Prescription abuse: A deadly rural problem
Tips from a panel at the 2011 Rural Health Journalism Workshop from speakers Kristine Bowers, membership service coordinator, Coalition on Appalachian Substance Abuse; Alison Knezevich, The Charleston (W.Va.) Gazette; Laura Ungar, medical writer, Louisville (Ky.) Courier-Journal.
From Laura Ungar:
Let the people tell the story. Finding "real people" took a lot of effort. We found the most success reaching out to community organizers. These people also introduced us to residents, who might not have talked to us otherwise. It also helped to visit people in person as opposed to relying on a phone interview.
Focus on the impact. At first, when we were discussing budget cuts with officials, we got the scoop on what those cuts meant: particular programs being cut, fewer police officers on the street, not as much drug education for children, etc. But an editor pushed us to go deeper. Who would be most affected by programs being cut and what would that mean for their lives?
The Centers for Disease Control and Prevention have some excellent databases. We used the compressed mortality data found in the CDC's Wide-ranging Online Data for Epidemiologic Research, or WONDER. We contacted state epidemiologists for help identifying the ICD-10 codes used to identify deaths from prescription drugs - there are over 100 codes - and then were able to plug them into this database to get the statistics that became the meat of our story. Reaching out to the epidemiologists was extremely important. Because there's no set of codes that specifically encompasses prescription drug deaths, we had to find our own set of codes. And we needed to tap into the expertise of epidemiologists to do this.
Follow the money to breathe new life into a stale story topic. When we first approached our editors about doing this story, we were met with hesitation. Some of them felt that prescription drug abuse was a tired topic in Kentucky. At a story meeting, an editor suggested juxtaposing the rising number of deaths with shrinking budgets of the agencies charged with fighting the abuse. This provided us a way to tell this story in a new way.
Look beyond the easy answers and stereotypes. We faced many stereotypes about the issue -- that it was a problem affecting mostly the poor and uneducated who chose to be addicts, etc. We were even told this by elected officials. But after digging deeper and talking to former addicts and community organizers, we found that this problem greatly impacts the middle class and that many of the addicts began taking prescription pills after legitimately being prescribed them by a doctor.
Try to bring in editors, photographers, designers and other team members early and often.
If you are working with others on the story, rely on one another's strengths and meet often to coordinate coverage. We co-writers started off meeting once or twice a month, then once a day as deadlines approached.
Put all your data into one spreadsheet with several tabs and designate someone to be in charge of it. Our main Excel file had 22 tabs, each a different spreadsheet grouping the numbers in a different way.
From Alison Knezevich:
When looking for "real people" to interview, seek out the people who see the problem at a very local level – treatment counselors, pastors, community coalitions. They can refer you to recovering addicts.
Talk to law enforcement at all levels, from local sheriffs and prosecutors to state police to the FBI and DEA agents in your region.
Be sure to talk to members of the medical community, e.g. rural doctors, emergency room doctors, and pharmacists.
Court documents – such as affidavits and search warrants – from "pill mill" cases can give you some really vivid details. Also look for documents in civil lawsuits involving doctors who allegedly overprescribed and/or caused overdose deaths.
To find death rates and trends at a local level, enlist the help of a local epidemiologist or statistician from your state health bureau. National rates are kept by the CDC.
The DEA keeps record of state-by-state consumption of certain controlled substances. By combining this information with Census data, you can calculate how per capita consumption of painkillers has changed over time in your state. However, you must be persistent with the DEA in obtaining the most recent data. They are supposed to be updating their database to make it publicly available online, but I don't know when that will happen.
It is important to familiarize yourself with concepts of addiction when writing about drug abuse. The National Institute of Drug Abuse has lots of scientific information, and I also recommend reading the article "Addiction is a Brain Disease, and it Matters."
From Kristine Bowers
Substance use data sources for rural and Appalachain counties
More data sources for issues that relate to rural or Appalachian substance use are available for public use. These include sources in the federal government as well as individual states. Because 12 of the 13 designated Appalachian states contain some but not all Appalachian counties, accessing county-level or municipal data is critical to accurate assessments of the Appalachian experience. Some data is substate or regional but may include non-Appalachian counties. Counties with low populations may only have regional aggregate figures or such low numbers in relation that they may not seem statistically significant. Collection and reporting in small rural counties may be an issue.
Data that pertain to county units may be useful for researchers, community-based organizations, governmental agencies or individuals. Other more local sources, which may not be listed here, may be available from smaller organizational units such as county departments, schools or community coalitions from which permission must be granted for use. Using local sources like emergency room department intake or discharge data, alcohol control board permits granted, sales tax revenues from alcohol and mixed drinks, etc. may provide useful perspectives as well as key interviews with local stakeholders in substance use issues. Some local governmental units like fire departments, housing authorities, or EMS squads may even have budget data that provide a picture of the impacts. The local chambers of commerce members may also have stories or data.
Note: The data sources below employ a range in methodologies and data collection methods in a number of formats. Not all data applications listed use statistical software.
Public Health/Vital Statistics
Behavioral Risk Factor Surveillance System: The CDC's BRFSS tracks individual's health behaviors, such as smoking, alcohol use, sexual activity, exercise, receipt of screenings, and medication use. Data are collected each year and are available at the national and state levels as far back as 1984.
CDC WONDER: Wide-ranging Online Data for Epidemiologic Research (WONDER) provides a single point of access to the vast range of data offered by CDC. It includes reports and quantitative data on chronic diseases, health practice and prevention, communicable diseases, injuries, occupational health, environmental health and reference data.
CDC WISQRS: Web-based Inquiry System Query and Reporting System has fatal and non-fatal data. Searchable and mappable down to county level.
The Data Resource Center for Child & Adolescent Health includes over 100 standardized indicators from the two extensive state-based surveys on health and health care of children, youth, and families from The National Survey of Children's Health (NSCH) and The National Survey of Children with Special Health Care Needs (NS-CSHCN). It is searchable by age, race/ethnicity, income, health status and state.
National Epidemiologic Survey on Alcohol and Related Conditions: Sponsored by the NIH, the NESARC collects information on alcohol and drug use, abuse and associated illnesses in the U.S. population. Fielded for the first time in 2000-2001, the second set of data collection is currently in progress.
National Vital Statistics System: Datasets are a collection of vital events such as births, deaths, marriages, divorces, and fetal deaths in all 50 states and 5 territories.
Youth Risk Behavior Surveillance System: Sponsored by the CDC, the YRBS monitors health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth. YRBS topics include Tobacco use, diet, physical activity, alcohol and other drug use, sexual behaviors, unintentional injuries and violence. The survey is conducted of a sample of high school students every other year.
Community Anti-Drug Coalitions of America (CADCA) This national group of community coalitions also has data on their members and access to local and state coalitions as well as local state and federal contacts.
SAMHSA DASIS data:
The National Survey of Substance Abuse Treatment Services (N-SSATS) (formerly titled Uniform Facility Data Set (UFDS)) is designed to collect information from all facilities in the United States, both public and private, that provides substance abuse treatment. N-SSATS is one of three components of SAMHSA's Drug and Alcohol Services Information System (DASIS) and is designed to provide the mechanism for quantifying the dynamic character and composition of the United States substance abuse treatment delivery system. In 1995, SAMHSA created DASIS to facilitate the integration of its existing treatment service's datasets and to reduce redundancy in data collection and reporting. The other two DASIS components are the Inventory of Substance Abuse Treatment Services (I-SATS) and the Treatment Episode Data Set (TEDS). I-SATS is a comprehensive listing of all known substance abuse treatment facilities in the United States. TEDS is a client-level database of individuals admitted to publicly funded substance abuse treatment facilities and is available from the SAMHDA Web site. Together, these three DASIS components provide national- and state-level data on persons receiving alcohol and substance abuse treatment as well as data on the facilities providing the treatment.
NSDUH 2008: The National Survey on Drug Use and Health (NDSUH) is an annual nationwide survey that provides national and state-level data on the use of alcohol, tobacco, illicit and non-medical prescription drugs in the United States. This annual study is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the U.S. Public Health Service and part of the U.S. Department of Health and Human Services (HHS).
TEDS 2008: The Treatment Episode Data Set (TEDS), another component of DASIS, is collected annually and provides details on the characteristics of substance abuse treatment admissions and discharges. TEDS geographic data include state FIPS, CBSA, primary metropolitan statistical area (PMSA), Census region, and Census division.
2008 Treatment Episode Data Set - Admissions (TEDS-A)
2008 TEDS-A data available for download and online analysis include substance(s) abused, route of administration, frequency of use, age of first use, treatment service and client characteristics, referral sources, and number of prior treatment episodes. The TEDS-A Concatenated file has been updated to include data for 1992 to 2008.
The Drug Abuse Warning Network (DAWN) public health surveillance system monitors:
• Drug-related visits to hospital emergency department (EDs) and
• Drug-related deaths investigated by medical examiners and coroners (ME/Cs).
2008 Area Profiles of Drug-Related Mortality
Crime and Judicial Data
Bureau of Justice Statistics
This site from the Department of Justice allows users to create charts and statistical reports on incidents of violence and certain preventable injuries.
Of special note: U.S. Department of Justice
Spatial Analysis of Crime in Appalachia, James G. Cameron
Document No.: 189559, Aug. 6, 2001
ADAM II 2008
The Arrestee Drug Abuse Monitoring (ADAM II) program is a data collection program sponsored by the Office of National Drug Control Policy (ONDCP) to gather information on drug use and related issues from adult male offenders at the time of their arrest. ADAM II continues as a vital source of data for estimating trends in drug use in local areas, understanding the connection between drugs and crime, and describing drug market behavior in the adult male arrestee population.
The Drug Enforcement Agency (DEA) is responsible for enforcing the controlled substances laws and regulations in the United States. It has a wealth of information about law enforcement, drug control and substances of abuse.
The Office of Drug Control Policy coordinates U.S. drug policy and also has drug facts and links to other sources
Controlled Substance Databases
National Association of State Alcohol/Drug Abuse Directors is the national organization of single state authorities. Important links to data and people.
The National All Schedules Prescription Electronic Reporting Act – Some publications and links to other agencies.
National Association of States with Controlled Substances Authorities is the group for state prescription monitoring programs. Interesting links to people, policy and implementation.
Alcohol Policy Information System is a database of federal and state alcohol-related policies that have been enacted since 1998. The database includes legislative bills, statutes, and regulations.
The National Conference of State Legislatures is a bipartisan organization that serves the legislators and staffs of the nation's 50 states, its commonwealths and territories. NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state issues. NSCL monitors and publishes information about state legislative initiatives and issues in a timely fashion with links to all states and is a source of original data about key issues.
o Substance Abuse as a Cross-Cutting Issue (Matthew Gever, 2006)
o Other Substance Abuse-Related Resources
Cost Benefit Data
Medicaid Statistical Information System: This database from CMS collects information on services and payments rendered in the Medicaid program. Data are based on states' reports of Medicaid claims processed each year.
Bureau of Labor Statistics: The Department of Labor offers datasets that measure social and economic issues, including wages, income, employer-sponsored health insurance and other workplace benefits.
New study from the Department of Justice: Economic Impacts of Illicit Drug Use
SAMHSA Costs of Addiction
Statehealthfacts.org is a project of the Henry J. Kaiser Family Foundation and is designed to provide free, up-to-date, and easy-to-use health data on all 50 states. Statehealthfacts.org provides data on more than 450 health topics and is linked to both the Kaiser Family Foundation website and KaiserNetwork.org.
State and Local Area Integrated Telephone Survey, sponsored by the CDC, collects a broad range of health information, such as health insurance coverage, access to care, health status, utilization of services, and measurement of child well-being at the state and local levels. SLAITS is based largely on other federal government health surveys.
National Institute of Drug Abuse
NIDA InfoFacts: Workplace Trends (2008) and other publications
Some state bureaus of investigation have arrest and incident data available. State health departments and offices of chief medical examiners often have interesting statistical sources on mortality. Some good examples:
Maryland: Center for Substance Abuse Research (CESAR)
Tennessee: Department of Health Statistics
Virginia: Office of the Chief Medical Examiner
An Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region. Final report. Washington, DC: Appalachian Regional Commission. Zhang, Z., Infante, A., Meit, M., English, N., Dunn, M. and Bowers, K. 2008.
DataFerrett is a unique data mining and extraction tool. DataFerrett allows you to select a data basket full of variables and then recode those variables as you need. You can then develop and customize tables.
Inter-university Consortium for Political and Social Research (ICPSR) maintains and provides access to an archive of social science data for research and instruction, and offers training in quantitative methods to facilitate effective data use.
Kaiser Health Poll Search is an archive of public opinion questions on health issues that allows users to know what Americans think about health issues, as well as what Americans have thought about health issues over time. The Health Poll Search archive covers 29 topics and more than 300 subtopics, and holds more than 60,000 questions on health issues from health care surveys that have included questions on health.
The National Survey of America's Families, conducted by the Urban Institute, provides a comprehensive look at the well-being of children and non-elderly adults in the United States and in 13 states: Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin.
RAND conducts research on a broad range of social, economic, and political issues, including the U.S. health care system. RAND's public databases include information on education, population and demographics, and health and socioeconomic issues.
The Roper Center for Public Opinion Research is an archive, preserving the data from polls conducted by many leading survey research organizations for the use of researchers, students, and journalists.
The FDA provides a downloadable catalog of approved and tentatively approved prescriptions, over-the-counter and discontinued drugs.
The National Association of County and City Health Officials is a source of local health data.
National Rural Institute on Alcohol and Drug Abuse: Annual institute on rural drug issues
U.S. Dept. of Transportation: National Highway Traffic Safety Administration
Traffic Safety Annual Assessment & Other Publications
University of Michigan: Institute for Social Research: Survey Research Center
Monitoring the Future Survey: National data on prevalence (no state data available but may be available locally through participating schools)