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You’ve probably heard the under-world of drug abuse has taken on a new face over the past decade, with the rise of prescription pill addicts.

The story is more nuanced than that. But before looking at the nuance, here are a few surprising facts and a disturbing trend.

by Ashley Rose/Flickr

• Overdose deaths in King County dropped last year, from 161 to 130. And the most recent state-wide data, from 2009, also showed a drop to 324.
• The top 5 drugs involved in King County’s overdoses were, in order: Prescription opiates (painkillers)-130; Anti-anxiety and anti-depressant medications -79; Alcohol -62; Heroin -50; Cocaine -46
• The number of dirty needles exchanged for clean ones in King County more than doubled between 2007 and 2010

These figures were compiled from various sources by Caleb Banta-Green, an epidemiologist at the University of Washington’s Alcohol and Drug Abuse Institute. He’s presenting the work this week to a panel of the National Institute on Drug Abuse’s Community Epidemiology Work Group, representing 21 major cities, which is meeting in Seattle.

From painkillers to heroin?

He also told me that his biggest concern, looking forward, is what happens to the people who get addicted to painkillers, such as oxycodone.

“Prescription type opiates are pretty potent, but they’re also quite expensive. Heroin is much cheaper. So, my concern is that as people run out of resources to afford prescription type drugs, they’re going to need to move on to heroin.”

And sure enough, nearly 40% of heroin addicts interviewed at a treatment clinic in King County say they started with prescription drugs first. Other data, from the state crime lab, show drug busts for heroin are on the rise in a number of smaller counties (particularly on the Olympic peninsula and in Whatcom County). Heroin abuse used to be confined to Washington’s cities — primarily Seattle, Tacoma, Spokane, Everett and Yakima. Now, it’s appearing in small towns and rural areas.

The reason someone might be more likely to move from painkillers to opiates, and not another drug such as cocaine, is because they’re in the same family. Opiates come from the opium poppy – and include morphine, heroin, methadone and other prescriptions such as Vicodin and Oxycontin.

The number of people getting treatment for opiate addictions has gone up dramatically – thanks largely to a new replacement drug called suboxone, according to Banta-Green’s data from prescription records. It works sort of like nicotine patches for smokers. It’s a substitute drug that satisfies the physical addiction without making the person high.

A new treatment may be helping

Suboxone (also known as buprenorphine) was introduced nationally in 2003 and now more than 5,000 people are using it in Washington. It’s easier than the older replacement drug, methadone, because regular doctors can prescribe and monitor it. Methadone is available only through a few addiction clinics.

More people getting treatment is a good sign, insofar as people are fighting their addictions. But it’s also a sign of how pervasive the problem is.

The current crop of reports has some demographic data, regarding age, gender, and race of people using various drugs. It shows that painkiller abuse is growing in every sector, but especially among whites in their 20′s. On the other hand, cocaine is abused more widely by blacks and Hispanics over age 30, and especially over age 40.

The reports don’t attempt to dig deeper into who is abusing painkillers and why. There’s a big black market for the drugs, so some addicts are buying them like any other illegal substance. Pharmacies get robbed; medicine cabinets get plundered.

There’s a very readable story by Patrik Jonnson of the Christian Science Monitor, describing how law enforcement officers in rural America are scratching their heads over what they see as a new, invisible epidemic, and how some unethical doctors are feeding the demand.

Many people also become addicted while using painkillers with a legitimate prescription. And still others use opiates for long-term, chronic pain, with good medical supervision — and they never become addicted.

And, to put it in perspective, alcohol and marijuana are still by far the most abused drugs in Washington, based on the numbers of people seeking treatment for addictions.

Information on opiate medication and heroin safety and overdose prevention is available at StopOverdose and from the state Department of Health.

Warning map by NOAA, for a tsunami generated by the March 11th earthquake (yellow star is the epicenter, with the Americas to the right).

This has happened frequently enough (e.g. Haiti, Chile, New Zealand) that I’m thinking it would be useful to create a basic FAQ for earthquakes. Lots of FAQ’s exist, written by scientists, or emergency preparedness teams. But I haven’t come across one that’s written with the fears and fascinations of the public in mind.

I guess I’d start with a basic fact:

Not all earthquakes are of the same kind.

Just like there are different kinds of volcanic eruptions (picture Mt. St. Helens blasting its top, vs. Hawaii’s Kilauea oozing lava as tourists stand nearby) — there are different types of quakes. Many types. Too many, so let’s start with a basic division:

Subduction zone quakes vs. crustal quakes. What you see in Japan is the result of a subduction quake. New Zealand suffered from a crustal quake. Subduction quakes are typically off-shore, and these are the most common sources of tsunamis. Crustal quakes can run directly under a city, such as Seattle or Los Angeles, and in the aftermath, you sometimes can see a big section of earth thrust six or eight feet up from the ground next to it.

The region around Seattle gets both kinds.

Readers: Any other suggestions for another Mini-Lesson about  Earthquakes?

Re. the subduction quake, much has been written by other news sources (not all of it accurate, some of it overly alarmist). I wrote this following piece for KPLU:

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You may have heard Washington has an earthquake fault similar to the one that devastated Japan.  While there are many fault-lines criss-crossing western Washington, the only one that bears a strong similarity is under the ocean, parallel to our coast-line.  It’s called the Cascadia subduction zone.

Story starts on January 26, 1700

The Cascadia fault zone lies about 80 miles off-shore, where one of earth’s plates slides under another. It’s been silent for three centuries.  But, there’s strong evidence that in 1700 it let loose an earthquake slightly bigger than the one that hit Japan last week — sending a huge tsunami toward the Washington and Oregon coasts.

“It was probably a nightmare of five or six minutes of shaking, followed by a wall of water 30 to 40 feet high,” says oceanographer and tsunami expert Frank Gonzalez of the University of Washington, imagining what people here might have experienced. “It had to be a horrendous experience.”

Gonzalez, who had a long career studying tsunamis at NOAA, helped design the warning system of computers and ocean buoys that predicted where and when last Friday’s tsunami would hit the Pacific coast.

All the estimates and descriptions for a future devastating tsunami in the Pacific Northwest are based on that one three centuries ago. The Cascadia fault could rupture again, at any time, although it also could sit silent for another century or two. Most estimates say it’s on a 300-500 year recurrence cycle.

The details – who’s most at risk

According to computer models, our urban areas in Seattle, Tacoma, and Everett (along with Portland and Vancouver, B.C.) would see buildings damaged, roads buckled and some bridges collapsed. But, as in Japan, where few people died from the earthquake itself, much worse damage would be found on the coast.

The ensuing tsunamis would obliterate Ocean Shores, Westport, and the Long Beach peninsula, perhaps in less than a half-hour.  Towns on the Oregon coast would be even worse off, because the fault runs closer to their shoreline, says Tim Walsh, chief geologist of the Washington Department of Natural Resources (DNR) hazards program. Seaside, Ore. would likely get hit the worst. One study estimated about 50,000 people might die across the region.

Consider the images of Japanese towns completely wiped away by the waves:

“Earthquakes like this are reminders, and that they would happen in Japan where we have close ties, brings it all closer to home, somehow,” says Brian Atwater of the US Geological Survey and the University of Washington.

By the time an ocean tsunami hit Puget Sound, after passing through the strait of Juan de Fuca, it might be ten feet high, rather than 30-50 feet in Japan. The brunt of that wave would hit Whidbey Island, although many low-lying shorelines could see flooding, according to hazard maps created by DNR.

Japan’s experience, plus Chile’s and Papua New Guinea’s offer lessons

The fault that ruptured off of northern Japan hadn’t had such a big quake for over a thousand years.  In the year 869, a very similar set of tsunamis swept across the Sendai region, according to recent research.

Brian Atwater and colleagues wrote a classic essay called “Surviving a Tsunami,” based on three big ones prior to 1999 (and updated in 2005). It includes these sub-headings:

• Many Will Survive the Earthquake
• Heed Natural Warnings
• Heed Official Warnings
• Expect Many Waves
• Head for High Ground and Stay There
• Abandon Belongings
• Don’t Count on the Roads
• Go to an Upper Floor or Roof of a Building
• Climb a Tree
• Climb onto Something that Floats
• Expect the Waves to Leave Debris
• Expect Quakes to Lower Coastal Land
• Expect Company

The biggest new lesson so far from Japan is that debris – that means cars, busses, even houses – swept up in water moving 30 miles per hour can do more damage than anyone realized.

Japan also has invested more than any other country in structures — such as evacuation towers, flood-gates on rivers, and sea-walls. It’s still too early to say which of those helped. It’s possible those defenses work for more common earthquakes.  But, this quake was the fourth or fifth strongest ever recorded.

In an email, one scientist in Japan says she heard the tsunami washed people off the roof of an office building that was more than 40-feet tall. How can you prepare for that?

“You are talking about one of the forces of nature that packs more force per pound than any other,” says Gonzalez, referring to tsunamis. “You can minimize the fatalities, you can minimize the damage, but there are some things in nature where you can’t eliminate the danger.”

The quake hit Christchurch, New Zealand, a city comparable in size to Spokane, along a fault-line that was unknown until last September. That’s when an even larger quake hit New Zealand — but with limited damage, since it was centered farther from any city. Authorities in Christchurch were predicting the death-toll would rise to 300.

In recent years, scientists have found evidence of shallow faults across the northwest, such as the Seattle fault that runs beneath Qwest Field (the Seahawks stadium) and roughly follows Interstate-90.

“In fact, there’s sort of one per town,” says John Vidale, a professor of earth sciences at the University of Washington and director of the Pacific Northwest Seismic Network. “There’s the Tacoma fault, there’s the Olympia fault, there’s the Portland hills fault, there’s the south Whidbey fault, which runs up the east side of the Puget Sound.”

Just like in New Zealand, these shallow faults shake only rarely – perhaps once every 1,000 years, or even once in 10,000 years. Rare, but extremely deadly.

Comparing to Nisqually, ten years ago — smaller but stronger

In contrast, the most recent major earthquake in western Washington was the Nisqually earthquake. The tenth anniversary happens to be on Monday.

Seattle's Pioneer Square shortly after the 2001 quake.

It was bigger in magnitude than the one in New Zealand, but ten times as deep in the ground.

Here’s a comparison:

Christchurch quake, February 22 2011:

• Magnitude – 6.3
• Depth – 3.1 miles
• Time of day – 12:51 pm

Nisqually quake, February 28 of 2001:

• Magnitude – 6.8
• Depth – 32 miles
• Time of day – 10:54 am

The forces people felt in New Zealand were three to four times as strong as the worst shaking from the Nisqually quake, based on preliminary data, Vidale said via e-mail.

The University of Washington’s Vince Stricherz has written a nice look-back at the Nisqually quake and a few lessons that have been learned since then. For example, we have better maps of which neighborhoods have the highest risks, and more older buildings have been strengthened.

Still, the devastation in a city with modern building codes (as opposed to a city like Port-au-Prince, Haiti) should be sobering in Seattle, Portland, and anywhere in between.

“I think [the damage] would probably be worse here [in the Seattle area] than New Zealand, in that we are much more built up, and we have a lot of old structures built before we knew we have big earthquakes here,” says Vidale.

Emeritus Geology Prof. Robert Yeats of Oregon State University, quoted in a news release, agrees:

“It’s worth keeping in mind that New Zealand has some of the most progressive building codes in the world. They are better prepared for an earthquake like this than many U.S. cities would be.”

Disaster planners like to remind us that some simple preparations can help – such as tying down your water heater, reinforcing your chimney, and making sure you have an emergency kit and a plan.

Yes, there is.

“Our weather often is the just the opposite of what it is in the eastern part of the united states,” says Cliff Mass, professor of Atmospheric Sciences at the University of Washington.

“When we are cold, like it was just before Thanksgiving, they tend to be warm,” says Mass.

The reason we’re yin when they’re yang, and vice versa, has to do with the jet stream and “ridges” of high and low pressure in the sky, as Mass explains it.

A pressure ridge is parked over the Pacific Ocean, near our coastline. That’s sending the jet stream north.  For every ridge, there must be a valley (or “trough” in weather parlance), and a valley of low pressure has been stuck over the midwest. And, that’s sucking the jet stream, plus stormy Arctic air, back south, to the middle of the U.S.

“So the persistent ridging over us, bringing dry, cool weather this week over the NW, brings the opposite to those poor folks east of the Rockies. Want dry weather with lots of sun…forget Florida…head to Seattle,” writes Mass on his weather blog.

Sometimes, it’s the other way around, and the stormy trough is parked over Washington state, while the rest of the country gets the mild ridge.

The models, at this point, show a little weakening of the ridge and some light rain for us this weekend, but more sunny and clear weather next week.

It’s unusual to have a ridge last this long, but not unprecedented. The winter of 1976-77 had a similar pattern, but even more dramatic, with lots of dry days in western Washington. In January of 1977, a legendary blizzard hit upstate New York, and it snowed in Miami for the first time in history. Today’s (Wednesday Feb. 2nd) Seattle Times headline read:

“Once in a lifetime storm hits millions” (though it’s changed in the latest online version).

The one downside here in the NW: The Cascades had barely any snowpack in 1977. This year, the snowpack is running at about 70% of normal.

(If you’re looking for the audio version of this story, which aired on KPLU, you’ll find a link here.)

U.W. Medicine and Valley Medical Center proposed this week what they call a “strategic alliance.” Valley wants to retain its name, although the news release says Valley would become “part of U.W. Medicine.”

Earlier this year, U.W. Medicine took over running Northwest Hospital (in north Seattle), without actually owning the hospital.

As Dean Radford writes in the Renton Reporter:

Public Hospital District No. 1, which owns [Valley] medical center and neighborhood clinics, would still exist. Its five commissioners would sit on a larger board that would oversee management of Valley Medical. The Valley board would continue to oversee the hospital district itself.

In essence Valley Medical Center would become part of the UW Medicine system, which owns and operates Harborview Medical Center and the University of Washington Medical Center. UW Medicine also shares ownership and governance of Seattle Cancer Care Alliance, Children’s Hospital and Medical Center and Fred Hutchinson Cancer Research Center.

The bigger picture: U.W. Medicine and Swedish Medical Center are competing to be top-dog in the greater Seattle area. All the other hospitals are nervously watching, trying to decide if they can survive independently, or if they need to affiliate. I alluded to this in an article last spring, as the same pressures are reflected in the mad scramble to build new Emergency Departments all over King County.

The trend should be well-known to anyone in Pierce County, too, as the two major medical centers, Multicare and Franciscan, have been buying and opening outlying hospitals.

Under the new federal health law, the Affordable Care Act, hospitals are expecting they’ll need to have large networks of primary care physicians, along with specialists.

The law envisions a future payment system in medicine that penalizes hospitals whose patients do poorly after discharge. And, payments may become more similar to HMO’s (health maintenance organizations), such as Group Health Cooperative. Payments would be for achieving an outcome, keeping someone healthy, as opposed to paying every procedure and test individually.

Even if the Affordable Care Act is amended, as many in Congress now propose, the trend toward a new payment system has been embraced by many large businesses. They’re the ones who pay the bills for much of health care (along with the federal government, through Medicare).

A team based at Duke-National University of Singapore has been watching consumers at Taco Time restaurants, both in King County and in other counties, and found that adding all that info to the menus appeared to have no impact on people’s choices.  He published his results today (January 14, 2011) in the American Journal of Preventive Medicine.

As Shari Roan writes in the Los Angeles Times:

Thirteen months after the law went into effect, food purchases at the Taco Time restaurants in King County were identical to those at Taco Time restaurants where menu boards did not list nutritional information.

“Given the results of prior studies, we had expected the results to be small, but we were surprised that we could not detect even the slightest hint of changes in purchasing behavior as a result of the legislation,” the lead author of the study, Eric Finkelstein, of Duke-National University of Singapore Graduate Medical School, said in a news release. “The results suggest that mandatory menu labeling, unless combined with other interventions, may be unlikely to significantly influence the obesity epidemic.”

This will not be the last word on menu labeling.  The labels are coming soon to restaurants across the nation, because they were included in last year’s federal health care law, the Affordable Care Act.  And, other researchers have found conflicting results from studying menu labels in New York City and Seattle.

Confounding the research was the fact that Taco Time had recently started putting a “healthy choice” label next to some menu items, and consumers may have simply followed those logos.  Plus, as Alice Park at Time’s Healthland blog notes:

“…of course, there’s the possibility that people who chose to eat at fast food restaurants aren’t likely to be swayed by nutritional labeling. By walking into such establishments, they have already made a decision to put healthy choices aside.”

Over at Public Health Seattle & King County, spokesman James Apa tells me:

“We don’t subscribe to the conclusion that menu labeling doesn’t work.  We are doing separate, ongoing research.  We have survey data, and we found awareness and use at chain restaurants has increased, over the first 18 months.  A lot more people are saying, ‘Yes we are seeing it and using it.’

“And the second piece is, we are doing before implementation and during implementation studies, using people’s receipts. For this we’re focusing on burger chains. Are people eating fewer calories? The information there is preliminary.  Among people who say they saw and used the calories information, there was a decrease in calories purchased. “

Curiously, Apa says customers at one of the burger chains were eating fewer calories, but not at the others.  The researchers stood outside the restaurants and asked people for their receipts, then analyzed them for calories.

“For us, the bottom line is we can’t say what the full effect will be yet. This is all about addressing obesity, and we said from beginning, we are not expecting menu labeling itself to solve the obesity problem.  We want to know what kind of effect it can have,” says Apa.

(also posted at KPLU News)

Tuesday, May 11^th – First Lady Michelle Obama and Domestic Policy Council Director Melody Barnes will unveil the findings of the Childhood Obesity Task Force report, the result of the 90-day review that the President ordered around the launch of the Let’s Move! initiative in February.

Several of the Cabinet members and administration officials who are part of the task force will also attend this press briefing and be available to the media afterwards: Office of Health Reform Director Nancy-Ann DeParle, Secretaries Donovan, Duncan, Sebelius, SBA Administrator Mills, and FTC Chairman Leibowitz.

If the findings emphasize physical activity without making major recommendations about diet, then you can call it a victory for the food and beverage companies.  But, I expect they’ll have a little of everything.  From what I’ve learned lately, I wonder …

• Will it discuss ways to teach young families how to cook, especially using ingredients they’ve never tried?
• Will it suggest ways to make sure produce is affordable?
• Will it suggest a major tax on sugary beverages?
• Will it tackle the issue of food labeling and food marketing (health claims on packages and advertising to children)?
• Will it promote further study of the effects on obesity of hormone-mimicking chemicals on pregnant mothers and newborns?

Promoting physical activity is a good idea, too, for a lot of health reasons separate from weight-loss.  Mostly, I wonder if the report will spur any new action, beyond what’s already been attempted over the past decade.

(If you missed my story on why cooking classes might be important, here’s the link to KPLU.

I’ve been blogging about obesity issues all week (see “recent posts” or the tag “obesity”).  Today, I talked to Drewnowski.  I’ll share more about his ideas later. But, this one merits re-stating.  In work that was published in 2008, he took the basic federal data on obesity trends, and overlaid that onto a map of King County.  The wealthier the zip code, as measured by property values, the lower the obesity rates, and vice versa.

He told me the data might have been even more dramatic, because it turns out that the wealthiest areas (such as Medina) are not even represented.  As he put it, Rich people don’t answer surveys.

For the past two years, he’s been digging into some of the reasons why poor people are less healthy.  His baseline theory is the most obvious: eating well and taking care of yourself can be expensive, in time and money.

In work to be presented soon, he’ll argue against the idea that poor people need more grocery stores and fresh produce sold in their neighborhoods.  It turns out, most people will go several miles to get their groceries (except for the very poorest 1%).  Some people drive to the cheapest store, others drive to what they see as the better quality store. So, having more grocery stores wouldn’t make a difference.

You might get different results in Los Angeles, or Detroit — two cities where a lot of the research was conducted re.  lack of access to grocery stores.  He says that work doesn’t hold for Seattle/King County.

He does see a role for better food education (such as, cooking classes).  I’ll have that report Friday morning on KPLU.

Many states are planning to tax sodas.  Washington has jumped on this one, too. The taxes are mostly to help fill budget gaps, and way too small to make a meaningful health difference.

The man who’s studied this the most, and made it into a crusade, says the tax needs to be much higher than any state is considering: a penny-an-ounce.  That would add 12 cents to a can of soda, and more than 60 cents to those 2-liter bottles.  Kelly Brownell, of Yale University’s Rudd Center on Food Policy and Obesity, argues this would compel Americans to make healthier choices.

Yesterday’s NPR reports included a good overview from Jeff Brady, plus a pair of interviews by Michelle Norris.  Several listeners told me they felt Norris was too easy on the beverage industry spokesperson.

Studies have shown a pretty strong correlation between soft-drink consumption and weight gain.  And, the beverage industry response that Americans just need more exercise?  Exercise is good, but it’s not a major factor in the obesity crisis and can’t compensate for the big jump in calorie consumption.  The scientific evidence is pretty strong on that.  But, nutritionists will also tell you it’s too simplistic to think that cutting down on sodas by itself will solve the weight-gain problem.  It’s an important step, but there are additional dietary problems.

Neuhouser’s hypothesis is that the switch in diet is a trigger, going from typical rural Mexican meals dominated by beans, rice and fresh-made tortillas, to a more American diet that’s full of processed foods, white flour, fatty meats, and sugary drinks.  But, she also suspects the problem for Mexican immigrants is exacerbated by their genetic profile and how it reacts to the American foods.

She just received funding to study this in detail, by getting 50 Seattle-area Mexican women to eat their meals at the Hutch for a month, so she can control their diet, while monitoring their blood for a number of biomarkers.

The biomarkers might also help explain why Hispanic women tend to get a more virulent, hard-to-treat form of breast cancer.