OSHA proposed serious and repeat violations yesterday to Wayne Farms for a variety of safety hazards, including those that led to musculoskeletal injuries among the company’s poultry processing workers. By my calculation, it was the first time in more than a decade that the Labor Department used its “general duty clause” to cite a poultry company for ergonomic hazards.
OSHA conducted the inspection in response to a complaint filed six months ago by the Southern Poverty Law Center on behalf of a group of workers. The complaint described the harsh working conditions in the Jack, Alabama plant, and also provided specifics on management’s retaliation against workers who are injured or complain about hazards. The workers involved in filing the complaint should feel vindicated because OSHA’s citations validate their assertions.
OSHA’s investigation involved staff from its Mobile, Alabama and Atlanta, Georgia offices, as well as the agency’s top-notch ergonomist and occupational medicine physicians. They note that workers in the plant are required to perform:
“prolonged repetitive, forceful tasks, often in awkward postures for extended periods of time.”
Those tasks include cutting wings, cutting shoulders, sawing wins, pulling skin, and pulling tenders.
The OSHA team also identified gross deficiencies in the company’s lockout/tagout procedures. Such safeguards can help to ensure that workers were not caught-in or struck-by equipment when it is being cleaned or repaired. That’s bad enough, but Wayne Farms was cited by OSHA in 2011 for this same violation at one of the company’s other poultry processing plants. For the repeat infraction, OSHA has proposed a $38,500 penalty.
Besides validating the workers’ complaints, OSHA’s citations corroborate what researchers and worker advocates have been saying for decades: Injury rates based on employer self-reporting are works of fiction. OSHA assembled evidence against Wayne Farms on the ways in which the company gamed the system for recording injuries. OSHA’s Mobile, Alabama area director said,
“By failing to report injuries, failing to refer employees to physicians and discouraging employees from seeking medical treatment, Wayne Farms effectively concealed the extent to which these poultry plant workers were suffering work-related injuries and illnesses. And as a result, it reported an artificially lower injury and illness rate.”
I have no doubt that other poultry and meatpacking companies use the same dishonest practices to intentionally deceive the Labor Department and the public about working conditions in their plants. If you haven’t already, you should dismiss any assertions made by the National Chicken Council and other industry groups that poultry slaughtering plants are safe and worker injury rates low. That goes for the safety award given to Wayne Farms in 2011 for its “outstanding safety performance.” The company touts its behavior-based safety program called “WorkSAFE” which
“focuses on helping employees identify unsafe behaviors and remain conscious of their environment and potentially dangerous situations.”
What a bunch of baloney. Workers at Wayne Farms know what causes their injuries. It’s not their “unsafe behaviors.” It’s all about the incessant repetitive motions, fast work pace and deficient equipment in their jobs. These are all things that the company controls, not the workers. The “unsafe behaviors” are the company’s not the workers’.
For me, some of the most powerful language in the OSHA citations is the long list of feasible options the agency offers Wayne Farms to fix the ergonomic hazards. For workers in the chicken deboning area, OSHA explains that the company could:
- increase the recovery of affected body parts through task rotation during the work shift (rotation to tasks without continuous use of a knife, scissors or forceful grip);
- increase recovery time through implementation of mini-breaks, increase cycle time for each task, establish a rotation on a daily basis between departments to increase recovery time (such as rotation between debone and marination);
- provide knives with handles designed for repetitive tasks;
- provide hand tools with textured handles to reduce employee grip force, larger quillons (guard) before the blade to prevent hand from sliding down knife-allowing reduced grip force;
- install mechanical skin removal equipment or provide textured gloves to reduce hand force required in pull skin;
- provide air-assist powered scissors or wing cut;
- position the knife sharpener to minimize non-neutral wrist posture; and
- evaluate employees at each station to determine appropriate work platform height for each employee.
Surely, a firm with more than $1.9 billion in annual sales can afford buying some better hand tools and giving workers rest breaks.
Michelle LaPointe, senior staff attorney with SPLC remarked about the OSHA citations:
“The actions taken by the Occupational Safety and Health Administration go far beyond a company being fined for violations at a single poultry plant,” said Michelle Lapointe, SPLC senior staff attorney. …This is an industry where workers are forced to work at dangerously fast speeds that cause disabling injuries and often thrown away when they can no longer work.”
In a statement to Dave Jamieson of the Huffington Post, Wayne Farms said it is contesting the citations.
OSHA has taken an important step with these citations. It was Labor Secretary Elizabeth Dole in the late 1980’s that put citations for ergonomic hazards on the radar screen. Use of the general duty clause was embraced at the time, but largely abandoned over the last decade. Our government has failed to hold poultry companies accountable for the workplace hazards that cripple the hands, wrists, shoulders and backs of workers. I hope these citations are not an anomaly, but a sign of much more attention to the deplorable working conditions in poultry and meatpacking plants.
Raising the federal minimum wage isn’t only good for workers — it’s good for the federal budget as well, according to a new issue brief from the Economic Policy Institute.
Released earlier this month, the policy brief details just how many low-wage workers have to depend on public assistance programs to make ends meet and how increasing the minimum wage could save billions in federal spending — and those billions could be redirected toward creating stronger, more resilient anti-poverty programs. The brief reports that about half of all workers earning less than $10.10 per hour, the new minimum wage proposed in the federal Fair Minimum Wage Act of 2013, receive public assistance either directly or through a family member via programs such as Medicaid, the Earned Income Tax Credit, the Supplemental Nutrition Assistance Program (also know as SNAP and formerly known as food stamps), the Low Income Home Energy Assistance Program, the Supplemental Nutrition Program for Women, Infants and Children (WIC), the Section 8 Housing Choice Voucher program and the Temporary Assistance for Needy Families program. All of that adds up to more than $45 billion in government assistance each year.
“Essentially, low-wage employers are being subsidized by the taxpayer,” said brief author David Cooper in a news release. “Prices are going up, but paychecks are not, and taxpayers are making up the difference. We’ve long known that raising the minimum wage would help millions of workers and give the economy a boost — now we know it’s a winning idea for taxpayers, too.”
If the minimum wage went up to $10.10, which the federal legislation would do over the span of three years, more than 1.7 million Americans would no longer have to rely on public assistance to meet their basic needs. In fact, the policy brief reported that going up to $10.10 an hour would lower government expenditures by $7.6 billion each year — and that’s a conservative estimate. Overall, safety net programs would save 24 cents for every additional dollar in wages paid to workers who benefit from the minimum wage increase. Right now, accounting for inflation, the current federal minimum wage of $7.25 is about 25 percent less than the minimum wage in 1968. Cooper, an economic analyst, writes:
This failure to adequately raise the wage floor has contributed strongly to the stagnation of wage growth at the bottom of the wage distribution. This wage stagnation has, in turn, been the single greatest impediment to making rapid progress in poverty reduction in recent decades. Indeed, all of the decline in poverty reduction in recent decades can be accounted for by safety net and income-support programs. In fact, managers at some of the largest and most profitable corporations in the United States today actively encourage their employees to seek public assistance to supplement meager paychecks. All of this has led many to conclude that American employers are too often dodging their responsibilities as partners in the social contract — the understanding that Americans who work hard should be paid enough to make ends meet. Instead, too many low-wage employers are leaving both taxpayers and, more importantly, low-wage workers themselves to pick up the slack.
The policy brief examines two methods for estimating how a minimum wage change would affect enrollment in public assistance programs. The first is known as a quasi-experimental design or natural experiment and compares a labor market that did increase the minimum wage to a similar labor market that did not. In this case, Cooper cites a study that examined the effects of a minimum wage increase on SNAP enrollment and spending. That study found that a 10 percent increase in the minimum wage reduced SNAP enrollment by between 2.4 and 3.2 percent and reduced SNAP expenditures by 1.9 percent.
The second research method is known as the simulation method, in which researchers estimate how benefit expenditures would change as hourly wages change, with all else remaining the same. Using this method, Cooper compared the receiving of public assistance among low-wage workers to higher-wage workers and estimated how a raise in the federal minimum wage to $10.10 would affect the use of public assistance programs. He found that increasing the minimum wage would provide about $32 billion in additional wages to more than 27 million workers, which “would unquestionably improve living standards for millions of working families.” He also found that a $1 hourly wage increase would be expected to reduce the average annual benefit dollars received from all safety net programs by $126 per affected worker. In total, a minimum wage raise could save the nation $7.6 billion in safety net spending.
Cooper noted in his conclusion that the safety net programs explored in the brief are critical for struggling families and “if anything, these programs are in need of expansion.” However, he also wrote that it’s time to call on employers to do a better job.
“As American businesses achieve record profit levels, we have to question whether it is appropriate to rely more and more heavily on safety net programs as the sole policy tool to raise working individuals’ incomes or whether we should expect more from the businesses that employ them,” Cooper writes.
To download a full copy of the policy brief, “Raising the Federal Minimum Wage to $10.10 Would Save Safety Net Programs Billions and Help Ensure Businesses are Doing Their Fair Share,” visit the Economic Policy Institute.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
A new Data Note about Kaiser Family Foundation survey findings highlights how this country’s lack of nationwide paid sick leave places a disproportionate burden on women with children – and is particularly hard on low-income mothers. In Balancing on Shaky Ground: Women, Work and Family Health, Usha Ranji and Alina Salganicoff begin by noting that 70% of mothers with children under 18 are in the labor force. Then they report the results of survey questions on who takes charge of children’s healthcare and whether they have paid leave time to fulfill these responsibilities.
The 2013 Kaiser Women’s Health Survey (I wrote about some of its other findings here) and the 2013 Kaiser Men’s Health Survey asked respondents with children under 18 questions about who usually takes children for doctors’ appointments and cares for sick children. Eight-one percent of mothers reported that they’re usually the ones taking children for doctor’s appointments, and 39% said they’re usually the ones to take care of sick children (another 33% said it’s a joint responsibility). Among fathers, 16% responded that they usually take children for doctor’s appointments. And just three percent of fathers reported that they are usually the ones to take care of a sick child. Another 42% said it’s a joint responsibility.
“Caring for children’s health has tangible economic consequences, especially for women,” Ranji and Salganicoff write. Of the 39% of working mothers who must miss work to care for sick children, 60% of them report that they don’t get paid for the time they have to take off. And this percentage is significantly higher than the 45% of respondents who reported in the 2004 survey that caring for a sick child means missing out on pay.
The Data Note doesn’t speculate on why we’re seeing this increase in the percentage of working mothers who don’t get paid for the time they spend out of work caring for sick children. My guess is that the recent economic downturn and uneven recovery have left more women working in jobs that don’t offer paid sick leave. There’s a clear pattern to what kinds of jobs those are.
The third set of statistics in the Data Note adds to existing evidence that women who have lower incomes and work part-time are less likely to get paid sick leave from their employers. Seventy-one percent of working mothers with incomes at or above 200% of the federal poverty level report that their employers offer them paid sick leave, compared to just 36% of working mothers with incomes below 200% FPL. Seventy percent of full-time workers, compared to 25% of part-time workers, report having this benefit.
A recent analysis of the 2013 National Health Interview Survey by the Institute for Women’s Policy Research found that only 21% of workers in Food Preparation and Serving Related occupations and 28% of workers in Personal Care and Service reported having paid sick leave. To limit the spread of disease, it’s important for food workers and childcare providers to be able to stay home when they have the flu or another transmissible illness. When missing work means losing pay, however, many workers can’t afford to stay home and recover from their own illness, or care for a child who’s home sick from school. This is one of the reasons the American Public Health Association has adopted a policy statement calling for the US to improve access to paid sick and family leave.
The good news is that voters and legislatures across the US are acknowledging that if we want to encourage both work and good parenting, we need to make it possible for workers to stay home to recover from an illness or care for a sick child. Several cities have passed laws requiring employers to let workers earn paid sick time, and last month California became the second state to mandate paid sick days. (Connecticut was the first, although its law only applies to businesses with 50 or more employees.) Next week, Massachusetts voters will determine the fate of a ballot measure requiring paid sick days statewide.
I’m hopeful that in future Kaiser Family Foundation surveys we’ll see fewer working mothers reporting that they don’t get paid for time spent caring for sick children, and a disappearing gap in paid-sick-leave access between lower- and higher-income women. That would be good news for working women, and for public health.
Despite substantial public opposition and the “grave concerns” of about 50 members of Congress and significant unanswered questions about human and environmental health impacts, the Environmental Protection Agency (EPA) has approved a new herbicide called Enlist Duo for use on genetically engineered corn and soybeans in Illinois, Indiana, Iowa, Ohio, South Dakota and Wisconsin. EPA, which says it has approved Enlist Duo “to manage the problem of resistant weeds” is now considering approving Enlist Duo for use in ten more states: Arkansas, Kansas, Louisiana, Minnesota, Missouri, Mississippi, Nebraska Oklahoma, Tennessee and North Dakota.
Immediately following the EPA announcement, the Natural Resources Defense Council (NRDC) filed suit in the US Court of Appeals for the DC Circuit to block the registration of the new weed killer. A week later, on October 22nd, a coalition of farmers and environmental organizations – the National Family Farm Coalition, Center for Food Safety, Environmental Working Group, Earthjustice, Pesticide Action Network North America, Beyond Pesticides and the Center for Biological Diversity – filed suit in the Ninth Circuit Court of Appeals in San Francisco on behalf of their membership in the six Midwestern states where the herbicide would be used. They are also seeking to block the EPA’s approval of Enlist Duo. Both lawsuits contend that the EPA failed to adequately assess the herbicide’s impacts on human health and wildlife, including imperiled monarch butterflies.
Manufactured by Dow AgroSciences, Enlist Duo combines glyphosate – the active ingredient in Roundup, the most commonly used herbicide in the US – with what’s called a choline salt of 2,4-D – the country’s third most widely used herbicide. Enlist Duo would be used on corn and soybean seeds genetically engineered to withstand this herbicide combo. The US Department of Agriculture (USDA) approved these seeds last month. The aim of Enlist Duo is to tackle weeds that have become resistant to glyphosate that is now used on about 94 percent of the corn and about 89 percent of the soybeans planted in the US. The new seeds have been engineered to resist 2,4-D as well as glyphosate. A DowAgro Sciences press release calls the EPA’s approval of Enlist Duo, “a true victory for farmers” now grappling with glyphosate-resistant weeds across tens of millions of acres of American farmland.
2,4-D is already widely used on a wide variety of edible crops, landscaping plants, and lawn, pasture and turf grasses. Its use in Enlist Duo on the genetically engineered corn and soy could significantly increase use of 2,4-D, say both the EPA and USDA. In 2011, about 5 percent of US corn was sprayed with 2,4-D, which was used on about 11 percent of soybeans planted. In the Midwest where it’s been used most intensively, 2,4-D has drifted away from fields where it has been applied, contaminating surface and groundwater. Weeds resistant to 2,4-D have already be found in the Midwest. Through Enlist Duo, the Department of Agriculture expects 2,4-D use could grow by as much as 300 to 700 percent by 2020.
Human health concerns and data gaps – no exposure monitoring required
In studies with laboratory rats, 2,4-D has been linked to adverse effects that include reproductive, hormonal and other health impacts. 2,4-D itself is considered a synthetic hormone works to kill plants by disrupting the way certain plant cells grow. A number of human epidemiological studies – of farmers in Kansas and Nebraska and of California farm workers, among others – have found links between 2,4-D use and increased risk for non-Hodgkin’s lymphoma. But EPA’s assessment of Enlist Duo’s toxicity, gives the herbicide a pretty clean bill of health.
In its approval documents, EPA explains that it looked only at environmental and health effects of Enlist Duo’s 2,4-D component as it is that ingredient’s use that the agency considered “new” for regulatory purposes. Because glyphosate is already widely used on corn and soy and that ingredient wasn’t changing, EPA didn’t reassess those environmental health effects and concentrated on looking at impacts of expanding 2,4-D use.
The EPA says that, “When used according to label directions, Enlist Duo is safe for everyone, including infants, the developing fetus, the elderly and more highly exposed groups such as agricultural workers” and “safe for the environment, including endangered species.” The details of EPA’s approval documents, however, raise some questions about that safety. Studies reviewed by EPA show that there is evidence of 2,4-D’s adverse effects to the kidney, liver, thyroid and reproductive system when high doses were given to laboratory rats. Such exposure also produced effects on the adrenal glands, various hormones, metabolism and neurological function. The EPA also reports that in rats, lower levels of exposure produced what might be described as subclinical effects on thyroid function. These lower exposures also produced adverse nervous system and kidney effects, gait abnormalities, birth defects and lower birth weights. Previous EPA assessment of 2,4-D have found links to cancer inconclusive.
Yet in addition to an association with non-Hodgkin’s lymphoma, in studies of farmers who worked with 2,4-D, the herbicide has also been linked to suppressed immune system function, thyroid problems, lower sperm count and increased risk for Parkinson’s disease , as noted in a June 2014 letter from nearly three dozen scientists and physicians to EPA Administrator Gina McCarthy asking EPA not to approve Enlist Duo.
While the types of crops on which Enlist Duo will be used involve less labor of the type that would expose agricultural workers and its chemical ingredients are less toxic than some other widely used pesticides, enforcement of use requirements will be critical to minimizing drift and human exposure, says Migrant Clinicians Network Director of Environmental Health, Amy Liebman. Further, she says, “It is our long-held contention that chemicals should not be put on the market without a way to monitor exposure, particularly for applicators.” Approval of Enlist Duo does not include any requirements for human exposure monitoring.
Despite the lab study results, the EPA did not find any exposure risks of concern for those mixing, applying or otherwise handling Enlist Duo. And because of what EPA describes as the “low acute inhalation toxicity” for 2,4-D choline salt, it did not perform “a quantitative occupational post-application inhalation exposure assessment.” EPA also found no concerns posed by skin contact.
The agency assumes that because there is no concern for health risks to those handling and applying the herbicide, there would also be no health risks for those inhaling Enlist Duo in the field after it is applied. Using the same logic, EPA says there is no risk from such inhalation to bystanders.
Despite these conclusions, labeling requirements for Enlist Duo tell a different story. These say that “only protected handlers may be in the area during application” and no one should enter treated fields for 48 hours after the herbicide has been applied without personal protective equipment. Specified protective gear includes chemical-resistant gloves and protective eyewear, such as goggles, safety glasses or a face-shield. A Dow AgroSciences’ Material Safety Data Sheet (MSDS) also says: “After using this product, remove clothing and launder separately” and to promptly wash any exposed skin and to remove all clothing and shower after work and to launder any protective clothing separately from other household laundry.
Lack of proper training in pesticide use worries Jeannie Economos, Pesticide Safety and Environmental Health Project Coordinator with the Farmworker Association of Florida. “Farm workers that are not properly trained are likely to risk very dangerous take-home exposures,” she says and unknowingly expose their families.
Drift and other exposures
A big concern for human health and environmental exposure to Enlist Duo is drift, explains Bill Freese, Science Policy Advisor with the Center for Food Safety, a Washington, DC-based non-profit. In its approval of Enlist Duo, the EPA explains that the herbicide has been formulated to reduce volatility and hence drift. EPA also explains that the amounts of 2,4-D that would be used via Enlist Duo present no risks of concern from drift. Yet to minimize potential drift , EPA specificies that Enlist Duo can only be applied when wind is 15 miles per hour or less and with 30 foot buffer zones.EPA’s use instructions also caution against applying the herbicide during temperature inversions as that could increase risk of drift. Dow AgroSciences’ MSDS further says to prevent runoff, application should be avoided when heavy rain is forecast. Freese points out that pesticide application during high winds is common and that historically, 2,4-D has been frequently implicated in herbicide drift.
While the new formulation is supposed to minimize drift, other changes in how 2,4-D can be used in Enlist Duo have the potential to increase exposure. NRDC notes that Enlist Duo can be used during more of the growing season than was allowed for 2,4-D and thus “could mean wider human exposure.” On its own, 2,4-D was approved for use only on very short plants and could be applied “over-the-top” only on corn plants up to 8 inches tall and as a “pre-plant” application on soybeans. In its Enlist Duo formulation, 2,4-D can be used “over-the-top” on corn pants up to 48 inches tall and “over-the-top” on the soybean plants. A question to be asked is what the exposure potential would be for corn detasseling crews – that in the Midwest are often made up of teen-agers as young as 13 – that work during hot summer months, if adjacent fields are in the process of being treated.
Left unanswered in EPA’s Enlist Duo toxicity assessment, is that of effects of cumulative exposure to Enlist Duo and other pesticide chemicals. The EPA explains that it did not do such an assessment because it does not think 2,4-D behaves biologically in the same way as other herbicides and pesticides. But without exposure monitoring for Enlist Duo, it will be almost impossible to know if farm workers have been exposed, whether to this chemical formulation alone or in combination with others. And as Economos points out, “farm workers do travel,” so could be exposed to a variety of pesticides in multiple locations.
Unless the NGOs’ lawsuits prevail, Enlist Duo is poised to be used across great swaths of the American landscape, with uncertain health effects and even less information about where and to what extent people are being exposed. The EPA is accepting comments on its approval of Enlist Duo in the ten additional states until November 14, 2014.
Elizabeth Grossman is the author of Chasing Molecules: Poisonous Products, Human Health, and the Promise of Green Chemistry, High Tech Trash: Digital Devices, Hidden Toxics, and Human Health, and other books. Her work has appeared in a variety of publications includingScientific American, Yale e360, Environmental Health Perspectives, Mother Jones, Ensia, The Washington Post, Salon and The Nation.
A Q&A with public health leaders on the opioid epidemic: ‘Prescription opioid abuse is still raging out of control’
The statistics describing America’s prescription drug abuse epidemic are startling, to say the least. Here are just a few statistics from the Centers for Disease Control and Prevention: In 2009, prescription painkiller abuse was responsible for nearly half a million emergency department visits — a number that doubled in just five years. Of the more than 41,000 drug overdose deaths in the U.S. in 2012, more than half were related to pharmaceuticals. In 2012, U.S. health care providers wrote enough painkiller prescriptions — 259 million — to provide every, single American adult with their own bottle of pills. Prescription painkiller abuse cost the nation more than $55 billion in 2007 alone.
While pharmaceutical companies are making billions in painkiller profits, it’s the public sector that ends up bearing the burden and cost of the widespread fallout that accompanies skyrocketing sales of highly addictive prescription opioids. Law enforcement, criminal justice, health and behavioral health care systems, and state and local public health departments are now on the front lines of an addiction and overdose crisis that continues to spiral out of control. And in addition to the painkiller problem, many state and local officials are reporting spikes in the use of another, more notorious opioid: heroin.
A handful of those frontline responders came together for a congressional briefing on the opioid epidemic in September and called on federal policy-makers to take a more concerted and coordinated effort to address a problem that, on more than one occasion, has been described as a public health crisis. Organized and hosted by the Big Cities Health Coalition (BCHC), the Sept. 16 briefing — “The Opioid Epidemic: Reporting from the Front Lines of America’s Big Cities” — featured insights and remarks from Barbara Ferrer, who until recently served as executive director of the Boston Public Health Commission; Bechara Choucair, commissioner of the Chicago Department of Public Health; and Mary Travis Bassett, commissioner of the New York City Department of Health and Mental Hygiene.
All three described their city’s experience in grappling with the opioid epidemic — click here to watch a video of their remarks. Chicago, in particular, has taken direct action against the pharmaceutical companies that manufacture painkillers. In June, the city filed a claim against five drug companies seeking compensation for damages and for the companies to forfeit revenue stemming from fraudulent marketing claims that pharmaceutical opioids are rarely addictive.
During the briefing, the BCHC members called for three specific federal actions. The first is passage of a federal Good Samaritan Law, which would among other measures, give legal protection to those who intervene in a drug overdose. The second is increasing access to naloxone, a drug that can effectively reverse the effects of an opioid overdose and can be easily administered by first responders as well as friends and families of those struggling with opioid addiction. The third action is the creation of a federal interagency task force to address insurance barriers to addiction treatment. (Increasing funding for addiction treatment services may be a particularly challenging goal. A recent study found that the public has significantly negative views of drug addiction, with 43 percent of adults in a nationally representative survey saying they oppose insurance parity for drug addiction.)
Below is a Pump Handle (PH) Q&A with two public health officials at the forefront of the opioid epidemic within America’s big cities: Choucair of the Chicago Department of Public Health and Hillary Kunins, assistant commissioner at the New York City Department of Health and Mental Hygiene.
PH: Opioid use and overdose has been at crisis levels for some time now. Why did the BCHC decide to host a congressional briefing now? Are we at a particularly critical point in the epidemic?
Choucair: Cities have been on the front lines of the opioid crisis for more than a decade. Despite our best efforts, prescription opioid abuse is still raging out of control. In Chicago, we work to help residents in recovery, but we are also looking upstream to help stop the problem before it starts. We know drug companies have engaged in deceptive practices and downplayed the risk of addiction when it comes to prescription opioids — leading many good, law-abiding people to become addicted to prescription drugs or turn to the streets to seek out heroin. This is why Mayor (Rahm) Emanuel and Chicago have filed suit against Big Pharma to require all companies to accurately represent the risks of these drugs and ensure doctors and patients can make informed choices about their care.
Even with these innovative steps, there is still a huge challenge ahead of us. Just (recently), the CDC reported 17,000 annual deaths from overdoses and a rise in heroin use, linking these numbers directly to prescription painkillers. Cities can’t fight this battle alone. We need all hands on deck if we are going to win, including increased leadership from the federal government.
PH: Is federal action to expand access to naloxone preferred to state and local action? Or do we need a combination of both? Are you concerned that federal action may prevent local health officials from designing and tailoring a naloxone program to fit their community’s needs?
Choucair: We need all hands on deck if we are going to win, with cities, states and the federal government working together. Expanding access to naloxone is a vital and life-saving step. In Chicago, fire fighters and emergency medical technicians are armed with naloxone, which has been proven to save lives. Action on the federal level can sidestep two barriers some municipalities face: cost and outdated attitudes towards addiction. The first, cost, reflects the sad reality that local health departments are more likely than state and national health agencies to be restricted to incredibly tight budgets that might not allow for the addition of naloxone purchases. The second, outdated attitudes towards addiction, results in municipal governments refusing to support the use of naloxone out of the mistaken belief that the existence of a lifesaving antidote will encourage abusive drug behavior. This theory has been thoroughly debunked by scientific research, and we hope that national action will erase gaps in medical coverage for both overdose and addiction treatment.
Kunins: Both federal and state action is needed to increase access to naloxone for those at high risk of witnessing an overdose. A federal law that allows laypersons to carry and use naloxone, as we have in New York state, would increase access to naloxone greatly. In addition, (a) Good Samaritan law, which we are fortunate to have in New York State and which protects individuals from drug-related prosecutions in the setting of a drug overdose, should be adopted nationally. Finally, over-the-counter access to naloxone would be another way to facilitate access to and availability of naloxone to reverse overdose. These federal policies would help, not hinder, local health officials to prevent overdose in their communities. Knowledge of the local context, including opioid overdose trends and stakeholders, could be used in a synergistic way to tailor naloxone programs to the community’s needs.
PH: Some communities that have successfully curbed the illicit flow of prescription painkillers have experienced an increase in heroin use. A few months ago, I interviewed a local health official who told me that after successfully restricting the flow of painkillers, there was a nearly 100 percent switch to heroin among clients at the local needle exchange. What does a story like this tell us about the importance of addressing the opioid epidemic in a comprehensive way instead of focusing on either painkillers or heroin separately?
Choucair: Addiction to prescription painkillers and addiction to heroin are one and the same — both in terms of the chemical effects and their ability to ruin lives, tear families apart and kill the individuals using them. We are very concerned about individuals moving from prescription painkillers to heroin in response to either the lower price or the reduced availability of prescription drugs, which is why both the Big Cities Health Coalition and the City of Chicago have made addiction treatment such a high priority. Unless our public health and health care agencies are able to successfully intervene and rehabilitate an individual misusing prescription drugs, we will be turning addicts out onto the street in search of other alternatives.
Kunins: Using a comprehensive strategy to address the public health crisis related to opioids is very important. In New York City, we have taken a multi-pronged, public health response, including developing an innovative drug surveillance system, promoting safe and judicious opioid prescribing, promoting overdose prevention with naloxone, improving access to addiction treatment and conducting public education media campaigns. Although we have seen an increase in heroin overdose deaths the past three years in New York City, our data do not suggest that initiatives to limit opioid analgesic prescribing caused this trend, given that heroin overdose deaths began to increase prior to implementing these prescribing initiatives. Additionally, we are conducting real-time qualitative studies in the community to better understand this problem and we are finding that several patterns of new heroin users exist (not only those who transition from opioid analgesics to heroin). This is a complex story that is unfolding. A comprehensive public health response will help to understand and reduce overdose deaths.
PH: In efforts to prevent the diversion of prescription painkillers and refine prescribing practices, how can we ensure that legitimate chronic pain patients don’t get caught in the middle? Are you concerned that fewer and fewer doctors will be willing to prescribe painkillers to those who need them?
Choucair: I am a family physician, and I will be the first to say that we do not want painkillers to be banned or made unavailable for those patients for whom it is appropriate. We have gone too far in one direction by making prescription painkillers the first, most common, and often only method of pain management. Prescription painkillers should be used to address temporary pain in conjunction with other treatments, like physical therapy. Prescription painkillers are not appropriate for long-term or chronic pain in individuals who are not terminally ill, and physicians need to be more rigorous in screening for abuse risk factors.
Kunins: It is important to address patients’ concern for pain in a comprehensive and safe way. Although there is still a role for opioid analgesics in certain painful conditions, they are not always the appropriate treatment. In fact, for chronic pain that is not related to cancer, there is insufficient evidence for pain relief or improved function from long-term opioid use; however, there is a substantial risk for addiction and overdose. Efforts to promote safe and judicious opioid prescribing should be evidence-based and should encourage prescribers to carefully weigh the serious risks of opioid analgesics against possible benefits to the patient. In New York City, we urge consideration of non-opioid therapies to treat pain, whenever possible. However, if after thorough consideration of the risks versus benefits, opioids are prescribed, they should be for evidence-based indications, shorter durations and lower doses. This approach limits unnecessary exposure to opioid analgesics on the population level, preventing addiction and overdose, yet supports safe and appropriate treatment of pain.
PH: Public health officials are on the forefront of addressing the opioid use and overdose epidemic, yet we seem to hear little from the medical community, which is a key player in this problem. Are you hearing from physicians in your community who want more education and resources to help them responsibly prescribe painkillers? Do physicians in your community seem eager to help solve the problem?
Choucair: I am a physician and I can tell you I am concerned. Furthermore, physicians from around the country have reached out to me and expressed support for our efforts in Chicago. If you haven’t heard much from medical institutions yet, I expect you will soon. Public health officials and physicians are partners in this effort, as are policy-makers and community leaders — at every level.
Kunins: In New York City, we conducted office-to-office educational visits with more than 1,000 health care providers in Staten Island, our hardest-hit county. During these visits, we promoted our guidelines for safe and judicious opioid prescribing, provided resources and tools to implement these guidelines and received feedback. Providers were enthusiastic about our educational guidelines and were motivated to learn strategies to help address this serious problem.
To learn more about the Big Cities Health Coalition and its efforts to address prescription drug abuse as well as to access video from the September congressional briefing, click here. To learn more about the nation’s opioid epidemic, visit the Centers for Disease Control and Prevention.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.