WA) and DC have legalized marijuana for medical use.

In November 2014, Alaska became the 4th state (in addi-

The past year has been the year of cannabis with more and more states passing laws that legalize marijuana. Al-though these laws vary in their details, laws are gener-ally categorized according to the breadth of their cov-erage for medical use only or for additionally includ-ing recreational use. While several states have passed laws governing the grow-ing, use and distribution in their state, it is important to note these laws conflict with the federal laws that restrict ownership, growth and distribution of cannabis.

While injury prevention professionals look on with uncertainty about how to craft and deliver injury pre-vention messages, 23 states have legalized marijuana for medical use and 4 states for recreational use. On July 7th , 2014, NY State Gover-nor Andrew Cuomo signed the Compassionate Act, which legalized medical marijuana prescriptions for several conditions. In addi-tion to NY, 22 other states (AK, AZ, CA, CO, CT, DE, HI, IL, ME, MD, MA, MI, MN, MT, NV, NH, NJ, NM, OR, RI, VT and

MARIJUANA LEGALIZATION GROWS ACROSS STATES DESPITE FEDERAL PROHIBITION

CENTER FOR INJURY EPIDEMIOLOGY AND PREVENTION AT COLUMBIA UNIVERSITY

THE INJURY TIMES

POLICY AND LEGISLATIVE INITIATIVES FOR PREVENTION SUMMER 2015

This map shows states that have legalized some type of marijuana use: recreational (purple), medical (green), targeted (red).

Although the policies and impact differs across states, they general-ly have common features: limits on the length of time and dosage of prescriptions, requirements for a physical examination before

Source: CDC WISQARS data, 2015

INSIDE THIS ISSUE :

PRESCRIPTION DRUG

AND SUBSTANCE SAFETY

UNINTENTIONAL DRUG

OVERDOSE DEATHS

1

LEGALIZATION OF

MARIJUANA LAWS

1

STATEN ISLAND OVERDOSE

PREVENTION

2

DRUG FREE SCHOOL ZONE 2

DRIVING WHILE IMPAIRED 3

NYC INJECTING DRUG

USER INITIATIVE

4

DESIGNER DRUGS CREATE

NEW SAFETY RISKS

5

SUBSTANCE ABUSE AND

TRANSPORTATION

5

MEASURES TO CONTROL

SYNTHETIC DRUG USE

6

Unintentional drug overdose deaths overtake motor

vehicle deaths in U.S.

According to Centers for Disease Control (CDC), from 1999 to 2013, the amount of prescription painkillers dis-pensed nearly quadrupled during which time drug over-dose deaths became the lead-ing cause of injury deaths. In 2013, 43,982 drug overdose deaths were reported in the United States, of which 37% were related to opioids, a class of prescription drugs used to treat both acute and chronic pain.

Several states have taken ac-tions to combat the epidemic of prescription drug overdose. State programs in FL, NY, TN and OR have shown promis-ing results.

receipt of a prescription, use of tamper-resistant prescription forms, computerized data sys-tems to discourage doctor shopping and requirements for identification at purchase.

tion to OR, WA and CO) to legalize recreational use of can-nabis. More states are

(Continued on page 3)

Staten Island’s multipronged prevention approach shows promise in

lowering the opioid overdose mortality epidemic

cians in the City’s 11 public hospital emergency depart-ments from prescribing long-acting opioid painkillers. Also as part of this regulation in public hospitals, emergen-cy departments can prescribe no more than a 3-day supply of opioid painkillers and will not refill lost, stolen or de-stroyed painkiller prescrip-tions. Voluntary participation has been requested in the city’s private hospitals.

The NYC DOHMH took the lead and collaborated on the multipronged approach both citywide and in Staten Island with several interventions: 1) development and dissemina-tion of citywide opioid pre-scribing guidelines; 2) public education through a data brief for local media high-lighting Staten Island mortali-ty and prescribing data; 3) Staten Island town hall meet-ings convened by the NYC commissioner of health and meetings with Staten Island

stakeholders; 4) a Staten Island campaign to promote prescribing guidelines; and 5) a citywide airing of public service announcements on the dangers of opioid pain-killers with additional airing in Staten Island.

According to the MMWR (May 15, 2015 / 64(18); 491-494), after adopting the comprehensive public health

In NYC between 2000-2011, the rate of opioid analgesic-involved overdose deaths increased citywide by 57% (to 3.3 per 100,000 resi-dents) while the rate of in-crease in Staten Island was an overwhelming 257% (10.7 per 100,000 residents).

The NYC Mayor’s office and the NYC Department of Health and Mental Hygiene (DOHMH) developed public health responses targeted specifically to the issues sur-rounding this public health problem. Statewide legisla-tion was passed that launched a surveillance system to track the issue, the Internet System f o r T r a c k i n g O v e r -Prescribing (I-STOP). This law requires prescribers to review the state prescription monitoring system before prescribing a controlled sub-stance. In January 2013, one of the NYC mayor’s public health actions included issuing a guideline that forbids physi-

PAGE 2 THE INJURY T IMES

initiatives, a 29% decline of opioid overdose mortality rate from 2011 to 2013 was seen in the intervention bor-ough, Staten Island, with the rate for other four boroughs of NYC remaining un-changed during the same time frame. In 2013, opioid analgesic prescriptions being filled decreased by 9.8% in

(continued on page 5)

Buffer zones for schools: Drug free school zone laws

The illicit drug trade has long been credited with in-creased violence and vio-lence-related injury as well as increased poisoning and other ill health effects in communities. In 1984, the first drug-free school zone laws were passed as a part of federal “Comprehensive Criminal Control Act” to provide a drug-free area to protect children from drugs, drug-related gang violence

and illegal distribution of drugs in school areas. To-day, all states and DC have adopted some form of drug- free school zone laws.

In general, these laws are designed to enhance the penalties of drug trafficking that happens in school zones, but they vary in terms of the definition of school zones, type of drug

(continued on page 4)

Source: NYC DOHMH (Click Here for Full Poster)

ational use. MPP, like other advocacy groups, is divided into three entities— lobby-ing, education and financial support of congressional can-didates.

Although MPP does not pub-licly disclose its funding sources, it is reported that a small number of wealthy indi-viduals are providing substan-tial support for marijuana

legalization.

While legalization of medical marijuana can generate tax revenues for states and in-crease access for chronically ill patients by providing an alternative means of alleviat-ing pain, several studies show that legalization of marijuana may cause other unanticipated public health issues. Marijua-na use has been linked to in-

Focus on driving while impaired expands beyond alcohol to drugged

driving despite the greater challenge of diagnosis and detection

Driving while impaired has long been recognized as a road safety concern. While early historical efforts cen-tered on alcohol, the recent proliferation and legalization of formerly illegal substances, introduction of newly emerg-ing designer drugs and an aging population where polypharmacy may have unin-tended consequences all con-tribute to the increased chal-lenge of developing and en-forcing effective legislation for driving under the influ-ence of drugs (DUI-D).

According to the 2013-2014 National Roadside Survey of Alcohol and Drug Use by Drivers, an increase in drugged driving was noted with one in five drivers test-ing positive for at least one drug in 2014. In 2013, among tested drivers in the Fatality Analysis Reporting System (FARS), 38.4% of fatally-injured drivers were positive. Unlike alcohol, it is difficult

PAGE 3 THE INJURY T IMES

MARIJUANA LEGALIZATION GROWS ACROSS STATES DESPITE FEDERAL PROHIBITION

creased traffic and work-place injuries as well as un-intended ingestion and poi-soning among young chil-dren.

Some fear that legalization may send the wrong mes-sage to minors and make marijuana more accessible to underage users who are already at increased risk of both causing and being a traffic fatality.

for police to determine the level of impairment by drugs. Alcohol has rapid and reliable tests that can be effective for detecting and quantifying the active of-fending ingredient. For ex-ample, the breathalyzer, the Field Sobriety Test or blood alcohol tests may be used to assess the presence and/or impact. One response to this diagnostic challenge has been developing per se legis-lation, which forbids pres-ence of any illicit substance in a driver’s body while in control of a vehicle, without any other evidence of im-pairment.

While the White House Office of National Drug Control Policy (ONDCP) is working to educate and pro-vide technical assistance to states to advance per se leg-islation to simplify the proof of an impaired driving viola-tion, to date, only 19 states (AZ, DE, GA, IL, IN,

(Continued from page 1)

considering whether to follow their lead in legalizing mariju-ana for recreational purposes.

The Marijuana Policy Project (MPP), an organization that played an instrumental role in legalizing recreational mariju-ana in CO and AK, targeted five states (AZ, CA, NV, MA and ME) to assist in drafting a 2016 ballot initiative aimed at legalizing marijuana for recre-

based on scientific evi-dence, there is not enough evidence to set a threshold for drugged driving, so most states with per se laws have set zero toler-ance rules. Although a similar argument was made for alcohol decades ago, critics of the legisla-tion note that some indi-viduals may respond differ-ently to drugs and that the same concentration of drugs may cause serious impairment in one driver while not in others. Zero tolerance rules for pre-scription drugs may cause confusion among legal prescription drug users. Despite advances in recog-nition of the contribution of drugs to motor vehicle injury and death, the lack of a fast and reliable road-side device that can detect a range of drugs limits the implementation and en-forcement of DUI-D laws.

IA, KY, MI, MN, MS, NV, NC, OH, PA, RI, UT, VA, WA and WI) have a strict per se standard that forbids pres-ence of a substance or drug in drivers while in control of a vehicle.

Although per se laws are de-signed to help identify viola-tions, there are also limita-tions.

One major debate about drug per se laws is that while most of the states have a threshold for alcohol impaired driving

Syringe exchange programs increase safe disposal of used syringes, reducing the risk of accidental injury associated needle sticks as well as their primary goal of reducing dis-ease transmission though needle sharing. Prior to the initiative of needle exchange programs, discarded used syringes, sometimes tainted with HIV, Hep C or other infectious diseases, were a common occurrence in play-grounds in low-income com-munities.

Syringe exchange programs, first run underground by activists, have existed in New York City since the mid-1980s and were formally legalized and funded in 1992. Generally, syringe exchange programs interrupt HIV

transmission by reducing sy-ringe sharing. Before legal-ized syringe exchange pro-grams, the prevalence of HIV among people who inject drugs was approximately 50% in New York City. Since the legalization of syringe ex-change programs, the preva-lence of HIV among injecting drug users decreased by an estimated 75%, to approxi-mately 14% today. In 2013, 49 new HIV diagnoses were attributed primarily to injec-tion drug use, representing 1.7% of new HIV diagnoses in New York City. These numbers, in a city of 8.3 mil-lion residents, stand in stark contrast to geographic regions without comprehensive ongo-ing programs.

Despite more than thirty

BUFFER ZONES FOR SCHOOLS : DRUG FREE SCHOOL ZONE LAWS

activities and level of in-creased penalties conferred to those found violating the drug free zones.

Critics note the application of drug-free school zones affects people from different racial and socioeconomic back-grounds differently and leads to disparities in incarceration.

Recently, several states have reformed their state drug-free zone laws. Most of the re-forms include shrinking the drug-free zone and changing

PAGE 4 THE INJURY T IMES

the minimum penalty for violating the law.

Despite these changes, there continues to be a paucity of scientific re-search and evaluation data about the effect of drug-free zone laws on children, particularly on violence and injury prevention, despite the law being for-mulated specifically to shield children from these dangers.

successful NYC injecting Drug user initiative has injury prevention

IMPLICATIONS

(Continued on page 5)

epidemic of hepatitis C or HIV; 2) the local health department has declared a public health emergency; and 3) the primary mode of transmission of hepatitis C or HIV is injection drug use. Programs cannot re-ceive state funding to dis-tribute syringes.

Critics note that these re-strictions are not in line with public health research on syringe exchange pro-grams and recommenda-tions for best practices. Syringe exchange programs prevent bloodborne infec-tions, and requiring a pub-lic health emergency to exist before permitting prevention programs to

years of research on the public health benefits of syringe ex-change programs, some jurisdic-tions continue to restrict syringe intervention.

In February 2015, Indiana state health officials identified an in-crease of HIV infections linked to syringe sharing. By June 19, 170 new HIV infections in southeastern Indiana had been identified. At least 80% of these infections were linked to sy-ringe sharing. At the time of the increase, Indiana prohibited syringe exchange programs from operating in the state. Two months after the increase in HIV cases was identified, Governor Pence temporarily allowed syringe exchange pro-grams to operate in counties meeting the following criteria: 1) the county has an ongoing

(Continued from page 2)

Despite the difficulties in determining the contribu-tions of each public health intervention, when used in combination, they have moved the prescription drug overdose mortality in the

right direction. Staten Is-land, the borough with the highest pre-intervention death rate and strongest intervention response, saw a mortality decrease without a corresponding mortality

Staten Island and 8.2% in other boroughs. The rate of high dose prescription de-creased 8.2% in Staten Island, but increased 4.7% in the other four boroughs of NYC.

PAGE 5 THE INJURY T IMES

decrease in other parts of the city, suggesting that commu-nity-specific initiatives com-bined with improved pre-scription drug surveillance systems have been successful in tackling opioid overdose.

operate limits their effec-tiveness.

The evidence that needle sharing exchange programs work to prevent infectious disease transmission is strong, and it may also de-crease improper needle dis-posal. There are anecdotal

reports of exposure of playground-aged children to discarded syringes. More scientific information is needed on needle-related risks associated with im-proper disposal of syringes and how this changes with exchange programs.

successful NYC initiative has injury prevention IMPLiCATIONS

Source: NYC DOHMH (Click Here for Full Poster)

Staten Island’s multipronged prevention approach shows promise in

lowering the opioid overdose mortality epidemic

(Continued from page 2)

Designer Drugs create new

safety risks

dangers, are lured by its low price – a dose can be purchased for as little as $5.

Recently, officials have taken actions to prohibit flakka and other designer drugs. In January 2014, the Drug Enforcement Administration (DEA) temporarily listed flakka, along with 9 other syn-thetic cathinones as a Schedule I controlled sub-stance. In the past few months, several individu-als have been charged for importing, distributing and intending to distribute flakka.

(Continued from page 4)

Multiple modes of Transportation

are impacted by substance abuse

As far back as the 1980s, fol-lowing several catastrophic transportation-related events with alcohol and drug involve-ment, the National Transporta-tion Safety Board (NTSB) rec-ommended that the Depart-ment of Transportation (DOT) prohibit the use of alcohol and other drugs across transporta-tion sectors. In 1988, DOT issued rules for drug testing in individuals working in safety sensitive occupations in all are-as of commercial transporta-tion. In the early 90s, several programs were established to identify and prohibit drug abuse and misuse in aviation, railroad, commercial trucking, maritime and mass transporta-tion.

To date, substance impairment in transportation is still on

NTSB’s Most Wanted List and they noted that substance abuse is a contributing factor in transportation events across several modes of trans-portation. According to their recent study on drug use trends in aviation, the preva-lence of potentially impairing drugs increased from an aver-age of 11 to 23 percent of flying-related fatally-injured pilots during the periods from 1990-1997 to 2008-2012. To address the continu-ing substance abuse issues in transportation, the NTSB provided several recommen-dations including better data collection and reporting sys-tems, education programs for transportation operators, strict DUI-D laws and better law enforcement.

In May 2015, The New York Times reported that flakka, a hazardous new designer drug originating in China, is being blamed for 18 recent deaths in a single South Florida county. “Flakka” (alpha-PVP) is a designer drug synthesized to mimic cathinone, a con-trolled substance. Accord-ing to the National Institute on Drug Abuse, flakka, like other synthetic cathinones, can cause “excited deliri-um”, a condition that in-volves hyperstimulation, paranoia, and hallucina-tions, which can lead to violent aggression and self-injury. Potential users, sometimes unaware of the

The Injury Times-Serving Public Health Service Region II and Beyond

The Injury Times is primarily focused on legislative and policy issues that impact public health service Region II and beyond. Each issue of the newsletter generally focuses on a topic of importance in injury prevention. Send topics and story leads, articles or news to the Faculty Editor.

The geographic scope of PHS Region II covers New York, New Jersey, and the territories of Puerto Rico and the U.S. Virgin Islands. In this and subsequent is-sues, we will highlight national issues for an injury prevention area with particular attention to the leading legislative efforts that are in motion to strengthen the in-jury prevention initiatives across Public Health Service Region II and those beyond that have lessons for us locally.

About the Center for Injury Epidemiology and Prevention

The Center for Injury Epidemiology and Prevention at Columbia University (CIEPAC) is based in the Department of Epidemiology at the Mailman School of Public Health and the Department of Anesthesia at Columbia University Medical Center. The Center is funded in part by a grant from the National Center for In-jury Prevention and Control, Centers for Disease Control and Prevention. Our mission is to improve population health by reducing the morbidity and mortality from unintentional and intentional injuries through research, dissemination and translation of scientific discoveries, development of innovative training and educa-tion programs, and promotion of best practices and evidence-based interventions.

Our objectives are to integrate expertise and resources, facilitate interdisciplinary collaboration, forge diverse partnerships, thereby, accelerating the advancement of science and practice in the injury control field.

722 West 168th Street Columbia University

New York, New York 10032

E-mail for news and comments: jp376@cumc.columbia.edu

CENTER FOR INJURY

EPIDEMIOLOGY AND PREVENTION

AT COLUMBIA UNIVERSITY

FACULTY EDITOR: JOYCE C. PRESSLEY,

PH.D, M.P.H.

STUDENT EDITOR: CHANG LIU

CONTRIBUTORS: CHANG LIU, MICHELLE

NOLAN, MPH, PATRICK DAWSON, MPH

W E ARE ON THE W EB :

HTTP : // CUINJURYRESEARCH . ORG/

According to NIH’s National Insti-tute on Drug Abuse, increased hospi-talization and poisoning are being linked to a growing selection of syn-thetic drugs. This increase is report-ed in several states and has catalyzed officials to take actions to lower the injury, poisoning and other health impacts of these drugs. On June 15, 2015, The New York Times report-ed that DC Mayor, Muriel Bower, said she would submit emergency legislation that allows the police chief to shut down any business found selling synthetic drugs.

The variety in potency, purity and the practice of multi-drug usage have been linked to poisoning and other unintentional injuries, including car crashes and death.

The nation’s capital initiates action to control poisoning and

unintentional injury linked to the recent surge in synthetic drugs

Synthetic drugs are designed to mimic the effect of a controlled substance while attempting to avoid being classi-fied as illegal. These synthetic products are sold under several brand names, which often can be openly purchased at gas stations, convenient stores or or-dered online.

Teenagers and young adults can easily get access to these types of drugs and are reported to experiment with mix-ing them into food or drinks for them-selves or other teens who may be una-ware of the associated dangers.

While DUI-D laws in many states cov-er these drugs through more general clauses in the law, tests to confirm use of the drugs are lagging given the speed with which new designer drugs are

hitting the marketplace. Most of the health effects are not well studied and there are no FDA-approved medications for treating addictions to these drugs.

As states learn from each other’s successes and failures, scientists are working rapidly to develop better and more rapid tests for detection of a wider array of substances.