Public Health Officials are Overwhelmed!

Those of us who work on alcohol policy are wondering what has happened to the public health perspective. Many states are considering legislation to change alcohol regulation– often characterized as “modernization.” These debates are often couched as “economic development” but very rarely is there any opposition, perspective, or comment from the public health community. And, there is almost no discussion of the harm alcohol causes and the likely consequences of loosening our regulations. Legislators are very focused on creating jobs and tax revenue. Good government policies really need a balanced debate and to have public health officials to weigh in.

But, they are overwhelmed with the current opioid overdose epidemic. Indeed, it is shocking. In 2015 there were 52,404 overdose deaths and 2016 is likely to overshoot that amount. Many started with a legal prescription for pain killers, but became addicted. As pain killers became harder to get, some switched to heroin or other street drugs. The main overdose culprits are illegally obtained prescription drugs, synthetic opioids (fentanyl) and heroin. Deaths due to synthetic opioids increased 72% from 2014 to 2015 and heroin deaths went up 21%. There are recent incidents where fentanyl is sold as heroin and is mixed with cocaine. After all, you never are sure what you are getting from an illegal drug dealer! Even more horrifying is the recent appearance in street drugs of carfentanil, an elephant tranquilizer, 5,000 times stronger than heroin.

But, there are good reasons to pay attention to alcohol. According to the Centers for Disease Control, alcohol is still responsible for an estimated 88,000 deaths each year. Treatment issues, whether prescription drugs or alcohol, require a comprehensive approach. When I worked in prevention, I had an intern who said her mother was a meth addict. I asked what she meant by “was a meth addict.” She replied that her mother had kicked meth, but now was “just an alcoholic.” In fact, people with addictions frequently mix substances— legal and illegal. If alcohol becomes cheaper, less regulated and more available, addicts may be encouraged to use alcohol more frequently.

Many of the solutions proposed for the drug epidemic are not unlike those for alcohol: reduce access, expand treatment, and support law enforcement. Unfortunately, these tend to be long-term changes which may not have the immediate impact we seek. A nurse my daughter knows said she sees people every day seeking prescription pain killers. Few believe they are dependent on such drugs. Denial is one of the major obstacles to getting people the help they need.

Maybe we should broaden our approach. While we must continue to reduce access, expand treatment and support law enforcement, it may be time to consider ways to change our permissive culture around substance use and the practice of “getting wasted.” I recently saw a movie about a bachelorette party where the women got completely “wasted” on large amounts of cocaine! Why would such a dangerous practice be considered okay or funny?

We now have some successful models that involved culture change to consider. Our efforts to reduce underage drinking and drunk driving both involved culture change and both have resulted in major reductions. Remember when underage drinking was considered inevitable and a “rite of passage.” That has changed. Reducing this problem took a long time and a lot of work from community partners, but it was an exceptionally successful effort as youth are now drinking at historically low levels. This should serve as a model of what is possible. Here are some ideas about cultural issues that could be addressed:

1. Educate our citizenry about the danger of self-medication to mask both physical and mental paint. We need a better understanding of the role pain plays in life. I remember attending a conference in Africa and learning that African children are taught how to bear pain. I was struck by that because I don’t believe we teach our children this same thing. Too often pain is to be curtailed with a pill or some other substance. Yet, pain has important messages. When you break a bone, it is painful. The message is: go immediately to a doctor to fix it. In reality, pain is part of healing. Relationships that cause you pain may suggest a course correction. We all will lose loved ones at some point and must be able to go on with life. As a society we need a better understanding of when medication is appropriate for dealing with pain. After all, no one should expect a pain-free existence.

2. Support efforts to promote a “better drinking culture. Groups are springing up that advocate for “mindful drinking.” The focus is on drinking less but higher quality products. Such a group is betterdrinkingculture.org. According to their website, they are “a grassroots movement of people who love craft beer, spirits, and wine.” Their desire is “to shift our culture’s relationship with alcohol in a healthier and more positive direction—a lifestyle free from hangovers, pain, harm, and regret.”

3. Be like the Irish! Seriously! Irish youth are drinking at historically low rates. According to the European School Survey report (ESPAD), 15-16 year olds in Ireland use alcohol 48% less and binge 40% less than previous generations. One commentator noted that “Ireland is being hit by a wave of sobriety.” In 2005, Ireland consumed 14.41 liters per capita; in 2016, that dropped to 10.9 behind the British, French and Germans. Suggested reasons for the change include: the recession which ushered in a certain amount of austerity; the health and exercise craze; and, the fact that there are now alternatives to alcohol in pubs such as good tasting non-alcoholic beer.

But we still need our public health partners on alcohol policy. An episode in Massachusetts is really encouraging. Recently, the State Treasurer announced the creation of a task force to change the “antiquated and confusing rules that frustrate businesses and consumers.” But, public health advocates rose up and argued that “loosening alcohol rules will inevitably lead to higher rates of alcoholism, drunken driving, youth drinking, disease, and birth defects—even if each tweak, on its own, seems innocuous and is well-intended.”

And, maybe we need to broaden our approach to include promoting a healthy socializing culture where pubs, restaurants and bars are not a place to get “wasted,” but to enjoy the company of friends, hear good music and eat good food.

Sources:

“Increases in Drug and Opioid Involved Overdose Deaths—United States, 2010-2015. MMWR, December 30, 2016.

“A grim tally soars: More than 50,000 overdose deaths in the US,” Associated Press, December 9, 2016.

“Ireland: Young people in Ireland are drinking less alcohol than their parents and this could be the reason why. New figures show alcohol consumption is declining, as young people swig coffee and take up running. By Kim Bielenberg, Independent.ie, June 18, 2017.

MA: Mass. wants to update its alcohol laws. Not all are happy. Health advocates oppose loosening sought by business. By Dan Adams, Boston Globe, May 30, 2017. Website: betterdrinkingculture.org.

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