To fight smoking and drug abuse, Uncle Sam will try gross images and screenings

fda3smokewarns-300x166The U.S. government will try to tackle two of the toughest health care challenges around with new pushes involving graphic imagery and smoking prevention and the encouragement for doctors to screen their adult patients to better detect, avert, and treat drug abuse.

Both initiatives have their soft spots.

But officials say they must act in as many ways as they can. That’s because 480,000 people in the United States die each year from illnesses related to tobacco use, the American Cancer Society reports, adding, “This means each year smoking causes about 1 out of 5 deaths in the US.” Drug abuse and overdoses, meantime, killed more than 68,000 Americans in 2018 alone, exceeding the nation’s peak annual deaths from car crashes, AIDS or guns, the New York Times reported, based on data from the federal Centers for Disease Control and Prevention (CDC).

The federal Food and Drug Administration has campaigned for almost a decade to force Big Tobacco to adorn its cigarette packs with provocative images aimed at dissuading smokers’ use. As the New York Times reported:

“The warnings are required under the Tobacco Control Act, which Congress passed in 2009. The agency unveiled its first choices in 2010, featuring colorful — and gruesome — pictures to wrap around the top half of cigarette packages and also on 20 percent of the surface area of advertisements. A year later, the FDA whittled its final selection to nine images. Public health advocates loved them, but tobacco companies fiercely objected. A group sued the FDA, and in 2012 convinced an appeals court that these specific graphic images violated its First Amendment rights of free speech …The court ordered that the warnings be purely informational, not aimed at scaring smokers, nudging them to quit or imposing an ideology.”

Sent back to the drawing board, the agency has returned with 13 new prospects (the images and messages can be viewed, including in a nifty agency interactive feature, by clicking here). They speak for themselves (see images above). It is uncertain if Big Tobacco will fight these warnings, which research shows may have some powers of dissuasion.

The agency also has not, for now, developed ways to derail the differentiated Big Tobacco menace posed to the young with the super trendy practice of vaping and the use of devices like the market dominating Juul product. Though the FDA has cracked down on vaping and Juul, alternatives are now flooding in, with “Juul-alikes” further fueling what public health officials fear is the hooking of a new generation of users to highly addictive and harmful nicotine — and perhaps leading them to tobacco use, research warns. Authorities also are dealing with an unexplained rash of three dozen or so young people who have been hospitalized after vaping nicotine or marijuana.

A key call for more screening on drug use, abuse

As for dealing with the drug abuse and overdose crisis, much of it tied to opioid painkillers, the respected U.S. Preventive Services Task Force (USPSTF) has switched views and called on doctors and other health providers to health providers try “to determine whether their patients 18 or older are using illicit drugs, including non-medical use of prescription drugs,” the Washington Post reported.

The independent, blue-ribbon group of experts who assess and recommend best practices involving medical tests, screenings, and treatments earlier had declined to endorse this approach. But the group said in a draft of its screening recommendations that data on the extent of drug abuse had changed minds, noting:

“In 2017, an estimated 11.5% of Americans age 18 years or older reported current illicit drug use in a national survey. Illicit drug use is more commonly reported in young adults ages 18 to 25 years (24.2%) than in older adults (9.5%) or in adolescents ages 12 to 17 years (7.9%). In 2017, an estimated 8.5% of pregnant persons ages 18 to 44 years reported drug use in the last month. Among survey respondents age 12 years and older who reported illicit drug use in the last month, 85.3% reported using cannabis and 19.5% reported nonmedical use of psychotherapeutic drugs, including opioids, pain relievers, or other drugs. Less than 8% reported using cocaine, hallucinogens, or inhalants. An estimated 7.5 million persons age 12 years and older were classified as having a diagnosis of dependence on or abuse of illicit drugs in the past year. Illicit drug use is among the most common causes of preventable death, injuries, and disability.”

The group urged medical care givers to consider how much time they could devote to drug screening and to use accepted and available questionnaires prepared by respected groups. This is an important issue, considering that doctors on average spend slightly more than 17 minutes with patients in a given office visit, ducking in and out of exam rooms. If doctors try to gather information on patient drug use, especially using commonly available surveys, they may ask as few as six or eight questions, including whether patients have used marijuana or other intoxicants, how often, and when last.

The USPSTF endorsement of these screenings is “important because the Affordable Care Act requires that services recommended by the task force be covered free or with very small co-payments.”

Screening may be a start, but what about treatment?

But its advisory, which is still open to public comment, may not be as straight-forward as proponents see it. Will patients be frank with doctors or nurses or other care givers about illicit activities? Do clinicians have the training and experience to help patients if they open up about drug problems? Critics say, for example, that officials have been too slow to promote the training, availability, and easily access for naxalone, an effective antidote to overdoses of powerful opioids. The USPSTF itself noted that screenings are not meant to detect “drug dependence, abuse, addiction, or use disorders. Patients with positive screening results may therefore need to be offered or referred for diagnostic assessment.”

The USPSTF said it lacks the evidence to recommend drug screening for adolescents, and its proposed practices may create challenges for health care providers. They need, for example, to understand their legal responsibilities with pregnant women. Many jurisdictions make care givers and others “mandatory reporters,” meaning they must report to authorities their suspicions of child harm or abuse, potentially including an expectant mother’s drug use. Some clinicians also may be wary of their legal roles, if they learn of adult patients’ drug habits and practices, in general, and specifically if it may involve criminal activity.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by dangerous drugs, notably opioids. It has been a long, painful slide into the current drug abuse and overdose crisis. The addictive and potent prescription painkillers also have opened the floodgates to illicit drugs like heroin, methamphetamines, and cocaine. Illicit production of the extremely powerful and once, prescription-only drug fentanyl has created a public health emergency, experts at the nonpartisan, respected RAND Corp. say.

We may wish to consider every available and appropriate option to attack the nation’s drug abuse and overdose crisis. We also can continue taking as many steps as we can both to preserve free speech but also to abate the menace of Big Tobacco and smoking. We’ve got a lot of work ahead of us.

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