March 13, 2019
By Joyce Frieden
WASHINGTON -- The opioid epidemic, the measles epidemic, and the unintended consequences of marijuana legalization were some of the topics on the minds of big-city health commissioners as they convened here this week.
Like many other big cities, Columbus, Ohio has been hit hard by the opioid epidemic, Mysheika Roberts, MD, health commissioner of Columbus, Ohio, said at an event here sponsored by the Big Cities Health Coalition. "In Franklin County [where Columbus is located], we had a 581% increase in opiate overdose deaths from 2003 to 2017," she said, adding that about 450 people die from it every year. "The city has funded a comprehensive harm reduction program, conducted by one of our federally qualified health clinics; we provide naloxone training, HIV and hepatitis C testing, treatment referrals, and wound care."
Two of the city's more unusual efforts include several safe needle disposal boxes located throughout the city, which has reduced the number of needles discarded in parks and other public places, and a "surge notification system," under which the coroner's office, emergency medical services, police departments, and emergency departments alert other agencies via a conference call if they notice an unusually high number of people dying from overdoses or being transported to the hospital for overdose treatment.
"This helps us identify a concentrated area of overdoses," Roberts said. Two years ago, the notification system alerted officials to a high number of overdoses in a particular African-American community in Columbus. "We found a cocaine batch that had [been] contaminated by carfentanyl ... We were able to get on top of that quickly and made sure that people [in that community] had access to Narcan."
But funding such efforts continues to be a challenge, she added. "I know I'm not alone in that. We're going to continue to see more deaths in the community if we don't do something drastic to change things ... One area where we see a lot of [funds] draining is children's services; many children are becoming orphans" because their parents have died from drug overdoses.
The measles epidemic is weighing heavily on the mind of Rachel Banks, MPA, public health director of Multnomah County, Oregon, where Portland is located. "We're really focused on the measles vaccine exemption rate," specifically, the rate of "non-medical" exemptions where people seek exemptions for religious or philosophical reasons, she said, noting that the county is on its fifth recent measles outbreak.
In Oregon overall, 5.2% of children are unvaccinated due to a non-medical exemption; in Multnomah County, the rate is 6.1%. Similarly, Oregon has a statement measles vaccine exemption rate of 3.9%, compared with 4.3% for the county, she said, adding that the area's recent measles outbreak has increased vaccine uptake.
"We are concerned with disease spread and the impact on the healthcare system," said Banks. The county health system and the providers have used a joint plan to mitigate community exposures; that model has worked well. For example, "we had one outbreak in July 2018 -- we had three cases with no additional exposures after the first case, and stopped the subsequent spread, but it was very expensive and involved a highly skilled and trained staff."
There are two cost-related issues with the outbreak, Banks continued -- one is the cost of educating families seeking exemptions about the possible consequences, and the other is the cost of the outbreaks themselves. The policy solutions are clear: officials should take a balanced approach by supporting vaccines, while also working with affected families to convince them to take precautions to avoid spreading the disease.
Tomás Aragón, MD, MPH, public health officer for San Francisco, discussed the unintended consequences of marijuana legalization in his state. "In California, you can't consume cannabis in public, so people create consumption places," he explained. However, right now the prevalence of [cigarette] smoking is very low through decreasing demand and also through "de-normalization" -- making smoking not considered the cool thing to do. "So we don't want smoking to now start taking off, because they'll probably go beyond cannabis" and smoke tobacco too.
Clean indoor air and worker safety also could be affected by marijuana legalization, Aragón added, noting that under current state law, "workers are protected from second-hand smoke."
He is also concerned about the high potency of the marijuana being sold, some of which has a 90% level of its main ingredient, tetrahydrocannabinol (THC). "I feel like we're in the Wild West [of marijuana] ... I went to one retail place where the owner himself consumes cannabis 24/7 -- but only at a 25% THC level," said Aragón. Of the cannabis with 100% THC, the owner told Aragón, "I sell this stuff but I would never touch it."
Other health department heads discussed some of their successes. Virginia Caine, MD, director of the Marion County (Indiana) Health Department, where Indianapolis is located, said she recently testified before the Indianapolis City Council in support of a needle exchange program for the city. The day she appeared, Indiana's Attorney General, Curtis Hill, gave a press conference saying that needle exchange programs "enable drug addicts and make this a terrible epidemic for the young generation." Despite Hill's remarks, all 24 council members voted unanimously in favor of the program, Caine said.