A Public Health Guide to Ending the Opioid Epidemic, by Jay C. Butler and Michael R. Fraser, editors. 2019, 365 pp. New York, NY: APHA Press and Oxford University Press. $39.95.
In their new book, A Public Health Guide to Ending the Opioid Epidemic, Butler and Fraser have succeeded in providing a very much-needed contribution to all those interested in sound practical approaches to a raging health crisis causing more than 300 000 deaths of Americans since 2000. Drug overdose has become the leading cause of death in the United States for those younger than 50 years. The value of this text is derived from the experience and orientation of the editors who are public health practitioners who have grappled with the problem firsthand and strive to offer examples illustrating practical approaches that have worked. Jay Butler is the former state health official of Alaska. Michael Fraser is executive director of the Association of State and Territorial Health Officials. He writes of becoming aware of the opioid crisis after becoming familiar with the neonatal abstinence syndrome when he was chief executive officer of the Association of Maternal and Child Health Programs.
As former chair of the APHA Press Board, I learned that developing a book, with a range of contributing experienced authors in this field, is a formidable challenge. This is a fast-evolving subject, making capture of guidance in a book at a single point of time difficult, with potential contributors fearing that their advice will be out-of-date shortly after the ink dries on the page. And those best positioned to contribute are working so hard in the prevention and treatment of the epidemic that they are reluctant to spend time writing about it. Indeed, the authors in this book are personally or professionally engaged in responding to this crisis in a variety of governmental and community settings. And as the editors point out, they were willing to commit their guidance to writing outside of working hours.
This book does focus on public health factors that are key to making progress and provides actual examples of primary, secondary, and tertiary prevention. These include surveillance, health promotion, building community resilience, and mitigating the root causes of addiction.
The work is divided into 3 parts. Part 1 provides the public health perspective on the crisis, offering information for public health practitioners as they develop programs to respond to the opioid problem. This includes chapters on the emergence of the epidemic, approaches to preventing substance abuse and addiction, and stigma associated with addiction. Part 2 outlines public health and other health care partners including payers working together to address the epidemic. This section focuses on clinical practice and partnerships with public health. Chapters include nonopioid alternatives for pain, role of the community pharmacy, screening and brief intervention, and Vermont's Hub and Spoke System. Part 3 is concerned with systems-level approaches and primary prevention. Several chapters in this section describe "upstream" approaches to prevention.
Highlights of the book include examples from states that have taken major steps in mounting effective campaigns to directly confront the problem. Vermont's Hub and Spoke System of care for treatment of opioid misuse provides supports for both treatment providers participating in the system and patients receiving medication-assisted treatment (MAT) from them. Regional hubs are addiction specialists providing centralized core services to individuals requiring treatment. Stabilized patients can be transferred to spokes for ongoing treatment. Fraser and Levine describe the multiple facets of Vermont's response to the opioid crisis, terming it the "silver buckshot approach." Tactics include expanding access to naloxone, increasing MAT, and improving prescription drug monitoring programs.
The final chapter recounts the Pennsylvania experience in developing a culture of opioid stewardship. This outlines a unified response structure including efforts to increase treatment and recovery services and expanding the availability of the overdose reversal medication naloxone. An extremely valuable listing is provided of Pennsylvania's opioid stewardship guidelines.
I also draw the attention of the reader to chapters that were particularly important. These include chapters on the role of prescription monitoring programs and prescribing guidelines. While the latter does indicate correctly the need to individualize prescribing, according to needs of the patients with unique conditions, more discussion on recent controversy about problems caused by these guidelines contributing to difficult pain management situations would be helpful. As the chapter authors point out, guidelines will probably be outdated in 3 to 5 years and I look forward to more information in a future issue of this book. Other chapters of particular value include screening for the problem and engaging payers.
The editors are commended for producing a volume on one of our more pressing public health problems. Workable guidance is offered that can now be implemented on a broader basis. Again, as we make progress to counter this crisis, future editions will be most welcome.
-Lloyd F. Novick, MD, MPH
Editor