Current through Register Vol. 42, No. 5, February 29, 2024
(1)
According to the 2018 National Survey on Drug Use and Health nearly one (1) in
five (5) people aged 12 or older 19. 4%) used some form of illicit drug in
2018, which is an increase from 2015 - 2016. Deaths from opioid overdoses alone
were more than 42,000 in 2016.9 In Alabama the death
rate from drug overdoses climbed 82% from 2006 to 2014. The drug crisis affects
Alabama hospitals, schools, prisons, and
businesses.10 (Unless otherwise stated, all
statistics related to substance use disorders quoted in this section come from
the 2018 National Survey on Drug Use and Health).
(2) During 2018, approximately 20.3 million
people aged 12 or older had a substance use disorder (SUD) related to use of
alcohol or illicit drugs during the previous year, including 14.8 million
people with an alcohol use disorder and 8.1 million people with an illicit drug
use disorder. The most common illicit drug use disorder reported was the misuse
of marijuana (4.4 million people). An estimated 2.0 million people reported an
opioid use disorder, including 1.7 million people with a prescription pain
reliever use disorder and an additional 500,000 people with a heroin use
disorder.
(3) In terms of recent
initiates (new users within the previous year) to use or misuse of substances,
the substances most used or misused were alcohol (4.9 million new users),
marijuana (3.1 million new users), prescription pain relievers (1.9 million new
misusers), and cigarettes (1.8 million new users). According to the Substance
Abuse and Mental Health Services Administration ("SAMHSA"), in 2018 more than 4
out of 5 people aged 12 or older perceived great risk of harm from weekly use
of either cocaine (86.5%) or heroin (94.3%), while less than one-third of
people perceived great risk of harm from weekly marijuana usage (30.6%).
Approximately 2 out of 3 people perceived a great risk from daily binge
drinking (68.5%), and nearly 3 out of 4 people perceived great risk from
smoking one or more packs of cigarettes daily (71.8%).
(4) Substance abuse is more common among both
adolescents and adults who have a co-occurring mental health issue than among
those who do not. Adolescents with a mental health issue were reported as more
likely to binge drink (8.5%) or use an illicit drug (32.7%) versus those who do
not report a mental health issue (binge drinking 4.1%, illicit drug use 14%).
Similar difference in use are reported for adults aged 18 and older.
(5) According to SAMHSA, in 2018 an estimated
21.2 million people aged 12 and older needed substance use treatment in America
(7.8%). This includes approximately 3.8% of adolescents aged 12 - 17; 15.3% of
young adults aged 18 - 25; and 7% of adults aged 26 and older. Of these,
approximately 3.7 million people in America aged 12 and older received
treatment for substance use (1.4%), 2.4 million of whom received treatment at a
specialty facility. Among the estimated 18.9 million people aged 12 and older
who needed substance use treatment but did not receive any, approximately
964,000 perceived a need for treatment. Of those, approximately 40% did not
receive treatment because they were not ready to stop using, and approximately
one-third had no health care coverage and were not able to afford the cost of
treatment.
(6) The State should
encourage and promote a variety of treatments for SUD. Traditional treatments
for SUD include abstinence-based systems such as 12-step programs. Methadone
has been used successfully in recent years, especially for severe cases. SAMHSA
has recently reported significant success with Medication-Assisted Treatment
(MAT) which uses medications (primarily buprenorphine), in combination with
counseling and behavioral therapies, to provide a "whole-patient" approach to
the treatment of substance use disorders. Research shows that a combination of
medication and therapy can successfully treat these disorders, and for some
people struggling with addiction, MAT can help sustain recovery.
(7)
Marijuana. The primary
illicit drug used in 2018 was marijuana, with more than 43.5 million reported
users within the previous year. The percentage of people aged 12 or older
reporting marijuana usage within the previous year (15.9%) was higher than
percentages reported to SAMHSA from 2002 - 2017. The increase is primarily due
to increases reported in young adults (aged 18 - 25) as well as in adults (aged
26 or older). By comparison, and in contrast to these numbers, adolescents aged
12 - 17 did not show an increase in usage between 2014 -2018.
(8)
Prescription Drugs. The
second most reported form of illicit drug usage in 2018 was misuse of
prescription pain relievers, with 3.6% of the population reporting illicitly
using prescription pain relievers within the last year. For all people aged 12
or older, and for young adults aged 18 - 25, the percentage of the population
reporting illicit usage of prescription pain relievers decreased in 2018
compared to 2015 -2017. Similar decreases were reported for adolescents aged 12
-17 and for adults aged 26 or older compared to 2015 - 2016 but are similar to
the percentages reported in 2017. Among all people aged 12 or older in 2018 who
misused pain relievers in the last year, a significant majority (63.6%)
reported that the main reason for misuse was to relieve physical pain. More
than half of people who misused pain relievers in the last year 51. 3%)
reported obtaining the pain relievers from a friend or relative.
(9) According to the Alabama Department of
Public Health ("ADPH") 2017 Overdose Surveillance Summary, 836 people in
Alabama died of an overdose, 419 of which involved opioids. The top four (4)
drugs related to overdose deaths in 2017 were fentanyl (161 deaths); heroin
(128 deaths); methamphetamine (110 deaths); and cocaine (98 deaths) .
Additionally, in 2018 there were 11,081 visits to hospital emergency
departments in Alabama related to overdoses, with, 2,180 involving opioids.
There was a total of 20,353 overdose-related 911 runs in 2018, with 4,373
involving opioids. In 2017, the rate of drug overdose deaths in Alabama was
17.1 per 100,000 population, an increase from both 2016 (15.4 per 100,000) and
2015 (14.9 per 100,000). The rate for opioid deaths in Alabama in 2017 (8.6 per
100,000 population) was also an increase from both 2016 (7.0 per 100,000) and
2015 (5.7 per 100,000).
(10)
Opioid Abuse
(a) Opioids are a
class of drugs that include heroin as well as prescription pain relievers such
as oxycodone, hydrocodone, morphine and fentanyl. These drugs work by binding
to the body's opioid receptors in the reward center of the brain, diminishing
pain as well as producing feelings of relaxation and euphoria While most
overdose deaths are caused by illegal drugs, many people first become addicted
to opioids by using prescription drugs that were legally obtained.
(b) According to the Alabama Opioid Overdose
and Addiction Council, over 42,000 Americans died from opioid overdoses in
2016. According to SAMHSA, approximately 10.3 million people aged 12 or older
misused opioids in 2018. This number corresponds to approximately 3.7 percent
of the population. Of these, the vast majority (9.9 million users) misused
prescription pain relievers, compared to a much smaller population (808,000)
who used heroin. The majority of people who misuse prescription pain relievers
(9.4 million) had not used heroin, but a small number (506,000) misused
prescription pain relievers and used heroin within the last year. Among those
12 - 17 years old, approximately 699,000 adolescents misused opioids within the
last year, with another 1.9 million young adults between the ages of 18 - 25
also misusing opioids.
(c) In the
state of Alabama, the number of drug overdose deaths, including opioid deaths,
climbed eighty-two percent (82%) from 2006 to 2014. According to the Alabama
Department of Mental Health ("ADMH") Substance Abuse Division, in 2018 4,546
individuals were treated by the department, or by entities contracted by the
department, for heroin addiction with an additional 7,082 treated for addiction
to other opiates and synthetics. These statistics, however, do not include
individuals not treated by the department or its contracted entities. These
individuals make up approximately thirty-four percent (34%) of the patients
that received treatment for substance use related disorders by ADMH or
contracted entities.
(d) Currently
ADMH works with eighty-three (83) Certified and Contract entities to provide
services to individuals suffering from substance use disorders, providing
substance abuse treatment, medication assisted therapy and prevention services.
An additional eleven (11) providers are certified to provide prevention or
treatment services to patients, but do not receive funding from the Department.
There are twenty-one (21) Opioid Replacement Therapy (ORT) clinics throughout
the state that specifically target individuals suffering from Opioid Use
Disorders. Additionally, there are nineteen (19) public, non-profit regional
mental health boards, called 310 boards, throughout the state. Of these,
fourteen (14) provide substance abuse treatment services. Birmingham and
Tuscaloosa have regional boards, with additional mental health centers attached
to them.
(e) Governor Ivey created
the Alabama Opioid Overdose and Addiction Council through Executive Order 708
on August 8, 2017. The Council, co-chaired by the Commissioner of the Alabama
Department of Mental Health, the Attorney General of Alabama, and the State
Health Officer, was created to "study the State's current opioid crisis and
identify a focused set of strategies to reduce the number of deaths and other
adverse consequences of the opioid crisis in Alabama." The Council was given a
set of directives related to this purpose, including:
1. Advise and assist the Governor in the
development of a comprehensive, coordinated strategy to combat Alabama's opioid
crisis;
2. Gather and review data
characterizing the opioid crisis facing Alabama, including the threat of
synthetic opioids;
3. Review
strategies and actions already taken in Alabama to combat the opioid
crisis;
4. Review strategies and
actions of other States and the National Governor's Association Compact to
Fight Opioid Addiction; and
5.
Develop a comprehensive strategic plan to abate the opioid crisis in
Alabama.
(f) The State of
Alabama Opioid Action Plan, created by the Alabama Opioid Overdose and
Addiction Council and published December 31, 2017, describes a four-pronged
approach to addressing the current opioid crisis in Alabama. The four prongs to
the approach described by the council are:
1.
Prevention of opioid misuse. Including strategies to modernize the state's
Prescription Drug Monitoring Program (PDMP) to fully realize technological
improvements in how prescription opioids are prescribed and dispensed,
continuing improvements in the education of prescribers and
prescribers-in-training, the reduction of stigma attached to opioid addiction,
and the development of a centralized data repository that can be used to
understand and combat the problem;
2. Intervention within the law enforcement
and justice systems. Addressing drug trafficking laws and working with drug
courts in Alabama to encourage the use of medication assisted treatment (MAT)
for those with Opioid Use Disorders (OUD);
3. Treatment of those with OUDs. Increasing
access to care for those with OUD in Alabama and encouraging the use of
evidence-based practices to improve the identification and treatment of those
with OUD; and
4. Community Response
that engages ordinary Alabamians to become involved with finding solutions at a
local level. Focus on expanding the availability and usage of naloxone (a
potentially life-saving opioid reversal drug); the building of partnerships
with businesses, educational institutions and community organizations to
improve awareness and involvement; and encouragement for counties to adopt the
Stepping Up Initiative, which provides tools to create data driven strategies
that work within the judicial system.
(g) ADMH has received several grants in
recent years in order to combat substance use disorders, including the State
Opioid Response Grant, the Medication Assisted Treatment Prescription Drug
Opioid Abuse grant (in specific counties), another grant to expand Drug Courts
into specific rural counties, as well as grants from both the USDA (to provide
telehealth equipment in specific counties) and the CDC (in partnership with
ADPH to provide peer counseling in Emergency Departments).
(h) In 2019, Governor Ivey secured funding in
the state's operating budget to improve the Prescription Drug Monitoring
Program to, in part, make it easier to use for both physicians and pharmacists.
Also, Governor Ivey signed a law making it a crime to traffic in either
fentanyl or carfentanil, which are synthetic opioids with a higher potency than
heroin. The new law makes it a felony to knowingly possess more than a half
gram of fentanyl or a related synthetic opioid or to possess, sell, or deliver
a mixture containing fentanyl or a related synthetic opioid. Both Acts were
directly recommended by the Alabama Opioid Overdose and Addiction
Council.
(i) ADMH recently
partnered with Auburn University to create the Opioid Training Institute,
providing education to both community members and health care professionals
about the current status of opioid abuse in Alabama and to provide strategies
and solicit ideas on how to combat the crisis moving forward. The Department
has also worked with ADPH to supply naloxone to first responders throughout the
state in order to improve access to a potentially life-saving drug to any law
enforcement or medical professional who may be called upon to assist an
individual suffering from an opioid overdose.
(11)
Methamphetamine Use
(a) Methamphetamine is a potent stimulant
with high abuse potential that can be smoked, snorted, injected, or taken
orally. The desirable short-term effects of Methamphetamine or initial "rush"
is characterized by increased energy and alertness, elevated positive mood
state, and decreased appetite.11
(b) According to SAMHSA, in 2018
approximately 1.9 million people aged 12 or older used methamphetamines in the
past year. This number corresponds to approximately 0.7% of the population.
These numbers have not appreciably changed between 2015 and 2018. Among younger
users, approximately 43,000 adolescents between the ages of 12 and 17 used
methamphetamine in the last year, and approximately 237,000 young adults
between the ages of 18 and 25 used methamphetamines in the last year. In both
cases, the percentages of the population using methamphetamines in the last
year have not appreciably changed between 2015 and 2018.
(c) In the last two years, the number of
people abusing methamphetamine in Alabama has outnumbered the number of people
abusing other drugs such as cocaine, heroin and marijuana. Most of the users of
crystal meth in Alabama are people between 18 and 25 years of age.
(12)
Ecstasy. Ecstasy
abuse in Alabama continues to increase. Ecstasy, as well as similar drugs such
as LSD, GHB, and ketamine are primarily abused in night club settings and are
often referred to as "club drugs." Arrests, overdoses and emergency room visits
for club drugs have mirrored the increase in use. Ecstasy remains the leading
number one club drug, followed by GHB.12 GHB
overdoses have been reported in several areas of the state.
(13)
Cocaine. Cocaine is among
Alabama's most significant drug threats. Cocaine is widely available throughout
Alabama, as it ranks second for the number of drug addiction treatment
admissions. In 2010, 2,108 individuals were treated for smoking cocaine with an
additional 842 people treated for using cocaine through other routes of
ingestion.
(14)
Heroin. Heroin abuse, use, and sales have skyrocketed across the
nation. In fall of 2015, police departments across Alabama were expressing
concern over the growing number of deaths across all counties.
(15)
Alcohol Abuse
(a) According to SAMHSA, in 2018
approximately 139.8 million Americans aged 12 and older used alcohol in the
month prior to being surveyed, 67.1 million were binge drinkers during the same
time period, and 16.6 million were heavy drinkers during the same time period.
Approximately 2.2 million adolescents aged 12 - 17 drank alcohol within the
previous month, with 1.2 million of those binge drinking. For the purposes of
the survey, binge drinking was defined having had five (5) or more drinks on
the same occasion on at least one (1) of the previous thirty (30) days. Heavy
alcohol use is defined as binge drinking on five (5) or more days during the
previous thirty (30) days.
(b)
SAMHSA data from 2015 - 2016 indicates that approximately 43.94% of Alabamians
ages 12 and older reported using alcohol within the previous month. For
adolescents aged 12 - 17, the same survey indicates that 8.08% used alcohol
within the previous month, and for young adults ages 18 - 25, approximately
50.76% used alcohol within the previous month. Approximately 4.16% of
Alabamians ages 12 and over were reported to suffer from alcohol use disorder
in 2015 - 2016, with adolescents aged 12 - 17 being affected at a rate of 1.67%
and young adults aged 18 - 25 affected at a rate of
9.08%13. All of these rates are reported as being
lower than the national and regional averages for both alcohol use and alcohol
use disorder.
(16)
Tobacco
(a) More people die
every year from smoking than from murder, AIDS, suicide, car crashes, and
alcohol combined.14 Alabama has the
8th highest adult smoking prevalence rate in the
nation.
(b) ADPH reports that 21.5%
of adults in Alabama are current cigarette smokers. An estimated 23.3% of males
and 20.0% of females smoke. From 1996 to 2016 adult smoking prevalence fell on
average only 0.2% per year and 10.9% of high school students are current
smokers.15 According to the 2018 National Center for
Health Statistics, 10.1% of mothers reported smoking during
pregnancy.
(c) A key focus area for
the state should be the impact of smoking on Alabama's youth. According to the
2016 Youth Tobacco Survey (YTS), 10.9% of high school students are current
smokers. There was a significant difference in smoking prevalence between males
(12.9%) and females (8.8%) in high school whereas the prevalence in middle
school were very similar (3.4%). Also, the smoking disparity among
racial/ethnic groups increased in high school where white students (14.3%) were
twice as likely to smoke compared to African American (5.4%) and Hispanic
students (7.5%).
(d) Additionally,
secondhand smoke creates significant problems for Alabama citizens. Secondhand
smoke kills over 750 nonsmoking Alabamians each year. Children exposed to
secondhand smoke are at an increased risk for Sudden Infant Death Syndrome,
acute respiratory infections, ear problems, severe asthma, and reduced lung
function.
(e) The use of tobacco
creates an economic burden on the State as well. ADPH estimates that $5.16
billion in excess personal medical care expenditures were attributable to
smoking. There are an estimated $887.9 million in productivity losses as a
result of smoking-attributable premature death. An additional $1.33 billion in
productivity losses were estimated as a result of smoking-attributable
illnesses. And $187.5 million in economic costs were attributed to personal
medical costs and productivity losses associated with secondhand smoke. The
total annual economic impact of smoking in Alabama is estimated to be $7.6
billion.16
(f) Recent research has shown that youth
prevalence rates in Alabama have decreased substantially, although this is
known to be somewhat offset by a rise in the use of e-cigarettes among young
people in particular. The increase in the state's tobacco tax rate is expected
to continue to help reduce young people's initiation of tobacco use and will
likely generate an estimated $62 million of revenue annually.
(g) Efforts to address the tobacco problem in
Alabama have been led by ADPH. The Alabama State Plan for Tobacco Prevention
and Control is the result of the efforts of the Alabama Tobacco Use Prevention
and Control Task Force. The task force is composed of agents of ADPH and its
national, state, and local partners. Representatives of task force partner
organizations met in March of 2015 to review the state's progress regarding
tobacco prevention and control and update the previous plan drafted in
2010.
(h) One of the key partners
ADPH is coordinating with is the Tobacco Prevention and Control (TPC) Branch of
North Carolina Department of Health and Human Services. The TPC works with
local coalitions, community agencies, and state and national partners to
implement and evaluate effective tobacco prevention and cessation activities
that meet the following goals:
1. Eliminating
environmental tobacco use exposure.
2. Promoting quitting among adults and
youth.
3. Preventing youth
initiation.
4. Identifying and
eliminating disparities among populations.
(i) Another initiative that Alabama should
support is the Federal Drug Administration's Youth Tobacco Prevention Plan, a
series of actions to stop youth use of tobacco products, especially
e-cigarettes, with special focus on three key areas:
1. Preventing youth access to tobacco
products.
2. Curbing marketing of
tobacco products aimed at youth.
3.
Educating teens about the dangers of using any tobacco product, including
e-cigarettes, as well as educating retailers about their key role in protecting
youth.
(j) While the ADPH
efforts have had some minor success, the state still trails the country in its
efforts to reduce tobacco related illness and death. The State Plan for Tobacco
Prevention and Control may be seen as an important step in the process of
moving the state along the right track toward reaching those
goals.
(17)
Vaping
(a) E-cigarettes are
battery-powered devices that allow users to inhale aerosolized liquid.
E-cigarettes are also called vapes, vape or hookah pens, electronic nicotine
delivery systems (ANDS), mods, vaporizers, and tank systems. Even though
e-cigarettes do not contain any tobacco, the Food and Drug Administration (FDA)
classifies them as "tobacco" products. The amount of nicotine provided by
e-cigarettes varies by device.
(b)
These devices have become the most used tobacco product among Alabama youth in
the past few years. Until recently these devices were not regulated as typical
tobacco products. In fact, the e-cigarettes are not currently listed in any
sections of the State's statutes included in the definition of "Tobacco
Products." Originally e-cigarettes were offered as an alternative to regular
tobacco products as a means of assisting in smoking cessation. Their
popularity, especially among youth, has overtaken any effort to reduce smoking
and tobacco addiction.
(c)
According to the American Cancer Society the possible long-term health effects
of e-cigarettes aren't yet clear, but there have been recent reports of serious
lung disease in some people using e-cigarettes or other vaping devices.
Symptoms have included:
1. Cough, trouble
breathing, or chest pain;
2.
Nausea, vomiting, or diarrhea; and
3. Fatigue, fever, or weight loss
(d) Furthermore, recent reports
show nicotine exposure can harm brain development and as a result is more
harmful to adolescents. Nicotine can also cause harmful physical effects to the
cardiovascular and central nervous system. Eating, drinking, or absorbing
nicotine in any way can lead to nicotine poisoning, especially in children. If
used during pregnancy, nicotine may also cause premature births and low
birthweight babies.
(e) Nicotine,
the main drug in tobacco products and e-cigarettes, is known to be highly
addictive. Developing adolescent and young adult brains are even more
susceptible. In addition to being highly addictive, the American Cancer Society
reports that nicotine is a major carcinogen and can cause lung disease, heart
disease, and cancer.
(f) Besides
nicotine, e-cigarettes and e-cigarette vapor contain propylene glycol and/or
vegetable glycerin. These are substances which have been found to increase lung
and airway irritation after concentrated exposure.
(g) In addition, e-cigarette and e-cigarette
vapor may contain the chemicals or substances listed below:
1. Volatile organic compounds (VOCs): at
certain levels, VOCs can cause eye, nose and throat irritation, headaches and
nausea, and can damage the liver, kidney and nervous system.
2. Flavoring chemicals: some flavorings are
more toxic than others. Studies have shown that flavors contain different
levels of a chemical called diacetyl that has been linked to a serious lung
disease called bronchiolitis obliterans.
3. Formaldehyde: this is a cancer-causing
substance that may form if e-liquid overheats or not enough liquid is reaching
the heating element (known as a "dry-puff").
(h) The FDA does not currently require
e-cigarette manufacturers to stop using potentially harmful substances. And, it
is difficult to know exactly what chemicals are in an e-cigarette because most
products do not list all of the harmful or potentially harmful substances
contained in them.
(i) The
Stringer-Drummond Vaping Act, HB41, passed in May 2019. It requires the Alabama
Alcoholic Beverage Control Board to regulate retail sales of alternative
nicotine devices like sales of tobacco products and prohibits the sale or
transfer of alternative nicotine products to minors. The law also prohibits
retailers and manufacturers of alternative nicotine products and electronic
nicotine delivery systems from advertising the products near schools; and to
prohibit specialty retailers of electronic nicotine delivery systems from
opening new places of business near schools, childcare centers, churches, and
other facilities. The law prevents retailers and manufacturers of alternative
nicotine products or electronic nicotine delivery systems from advertising
those products as tobacco cessation devices as a healthy alternative to
smoking. E-cigarettes may only be sold in tobacco, mint, or menthol
flavors.
(j) The Stringer-Drummond
Act also requires retailers of alternative nicotine products or electronic
nicotine delivery systems to obtain a tobacco permit, to comply with FDA
regulations governing the retail sale of alternative nicotine products and
electronic nicotine delivery systems. Vendors must post warning signs in their
stores regarding the dangers of nicotine use and potential risks associated
with vaping.
(k) Under the Act,
anyone selling e-cigarettes is prohibited to sell or transfer alternative
nicotine products or electronic nicotine delivery systems to minors; and in
connection therewith would have as its purpose or effect the requirement of a
new or increased expenditure of local funds within the meaning of Amendment 621
of the Constitution of Alabama of 1901, now appearing as Section 111.05 of the
Official Recompilation of the Constitution of Alabama of 1901, as
amended.
(l) ADPH recently
recommended that all consumers consider refraining from the use of electronic
cigarette and vape products until national and state investigations into
vaping-related deaths and illnesses are complete. This recommendation came
after the Centers for Disease Control and Prevention reported a cluster of
severe pulmonary disease among people who use e-cigarettes or vape products,
with more than 800 cases of lung injury reported from forty-six states and one
U. S. territory. Two-thirds of cases are 18 - 34 years old, and twelve (12)
deaths had been confirmed by September 2019 in ten (10)
states.
9
2018 National Survey of
Drug Use and Health, Substance Abuse and Mental Health Services
Administration (SAMHSA), Department of Health and Human Services (HHS).
2018.
10
State of Alabama Opioid
Action Plan, produced by the Alabama Opioid Overdose and
Addiction Council, 2017.
11 Rawson RA, Gonzales R, McCann MJ,
Obert J. Methamphetamine use among treatment-seeking adolescents in
Southern California: participant characteristics and treatment
response. Journal of Substance Abuse Treatment. 2005; 29:67-74.
12 Downloaded from
Addictionrecovery.net, November 11, 2019.
13
Alabama Drug Abuse
Statistics, 2019, www.recoveryconnection.com: owned and
operated by Lakeview Health.
14 Alabama Department of Public Health.
2019
15 2016 Behavioral Risk Factor
Surveillance System (BRFSS), Centers for Disease Control.
16 Dunlap, S.T. & McCallum, D.
(2019). Update: The Burden of Tobacco in Alabama, 2019.
Tuscaloosa, AL: Institute for Social Science Research, University of
Alabama.
Author: Statewide Health Coordinating Council
(SHCC)
Statutory Authority:
Code of Ala.
1975, §
22-21-260(4).
