying from unintentional injury at home, with more than 30,000 deaths occurring between 2000 and 2008, finds a new study in the American Journal of Preventive Medicine. Poisoning, falls and fire/burn injuries caused the most fatalities, respectively.

The study reveals that poisonings were the leading cause of unintentional home injury deaths for those ages 15 to 59 years, largely resulting from unintentional drug overdoses of narcotics, hallucinogens and other drugs.

Additionally, more men and boys died from home injury than women and girls did and adults 80 years and older had higher rates of injury-related in-home death than other ages.

“These injuries are predictable and preventable,” said lead author Karin Mack, Ph.D. of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention.

Mack and her colleagues called for more research to develop effective interventions to modify the home like smoke alarms, limiting access to non-prescription drugs, and closer supervision of children.

Other helps would be broader dissemination of prevention messages to specific audiences including healthcare and education providers, law enforcement and policymakers, and media, they said.

The researchers used combined state-specific death certificate data from the National Vital Statistics System, an inter-governmental public health database. New Mexico had the highest rates of unintentional home injury death during the study period with the lowest in Massachusetts.

Mack said that despite the uptick in home injury during the study period, she was encouraged by momentum occurring in the field of healthy homes, citing two publications that helped spark national interest in home safety: a 2009 report, “The Surgeon General’s Call to Action to Promote Healthy Homes,” and a 2011 report from the American Public Health Association, “Healthy & Safe Homes: Research, Practice, and Policy”.

Much more needs to be done, said Carol W. Runyan, M.P.H., Ph.D., a professor of epidemiology and community and behavioral health at the Colorado School of Public Health.

“The increases in poisoning, largely due to prescription pain medication, have been most dramatic over the past decade, signaling a need to rethink how pain medications are prescribed and used,” she said.

Falls continue to be the major source of fatal home injury in older adults and suffocation the leading cause for infants, Runyan said.

“As the authors note, most of these injuries are preventable through changes in the home environment and safety practices. Unfortunately, this enormous and costly public health problem has not received the national attention it deserves. Funding to understand and address the problem is a pittance compared to other health problems and many health professionals are poorly trained to address these challenges,” she said.

Runyan said the deaths are not inevitable results of uncontrollable or accidental circumstances. “Hopefully this paper will stimulate a shift in the national attention and support for prevention,” she said.
Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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