Introduction: The Center for Disease Control defines injury as bodily harm resulting from severe exposure to

Transcription

1 Tyler Adamson MPH Introduction: The Center for Disease Control defines injury as bodily harm resulting from severe exposure to an external force or substance (mechanical, thermal, electrical, chemical, or radiant), where intent is determined by the nature of the injury and the mechanism by which it happens (Center for Disease Control and Prevention 2007). For example, injury related to falling is considered unintentional, since rarely does an individual fall on purpose, or with the intent to injure oneself. In comparison, injuries related to interpersonal or collective violence are classified as intentional injuries, since there is an intent to harm. In the United States, unintentional injury (UI) remain the fourth leading cause of death overall, but the first for ages 1-44 leading to 136,053 deaths in When you calculate the costs associated with medical treatment and work loss are combined, this equated to over $113 billion lost as of 2010 (CDC 2005). Unintentional injuries continue to plague American Indian and Alaskan Native (AI/AN) communities across the United States as well. UIs remain the leading causes of death for AI/ANs ages 1-54, and the third overall. AI/AN people are also 1.4 to 3 times more likely than their non-hispanic, White counterparts to die from the 3 leading causes of unintentional injury; poisoning, motor vehicle traffic, and falls. (Murphy, Pokhrel, Worthington, Billie, Sewell, Bill 2014; Warner, Chen, Mkuc, Anderson, & Minino 2008). In 2016, this corresponded to 2,265 deaths and 52,388 Years per Life Lost (YPLL) or 26.6% of the total, and more than the next 3 causes combined (Center for Disease Control and Prevention 2005). This is of noteworthy concern since many of these injuries are indeed preventable. However, for many areas, with those on Tribal Lands being no exception, rurality and slim resources make it even more difficult to design, develop, and implement strategies for addressing such disparities. Define the Problem: Unintentional poisoning (UP) remains a major problem in the US, yet as of recent there have been even more elevated levels of such, partially attributed to opioids. Which are of grave concern, and

2 one that is not receiving attention commensurate with the true magnitude of the matter; some of which may yet to be fully realized. Increased levels of unintentional poisoning are a widespread issue throughout the country, but rural and marginalized regions have been hit especially hard by this epidemic. From 1999 to 2004, death from unintentional poisoning in urban ( large central metro ) counties, increased by 51%, while rural ( noncore, nonmetropolitan ) counties increased 159% (Monnat & Rigg 2016, Paulozzi & Li 2008). This is further reflected in AI/AN communities, often rural, with poisoning death rates among AI/AN persons being higher than Whites in all Indian Health Service (IHS) regions except the East (Murphy, Tierney et al 2014). In 2010, deaths due to unintentional poisoning cost $42.6 billion in costs from medical treatment and work loss nearly 38% of the total cost of all injuries that year. That comes out to over $671 million dollars for AI/AN communities alone (CDC 2005). And in 2016, unintentional poisoning accounted for nearly ¼ of total YPPLs in AI/AN people, second only to unintentional motor vehicle traffic (CDC 2007). These striking figures are but a small sample to highlight just how rampant such matters have become in these populations. Unfortunately for those residing in places like the Western US (Washington, Montana, Alaska etc) and others, these regions remain at the forefront of the epidemic accounting for more than 50% of total American Indian and Alaskan Native deaths attributed to unintentional poisoning in 2016, despite only representing a quarter of the United States. What then, makes these communities, and the individuals who reside in them, more at-risk for unintentional poisoning than others? Identify Risk Factors: For most of the United States, the burden of deaths from unintentional poisoning falls on people aged 20-35, however for the Western region, the burden shifts to mostly on the middle-aged and elderly, ages (CDC 2005). And as mentioned previously, individuals who live in more rural areas are at higher-risk than their more urban counterparts (Muazzam, Swahn, Alamgir, & Nasrullah 2012), which is only exacerbated by other various socioeconomic factors, including but not limited: poverty, unemployment, education, access to health care, and differences in medication dispensing policies

3 (NSDUH 2012). For the middle-aged and elderly, chronic pain management remains an issue and often patients will have multiple prescriptions for medication, which will leave them more susceptible to unintentional poisoning (Dunn, Saunders, Rutter, Banta-Green, Merrill, Sullivan, & Korff 2010). This susceptibility becomes more severe when individuals from this age group also have dementia, Alzheimer s, or other serious conditions that may cause cognitive decline (Zhang, Hongping, Wei, Feng, Han, Mo, Chen, Jianquan, Peng, Songxu, Du, & Yukai 2017). For Americans Indians and Alaskan Natives in this age group, many happen to live in more rural areas where resources are limited, and for those that are available, they are often overwhelmed, so individuals may fall through the cracks more easily. Potential Prevention Program: Since most of the unintentional poisonings that happen in this demographic (AI/AN, 50-64) in the Western United States is related to prescriptions, it is only appropriate that an intervention seek to target the circumstances surrounding this issue. It s imperative however, that any potential intervention proposed in American Indian and Alaskan Native communities regarding unintentional poisoning, is done with and for the community. Which means including them throughout the entirety of the development and implementation process. Before any development or proposal can be developed, it s crucial to understand the factors in play that affect behaviors that can lead to unintentional poisoning; to both contextualize the issue, and thereby allow for appropriate intervention activities to address those behaviors. For American Indians and Alaskan Natives aged 50-64, the target behavior that is often the biggest risk factor for unintentional poisoning is multiple prescriptions and adherence, often related to chronic pain management, or other long-standing conditions that require medicines (see Figure 1): Figure 1: PRECEED/PROCEED MODEL Target Behavior Prescription and medication utilization and adherence

4 Predisposing Factors Medication is the first-line method to deal with long-term conditions and chronic pain Primarily Western-medicine focused model of care; leads to overreliance and overutilization of medication Mixed policies on restrictions of prescribing for providers Reinforcing Factors Relief that medication provides Social support and peer influence who may also utilize similar methods for their own conditions Continued prescribing of medication without little to no review Enabling Factors Developing a region-wide, prescription drug monitoring program (PDMP) in conjunction with the IHS Informational campaign and accountability system for communities using local stories and providing medication take back drop boxes Community mobilization and grassroot advocacy for consistent drug and prescribing laws for the entire region The predisposing, reinforcing, and enabling factors that affect prescription and medication utilization and adherence highlight that a potential program to prevent unintentional poisoning in this population must be multi-faceted. That the behavior is not only individualistic, but part of a broader picture that involves providers and social networks (Warner et al 2008). One of the major portions of the interventions, is to develop an area-wide Prescription Drug Monitoring Program (PDMP). Which is a database that tracks prescriptions and controlled substances, and allows for providers and pharmacies to be notified of patients who may be at-risk for poisoning from misuse or excessive numbers of prescriptions. These databases would be enacted at the state-level in conjunction with Indian Health Service facilities so that even if this population was to seek care outside of the IHS, they d still be tracked. Including with this system is the CDC generated Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guideline framework, which is a set of substantiated trainings for providers and informational resources for patients on medication regiments and adherence to avoid unintentional poisoning (Dowell, Haegerrich, & Chou 2016). The second feature of the intervention is community-based, and community-driven. To highlight the impact this issue has had on the community, stories from the friends and family of individuals who ve fallen victim to unintentional poisoning will be collected through focus groups, and with their blessing and permission can then be used develop an

5 awareness and advocacy campaign through multiple forms of media (social, news, radio, etc), town halls, and coalition building, as well as suggest where to place prescription take back drop boxes at local agencies; much like that of Project Lazarus, but community-driven and centered (Albert, Brason, Sanford, Dasgupta, Graham, & Lovette 2011). In the focus groups, community leaders and members will be able to propose alternative, culturally-centered therapy programs for pain management. Additionally, to nominate persons who they believe would be ideal candidates to serve as lay health advisors/accountability buddies for this population of interest. These individuals will help to check-in, accompany, and receiving training on ways to recognize warning signs and people who may potentially be at-risk this group will receive stipends for these roles. Ideally, they would be younger, so that they can support and learn from elders, and help to integrate the education and skills they receive in their own lives and networks, and help to prevent further unintentional poisonings in the future. It s important to reiterate an earlier point - that it s essential to successful, sustainable injury prevention interventions that programs are tailored to specific, to local settings and problems (Murphy et al 2016), and this proposal seeks to do just that. Conclusion: Unintentional injuries remain one of the leading causes of death in the United States this is particularly true for American Indians and Alaskan Native communities throughout the country, with alarming increases in unintentional poisonings as of recent. Individuals ages living in rural communities throughout the Western United States are at elevated risk due to various socioeconomic factors, increased numbers of prescriptions, and access to health care related resources (or lack thereof). Proposed here is a multi-faceted programmatic intervention consisting of local, state, and regional activities designed to help fight the epidemic plaguing these communities. From gathering suggestions for locations of prescription take back locations, to collecting stories from family and friends who ve lost loved ones in this demographic to unintentional poisoning through focus groups. These stories will be used to design educational, informational, and advancement campaigns aimed at raising awareness of the

6 issue and to advocate for clarification and changes in regional laws that dictate the prescribing power of providers. Also in these focus groups is a chance to propose alternative, culturally-centered activities for pain medication, and nominate individuals (preferably younger) who can serve as lay health advisors/accountability buddies to those aged 50-64; to check-in and care for this community, but also in hopes that they ll be able to integrate such training in their own lives and networks, hopefully preventing more unintentional poisonings in the future. Lastly, this prevention suggests implement a prescription drug monitoring program for state and regional agencies, in conjunction with the IHS to better track prescriptions and controlled substances, and furthermore, to provide training to providers and information to patients around prescription management and adherence. This proposal will be tailored to individual communities and tribes before implementation, and will be culturally focused, and community-centered.

7 References : Albert S, Brason FW, Sanford CK, Dasgupta N, Graham J, Lovette B. (2011). Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 12 (Suppl 2): S Centers for Disease Control and Prevention. (2005). National Centers for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Jan Centers for Disease Control and Prevention. (2007). Definitions for WISQARS. Centers for Disease Control and Prevention Dowell D, Haegerich TM, Chou R (2016) CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm;65(No. RR-1):1 49. DOI: Dunn, K. M., Saunders, K. W., Rutter, C. M., Banta-Green, C. J., Merrill, J. O., Sullivan, M. D., Von Korff, M. (2010). Overdose and prescribed opioids: Associations among chronic non-cancer pain patients. Annals of Internal Medicine, 152(2), Monnat, S. M., & Rigg, K. K. (2016). Examining Rural/Urban Differences in Prescription Opioid Misuse Among U.S. Adolescents. The Journal of Rural Health : Official Journal of the American Rural Health Association and the National Rural Health Care Association, 32(2), Muazzam, S., Swahn, M. H., Alamgir, H., & Nasrullah, M. (2012). Differences in Poisoning Mortality in the United States, : Epidemiology of Poisoning Deaths Classified as Unintentional, Suicide or Homicide. Western Journal of Emergency Medicine, 13(3), Murphy, T., Pokhrel, P., Worthington, A., Billie, H., Sewell, M., & Bill, N. (2014). Unintentional Injury Mortality Among American Indians and Alaska Natives in the United States, American Journal of Public Health, 104(Suppl 3), S470 S Paulozzi LJ Xi Y. (2008). Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf;17(10): Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2012). The NSDUH Report: Need for and Receipt of Substance Use Treatment among American Indians or Alaska Natives Warner M, Chen LH, Makuc DM, Anderson RN, Minino AM. (2008). Drug poisoning deaths in the United States, NCHS Data Brief; 81:1-8 Zhang, Hongping & Wei, Feng & Han, Mo & Chen, Jianquan & Peng, Songxu & Du, Yukai. (2017). Risk factors for unintentional injuries among the rural elderly: A county-based cross-sectional survey. Scientific Reports /s