Opioid harm reduction: A comprehensive approach

By DR. DAVID J. HOLCOMBE | Medical Director, LDH Region 6

Opioid overdoses continue to claim over 100 American lives every day (46,029 in 2017). This slaughter now exceeds the number of annual traffic deaths (37,000 in 2017), which has benefited from gradual reductions related to improved safety in both roadways and vehicles. In an Annals of Internal Medicine article, Drs. Levine and Fraser proposed elements of a comprehensive public health response to the opioid crisis.

They established six categories to approach the crisis: (1) Leadership, (2) Partnerships, (3) Epidemiology, (4) Prevention/Education, (5) Treatment and Recovery and (6) Overdose Prevention. Some of the key elements of each category proved a framework for a coordinated approach in which public health plays a leading role.

Leadership entails the engagement of all leaders from the governor’s office down to community leaders, not only in healthcare, but also in education, corrections, social services and economic development.

Partnerships include not only those within communities, but also those between states, the federal government, faith-based organizations and health community coalitions, among others.

Epidemiology serves to create databases and dashboards available to all interested and engaged parties. The Louisiana Opioid Data and Surveillance System fulfills this valuable role by providing local data relating to specific populations.

Education and prevention involves prescribers, pharmacists and the public. This includes the state Prescription Monitoring Program, regulation of pain clinics, sanctions for over-prescribers, and working with school-based health clinics and the Department of Education to improve drug awareness.

Treatment and recovery must be enhanced with increased availability to rehab facilities, expansion of medication assisted treatment (MAT), use of telehealth in rural areas, and improved post-recovery programs addressing employment, housing, transportation and other social needs.

Harm reduction and overdose prevention must include safe syringe programs (such as one being proposed locally), increased availability of naloxone (Narcan®), and improved diagnosis and treatment of underlying pre-disposing mental health factors such as depression.

This ambitious plan reflects a multi-faceted approach and broad engagement from multiple elements of society. It recognizes the importance of social determinants such as educational level and income, as well as the necessity of addressing glaring issues of health inequity. Public health can have a primordial role in tackling the opioid epidemic, but it cannot act alone or in a vacuum. We all helped create the world of opioid addiction in one way or another, and now we must rise to the occasion to help mitigate and eradicate it.

What do we do when we think it could be Alzheimer’s disease?

By GINA ROSSI | LCSW-BACS, MHSA, LDH Office of Aging and Adult Services

There can be nothing more heartbreaking and frightening than watching a parent or loved one slowly decline with memory problems or signs that indicate they may have dementia. Ask any older person about their biggest fears and inevitably the words “Alzheimer’s disease” enter into the conversation.

Approximately every 6 minutes someone receives an Alzheimer’s diagnosis. In Louisiana, 87,000 people over the age of 65 are living with Alzheimer’s, and 232,000 family caregivers are dealing with the effects of their loved ones needing care and support.

Alzheimer’s disease is a sixth leading cause of death in the U.S.  In 2017, there were 2,188 deaths in Louisiana related to Alzheimer’s, a 170% increase since 2000. This figure is projected to increase by 23.6% by 2025. Frightening, right? Despite this, only 16% of seniors receive regular cognitive assessments during routine health checkups. If you see signs, consult your primary care physician or neurologist.

The more we talk about Alzheimer’s, the more people are educated about its symptoms. The other side of the coin is that without clear guidance and professional consultation, our fears can cause us to jump to conclusions. For this reason, the Alzheimer’s Association provides education about this disease and what signs and symptoms we should be looking for.

It is important to know that dementia is an umbrella term and while Alzheimer’s disease is the most common cause of dementia, there are many reasons why someone may be showing signs of dementia.

Know the 10 signs of Alzheimer’s

1. Memory loss that disrupts daily life
2. Challenges in planning or solving problems
3. Difficulty completing familiar tasks at home, at work or at leisure
4. Confusion with time or place
5. Trouble understanding visual images and spatial relationships
6. New problems with words in speaking or writing
7. Misplacing things and losing the ability to retrace steps
8. Decreased or poor judgement
9. Withdrawal from work or social activities
10. Changes in mood and personality

The three stages of Alzheimer’s

• Mild (early stage): The person is still able to function independently but may feel they are having memory lapses such as forgetting words or familiar locations. Friends or family who are close may notice a change. If you are a caregiver dealing with this stage, make plans now for an assessment so future plans (and support for you) can begin.
• Moderate (middle stage): The disease has progressed and the person may no longer do routine tasks and become confused about their history. This is the longest period and the most difficult for caregivers as they have to deal with the person’s anger, frustration, and increased wandering. If you are a caregiver dealing with this stage, get support NOW.
• Severe (late stage): In this stage, the person needs 24-hour care with daily activities and personal care. They are no longer responding to their environment and are unable to communicate, which is especially troublesome for those experiencing pain. In the final stages, death is a result of infections such as pneumonia or bed sores. If you are a caregiver dealing with someone in this stage, know that you have done the best that you can. Be kind to yourself.

Clinical trials, research and resources

It is true that there is no cure for Alzheimer’s disease, but through research we know there are ways for us to reduce the risk, including activities such as regular exercise, keeping one’s blood pressure within current healthy guidelines and engaging the brain. These small things help us maintain and protect our brain health.

While there is no cure, clinical trials continue locally and nationally. There are many important advances and efforts to help people better cope with the effects of the disease and to work toward a cure. Research also continues into how to help a person live with Alzheimer’s while focusing on the needs of the primary caregivers who experience the physical, emotional and mental burden of caring for someone who has Alzheimer’s.

Someone who is unable to care for themselves and who needs care in the home may be eligible for home and community-based services. For more information about these services, call Louisiana Long Term Care Options at 1-877-456-1146. Here are some additional places to go for help:

• Louisiana Department of Health, Office of Aging and Adult Services Help Line: 1-866-758-5035
• Louisiana Department of Health, Office of Aging and Adult Services
• Alzheimer’s Association
• Alzheimer’s Services of the Capital Area
• Alzheimer’s Association Clinical Trials
• Database of privately and publicly funded clinical studies around the world

Be a food safety superhero

Many people have daydreamed about being a superhero. Who wouldn’t want to have the power of flight or super strength? Well, those kinds of powers may be out of our reach, but there’s one that isn’t: being a food safety superhero. With September being Food Safety Education Month, it’s a great time to learn about preventing foodborne illnesses and how to keep food safe.

Much like Batman and his familiar rogues’ gallery of villains — the Joker, Catwoman and the Penguin, just to name a few — the kitchen also has its common culprits when it comes to food poisoning and foodborne illnesses. When contaminated and consumed, these foods can make a person very sick. Let’s take a closer look at the usual suspects.

First, a little sanitation: Always wash your hands with soap and warm water before handling food and immediately after handling any raw food. Wash your counter tops, cutting boards, dishes and utensils with soap and hot water between the preparation of raw foods and cooked or ready-to-eat foods.

Chicken, beef, pork and poultry

• The bad guys: campylobacter, salmonella, Clostridium perfringens, E. coli, yersinia and other bacteria
• How to fight back: Never wash raw poultry or meat, since this increases the chances of spreading bacteria to other foods and surfaces. Cook your poultry and meat thoroughly to a safe internal temperature using a cooking thermometer and these charts. Don’t rely on the meat’s color or juices to tell you if it’s fully cooked. Refrigerate any leftovers within two hours of preparation at a temperature of 40 degrees Fahrenheit or colder. Divide larger cuts into small quantities for refrigeration, as this helps the meat cool quickly and prevent bacteria from growing.

Seafood and raw shellfish

• The bad guys: Vibrio, salmonella, listeria, norovirus and other bacteria
• How to fight back: Cook raw seafood to proper temperatures, usually an internal temperature of 145 degrees. Other ways to tell if seafood is done are if fish flesh is opaque and separates easily with a fork; shrimp, scallop, crab and lobster flesh become firm and opaque; and the shells of clams, mussels and oysters open during cooking (unopened ones should go in the trash). Don’t eat seafood if it smells sour, rancid or like ammonia. Cooked seafood should be refrigerated if it’s been out for more than two hours or for more than an hour when temperatures are 90 degrees or higher. Refrigerate at 40 degrees or colder.

Fruits and vegetables

• The bad guys: salmonella, E. coli and listeria
• How to fight back: Wash your hands and all utensils and food prep surfaces before and after preparation. Under running water, wash or scrub your produce and cut away any damaged or bruised areas, then dry with a clean paper towel. Keep produce separate from raw meat, poultry and seafood. Refrigerate your prepared fruits and veggies within two hours, or one hour if it’s 90 degrees or hotter outside. Store in a clean container in a refrigerator at 40 degrees or colder.

Sprouts

• The bad guys: salmonella, E. coli and listeria
• How to fight back: Cook sprouts such as alfalfa or bean thoroughly to kill off any germs.

Raw milk, raw milk soft cheeses and other raw milk products

• The bad guys: campylobacter, cryptosporidium, E. coli, listeria and salmonella
• How to fight back: Choose products that have been pasteurized — if the label says “pasteurized,” it’s safe to consume. These products include milk, yogurt, ice cream and soft cheeses like queso fresco, queso blanco, brie, Camembert and feta. Pasteurization is a process that heats raw milk to a specific temperature just long enough to kill off germs. This process doesn’t destroy enough of the nutritional benefits of raw milk to make raw milk worth the risk. Refrigerate milk products at 40 degrees or colder. Keep your eye on the expiration date. If a product is past this date, throw it out to reduce your chances of getting sick.

Eggs

• The bad guy: salmonella
• How to fight back: Buy and use pasteurized eggs and egg products from stores and suppliers, and never buy cracked or dirty eggs. Cook your eggs thoroughly, until the whites and yolks are firm. If your recipe calls for raw or undercooked eggs, such as Caesar salad dressing or eggnog, make sure you only use pasteurized eggs and egg products. No matter how tempting it may be, do not taste or eat raw batter or dough that contains eggs. Eggs and any foods containing eggs should be refrigerated shortly after cooking. Refrigerate eggs at 40 degrees or colder.

Raw flour

• The bad guys: E. coli and other bacteria
• How to fight back: Most flour is a raw agricultural product, which means it hasn’t been treated to kill bacteria. When you cook with flour, the heat from cooking kills off the bacteria. That’s why you shouldn’t eat raw dough or batter. It’s delicious, but it’s not worth the risk. Just don’t do it.

Now that you’re armed with information, you can take the fight to foodborne illnesses. It’s in your power to protect yourself and your loved ones from sickness.

Generation Rx part of the prescription to treat the opioid crisis

Prescription misuse among teenagers and young adults was the topic of a workshop during the Louisiana Opioid Action Summit held Sept. 4-6. Summit attendees learned about Generation Rx, a free program created to help raise awareness about misuse of prescription pain relievers. Such misuse has been viewed as a key driver of the opioid epidemic, and the Louisiana Department of Health has led efforts to educate physicians about the dangers of overprescribing opioid pain medication.

However, more can be done to educate people from all age groups about the dangers of prescription misuse. That's where Generation Rx comes in. The program has specially designed educational materials targeting five age groups (elementary, teen, college, adult and older adult), with materials for young people that can be used in K-12 education and in higher education.

Nicole Cartwright Kwieck, a clinical professor of pharmacology at The Ohio State University, where Generation Rx was developed, presented during the summit session on teens and young adults. Kwieck said that a team of researchers and professors created Generation Rx after realizing there was a need for better education around prescription drug use — particularly in school settings.

“We do a terrible job in this country teaching people how to use medications,” Kwieck said. “If you think back on your own experience ... you were probably weren't taught in school. You were probably taught by a parent or a loved one, maybe a professional.”

Reaching younger audiences

The core messages communicated through Generation Rx are:

• Only use prescription medications as directed by a health professional.
• Never share your prescription medications with others or use someone else’s medications.
• Always store your medications securely to prevent others from taking them, and properly dispose of medications that you no longer need.
• Be a good example to those around you by modeling these safe medication-taking practices and discussing the dangers of misusing prescription drugs with your family, friends, colleagues, students or patients.

In developing the teen and higher education-focused section of the program, Kwieck said, program authors considered the idea that teens and young adults are often seeking new experiences and may see the risk of any type of drug misuse as compelling. They also tend to overestimate the risky behaviors of their peers, leading to conclusions such as “Everyone else is doing it so I can, too.”

The materials were also developed with the idea that teens often don't respond well to lectures and have short attention spans, so the activities are designed to get “them out of their seats” and highlight the dangers that prescription misuse poses. Activities include a Family Feud-style game, an interactive discussion designed around a PowerPoint presentation and skits that allow participants to act out various scenarios.

Rusty Fornea, who spoke during the session for the Washington Parish-based ADAPT Inc., said the organization deployed Generation Rx in parish schools in the spring and received positive responses. Some of those schools, Fornea said, have asked when Generation Rx will return.

“Once we were able to get it rolling, the facilitators and the youth really enjoyed it because it's interactive,” Fornea said.

Widespread misuse

More than 5,700 Americans misuse a prescription pain reliever each day, according to the National Survey on Drug Use and Health.

While 83% of those prescriptions came from a single doctor, more than half of those misused were obtained through a friend or relative, according to data from SAMSHA. That means that misused prescription pain relievers are often not prescribed to the person taking them, which is helping fuel the opioid crisis and leading to addiction and overdose deaths.

You can learn more about Generation Rx here.

We can all play a role in preventing suicide

By DANITA LEBLANC | LCSW-BACS, LDH Office of Behavioral Health

Each death by suicide has a ripple effect throughout families and communities. Over the last 30 years, the suicide rate in the United States has continued to rise. In this country, 47,173 individuals died by suicide in 2017; that is 129 people per day. That same year, 720 individuals died by suicide in Louisiana.

Suicide is generally not on your radar until it affects you personally. Even when a family member or friend is showing warning signs, it can be difficult to talk about. Oftentimes small gestures can make a big difference.

Family, friends and co-workers often see that someone is in distress before professionals become aware of them. We can learn to be alert to the signs that someone might be thinking of suicide, we can learn how to ask about suicide, we can help keep someone safe, we can be there for them and we can learn how to connect them to help.

Some warning signs that someone may be having thoughts of suicide include:

• Talking about wanting to die or to kill oneself
• Looking for a way to kill oneself, such as searching online or buying a gun
• Talking about feeling hopeless or having no reason to live
• Talking about feeling trapped or in unbearable pain
• Talking about being a burden to others
• Increasing the use of alcohol or drugs
• Acting anxious or agitated; behaving recklessly
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings
• Sudden improvement after having been depressed

Five action steps

We can all have a role in preventing suicide. The #BeThe1To campaign encourages these five action steps to prevent suicide.

1. ASK: Ask directly about suicide in a way that sounds like you want to know the answer. Studies show that asking at-risk individuals if they are suicidal does not increase suicide or suicidal thoughts. Direct questions like “Are you thinking about suicide?” or “Are you thinking about killing yourself?” communicate in a supportive and non-judgmental way that you are open to talking about suicide. You could also let them know what you see, hear, sense or learn about them that provides you with clues that something isn’t right.
   
   Example: Mary, I’ve noticed you seem distressed and have been keeping to yourself since your house flooded. Sometimes when people have had a traumatic experience like that, they think about suicide. Are you thinking about suicide?
   
   Take them seriously. Listen while they talk about the situation causing them emotional pain. Also listen for any potential reasons they want to stay alive. Both are important. Do not impose your reasons for why they should want to live; help them focus on their reasons.
   
2. KEEP THEM SAFE: Once we agree that suicide is the focus, we need to know a few things about how to keep them safe. To figure out how to keep them safe, we need to know more about the situation and their plan. Have they already done anything to try and kill themselves? Have they thought about how they would kill themselves? Is the plan detailed as to what, when and where? The more detailed the plan is, the higher the severity of risk.
   
   Reducing a person’s access to highly lethal means that they plan to use to kill themselves is an important part of suicide prevention. Keep the person safe by putting time and distance between the person and their chosen method. Over 40% of the time, the decision to act on thoughts of suicide and the act of suicide is less than 10 minutes.
   
3. BE THERE: Support the person at risk of suicide. Stay with them or help connect them to other support. Is there someone else in the person’s life who is available, willing and able to help if needed? Being there could mean being physically present or speaking with them on the phone, or any other way that shows support. Actively listen to what they say and let them know you hear them. Make sure you follow through on whatever you say you will do. Do not commit to anything you are not willing to do.
   
4. HELP THEM CONNECT: Help the person with thoughts of suicide connect with ongoing supports that can help them establish a safety net for those moments they find themselves in a crisis. The National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) will connect you to the crisis call center closest to you based on your area code. If texting is preferred, text to 741741; the website www.crisistextline.org has information on what happens when the text is used. If it is an emergency, contact 911 or go to the nearest emergency room.
   
   Explore some possible supports with the person in crisis. Are they currently seeing a mental health professional? Have they in the past? Is this an option for them currently? Are there other mental health resources in the community that can help? Is there an Employee Assistance Program at the person’s workplace? In Louisiana, local governing entities responsible for behavioral health and developmental disability services may be able to help.
   
5. FOLLOW UP: After your initial contact with the person experiencing thoughts of suicide and after you have connected them with the immediate support systems they need, follow up with them to see how they are doing. Leave a message, send a text or give them a call. The follow up step lets you check in with them to see if additional support is needed and conveys caring and concern to the person thinking about suicide. This contact can also contribute to increased feelings of connectedness.

If someone you know is struggling, don’t be afraid to reach out to them. Each of us can be the one to help.