Ala. Admin. Code r. 410-2-2-.07

Current through Register Vol. 43, No. 1, October 31, 2024

Section 410-2-2-.07 - Substance Use Disorder

(1) According to the 2018 National Survey on Drug Use and Health nearly one (1) in five (5) people aged 12 or older (19.4%) used some form of illicit drug in 2018, which is an increase from 2015 - 2016. Deaths from opioid overdoses alone were more than 42,000 in 2016.^[1] In Alabama the death rate from drug overdoses climbed 82% from 2006 to 2014. The drug crisis^[2] affects Alabama hospitals, schools, prisons, and businesses. (Unless otherwise stated, all statistics related to substance use disorders quoted in this section come from the 2018 National Survey on Drug Use and Health).

(2) During 2018, approximately 20.3 million people aged 12 or older had a substance use disorder (SUD) related to use of alcohol or illicit drugs during the previous year, including 14.8 million people with an alcohol use disorder and 8.1 million people with an illicit drug use disorder. The most common illicit drug use disorder reported was the misuse of marijuana (4.4 million people). An estimated 2.0 million people reported an opioid use disorder, including 1.7 million people with a prescription pain reliever use disorder and an additional 500,000 people with a heroin use disorder.

(3) In terms of recent initiates (new users within the previous year) to use or misuse of substances, the substances most used or misused were alcohol (4.9 million new users), marijuana (3.1 million new users), prescription pain relievers (1.9 million new misusers), and cigarettes (1.8 million new users). According to the Substance Abuse and Mental Health Services Administration ("SAMHSA"), in 2018 more than 4 out of 5 people aged 12 or older perceived great risk of harm from weekly use of either cocaine (86.5%) or heroin (94.3%), while less than one-third of people perceived great risk of harm from weekly marijuana usage (30.6%). Approximately 2 out of 3 people perceived a great risk from daily binge drinking (68.5%), and nearly 3 out of 4 people perceived great risk from smoking one or more packs of cigarettes daily (71.8%).

(4) Substance abuse is more common among both adolescents and adults who have a co-occurring mental health issue than among those who do not. Adolescents with a mental health issue were reported as more likely to binge drink (8.5%) or use an illicit drug (32.7%) versus those who do not report a mental health issue (binge drinking 4.1%, illicit drug use 14%). Similar difference in use are reported for adults aged 18 and older.

(5) According to SAMHSA, in 2018 an estimated 21.2 million people aged 12 and older needed substance use treatment in America (7.8%). This includes approximately 3.8% of adolescents aged 12 - 17; 15.3% of young adults aged 18 - 25; and 7% of adults aged 26 and older. Of these, approximately 3.7 million people in America aged 12 and older received treatment for substance use (1.4%), 2.4 million of whom received treatment at a specialty facility. Among the estimated 18.9 million people aged 12 and older who needed substance use treatment but did not receive any, approximately 964,000 perceived a need for treatment. Of those, approximately 40% did not receive treatment because they were not ready to stop using, and approximately one-third had no health care coverage and were not able to afford the cost of treatment.

(6) The State should encourage and promote a variety of treatments for SUD. Traditional treatments for SUD include abstinence-based systems such as 12-step programs. Methadone has been used successfully in recent years, especially for severe cases. SAMHSA has recently reported significant success with Medication-Assisted Treatment (MAT) which uses medications (primarily buprenorphine), in combination with counseling and behavioral therapies, to provide a "whole-patient" approach to the treatment of substance use disorders. Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery.

(7)Marijuana. The primary illicit drug used in 2018 was marijuana, with more than 43.5 million reported users within the previous year. The percentage of people aged 12 or older reporting marijuana usage within the previous year (15.9%) was higher than percentages reported to SAMHSA from 2002 - 2017. The increase is primarily due to increases reported in young adults (aged 18 - 25) as well as in adults (aged 26 or older). By comparison, and in contrast to these numbers, adolescents aged 12 - 17 did not show an increase in usage between 2014 - 2018.

(8)Prescription Drugs. The second most reported form of illicit drug usage in 2018 was misuse of prescription pain relievers, with 3.6% of the population reporting illicitly using prescription pain relievers within the last year. For all people aged 12 or older, and for young adults aged 18 - 25, the percentage of the population reporting illicit usage of prescription pain relievers decreased in 2018 compared to 2015 - 2017. Similar decreases were reported for adolescents aged 12 - 17 and for adults aged 26 or older compared to 2015 - 2016 but are similar to the percentages reported in 2017. Among all people aged 12 or older in 2018 who misused pain relievers in the last year, a significant majority (63.6%) reported that the main reason for misuse was to relieve physical pain. More than half of people who misused pain relievers in the last year (51.3%) reported obtaining the pain relievers from a friend or relative.

(9) According to the Alabama Department of Public Health ("ADPH") 2017 Overdose Surveillance Summary, 836 people in Alabama died of an overdose, 419 of which involved opioids. The top four (4) drugs related to overdose deaths in 2017 were fentanyl (161 deaths); heroin (128 deaths); methamphetamine (110 deaths); and cocaine (98 deaths). Additionally, in 2018 there were 11,081 visits to hospital emergency departments in Alabama related to overdoses, with, 2,180 involving opioids. There was a total of 20,353 overdose-related 911 runs in 2018, with 4,373 involving opioids. In 2017, the rate of drug overdose deaths in Alabama was 17.1 per 100,000 population, an increase from both 2016 (15.4 per 100,000) and 2015 (14.9 per 100,000). The rate for opioid deaths in Alabama in 2017 (8.6 per 100,000 population) was also an increase from both 2016 (7.0 per 100,000) and 2015 (5.7 per 100,000).

(10)Opioid Abuse

a. Opioids are a class of drugs that include heroin as well as prescription pain relievers such as oxycodone, hydrocodone, morphine and fentanyl. These drugs work by binding to the body's opioid receptors in the reward center of the brain, diminishing pain as well as producing feelings of relaxation and euphoria While most overdose deaths are caused by illegal drugs, many people first become addicted to opioids by using prescription drugs that were legally obtained.

b. According to the Alabama Opioid Overdose and Addiction Council, over 42,000 Americans died from opioid overdoses in 2016. According to SAMHSA, approximately 10.3 million people aged 12 or older misused opioids in 2018. This number corresponds to approximately 3.7 percent of the population. Of these, the vast majority (9.9 million users) misused prescription pain relievers, compared to a much smaller population (808,000) who used heroin. The majority of people who misuse prescription pain relievers (9.4 million) had not used heroin, but a small number (506,000) misused prescription pain relievers and used heroin within the last year. Among those 12 - 17 years old, approximately 699,000 adolescents misused opioids within the last year, with another 1.9 million young adults between the ages of 18 - 25 also misusing opioids.

c. In the state of Alabama, the number of drug overdose deaths, including opioid deaths, climbed eighty-two percent (82%) from 2006 to 2014. According to the Alabama Department of Mental Health ("ADMH") Substance Abuse Division, in 2018 4,546 individuals were treated by the department, or by entities contracted by the department, for heroin addiction with an additional 7,082 treated for addiction to other opiates and synthetics. These statistics, however, do not include individuals not treated by the department or its contracted entities. These individuals make up approximately thirty-four percent (34%) of the patients that received treatment for substance use related disorders by ADMH or contracted entities.

d. Currently ADMH works with eighty-three (83) Certified and Contract entities to provide services to individuals suffering from substance use disorders, providing substance abuse treatment, medication assisted therapy and prevention services. An additional eleven (11) providers are certified to provide prevention or treatment services to patients, but do not receive funding from the Department. There are twenty-one (21) Opioid Replacement Therapy (ORT) clinics throughout the state that specifically target individuals suffering from Opioid Use Disorders. Additionally, there are nineteen (19) public, nonprofit regional mental health boards, called 310 boards, throughout the state. Of these, fourteen (14) provide substance abuse treatment services. Birmingham and Tuscaloosa have regional boards, with additional mental health centers attached to them.

e. Governor Ivey created the Alabama Opioid Overdose and Addiction Council through Executive Order 708 on August 8, 2017. The Council, co-chaired by the Commissioner of the Alabama Department of Mental Health, the Attorney General of Alabama, and the State Health Officer, was created to "study the State's current opioid crisis and identify a focused set of strategies to reduce the number of deaths and other adverse consequences of the opioid crisis in Alabama." The Council was given a set of directives related to this purpose, including:

1. Advise and assist the Governor in the development of a comprehensive, coordinated strategy to combat Alabama's opioid crisis;

2. Gather and review data characterizing the opioid crisis facing Alabama, including the threat of synthetic opioids;

3. Review strategies and actions already taken in Alabama to combat the opioid crisis;

4. Review strategies and actions of other States and the National Governor's Association Compact to Fight Opioid Addiction; and

5. Develop a comprehensive strategic plan to abate the opioid crisis in Alabama.

f. The State of Alabama Opioid Action Plan, created by the Alabama Opioid Overdose and Addiction Council and published December 31, 2017, describes a four-pronged approach to addressing the current opioid crisis in Alabama. The four prongs to the approach described by the council are:

1. Prevention of opioid misuse. Including strategies to modernize the state's Prescription Drug Monitoring Program (PDMP) to fully realize technological improvements in how prescription opioids are prescribed and dispensed, continuing improvements in the education of prescribers and prescribers-in-training, the reduction of stigma attached to opioid addiction, and the development of a centralized data repository that can be used to understand and combat the problem;

2. Intervention within the law enforcement and justice systems. Addressing drug trafficking laws and working with drug courts in Alabama to encourage the use of medication assisted treatment (MAT) for those with Opioid Use Disorders (OUD);

3. Treatment of those with OUDs. Increasing access to care for those with OUD in Alabama and encouraging the use of evidence-based practices to improve the identification and treatment of those with OUD; and

4. Community Response that engages ordinary Alabamians to become involved with finding solutions at a local level. Focus on expanding the availability and usage of naloxone (a potentially life-saving opioid reversal drug); the building of partnerships with businesses, educational institutions and community organizations to improve awareness and involvement; and encouragement for counties to adopt the Stepping Up Initiative, which provides tools to create data driven strategies that work within the judicial system.

g. ADMH has received several grants in recent years in order to combat substance use disorders, including the State Opioid Response Grant, the Medication Assisted Treatment Prescription Drug Opioid Abuse grant (in specific counties), another grant to expand Drug Courts into specific rural counties, as well as grants from both the USDA (to provide telehealth equipment in specific counties) and the CDC (in partnership with ADPH to provide peer counseling in Emergency Departments).

h. In 2019, Governor Ivey secured funding in the state's operating budget to improve the Prescription Drug Monitoring Program to, in part, make it easier to use for both physicians and pharmacists. Also, Governor Ivey signed a law making it a crime to traffic in either fentanyl or carfentanil, which are synthetic opioids with a higher potency than heroin. The new law makes it a felony to knowingly possess more than a half gram of fentanyl or a related synthetic opioid or to possess, sell, or deliver a mixture containing fentanyl or a related synthetic opioid. Both Acts were directly recommended by the Alabama Opioid Overdose and Addiction Council.

i. ADMH recently partnered with Auburn University to create the Opioid Training Institute, providing education to both community members and health care professionals about the current status of opioid abuse in Alabama and to provide strategies and solicit ideas on how to combat the crisis moving forward. The Department has also worked with ADPH to supply naloxone to first responders throughout the state in order to improve access to a potentially life-saving drug to any law enforcement or medical professional who may be called upon to assist an individual suffering from an opioid overdose.

(11)Methamphetamine Use

a. Methamphetamine is a potent stimulant with high abuse potential that can be smoked, snorted, injected, or taken orally. The desirable short-term effects of Methamphetamine or initial "rush" is characterized by increased energy and alertness, elevated positive mood ^[3] state, and decreased appetite.

b. According to SAMHSA, in 2018 approximately 1.9 million people aged 12 or older used methamphetamines in the past year. This number corresponds to approximately 0.7% of the population. These numbers have not appreciably changed between 2015 and 2018. Among younger users, approximately 43,000 adolescents between the ages of 12 and 17 used methamphetamine in the last year, and approximately 237,000 young adults between the ages of 18 and 25 used methamphetamines in the last year. In both cases, the percentages of the population using methamphetamines in the last year have not appreciably changed between 2015 and 2018.

c. In the last two years, the number of people abusing methamphetamine in Alabama has outnumbered the number of people abusing other drugs such as cocaine, heroin and marijuana. Most of the users of crystal meth in Alabama are people between 18 and 25 years of age.

(12)Ecstasy. Ecstasy abuse in Alabama continues to increase. Ecstasy, as well as similar drugs such as LSD, GHB, and ketamine are primarily abused in night club settings and are often referred to as "club drugs." Arrests, overdoses and emergency room visits for club drugs have mirrored the increase in use. Ecstasy remains the leading number one club drug, followed by GHB.^[4] GHB overdoses have been reported in several areas of the state.

(13)Cocaine. Cocaine is among Alabama's most significant drug threats. Cocaine is widely available throughout Alabama, as it ranks second for the number of drug addiction treatment admissions. In 2010, 2,108 individuals were treated for smoking cocaine with an additional 842 people treated for using cocaine through other routes of ingestion.

(14)Heroin. Heroin abuse, use, and sales have skyrocketed across the nation. In fall of 2015, police departments across Alabama were expressing concern over the growing number of deaths across all counties.

(15)Alcohol Abuse

a. According to SAMHSA, in 2018 approximately 139.8 million Americans aged 12 and older used alcohol in the month prior to being surveyed, 67.1 million were binge drinkers during the same time period, and 16.6 million were heavy drinkers during the same time period. Approximately 2.2 million adolescents aged 12 - 17 drank alcohol within the previous month, with 1.2 million of those binge drinking. For the purposes of the survey, binge drinking was defined having had five (5) or more drinks on the same occasion on at least one (1) of the previous thirty (30) days. Heavy alcohol use is defined as binge drinking on five (5) or more days during the previous thirty (30) days.

b. SAMHSA data from 2015 - 2016 indicates that approximately 43.94% of Alabamians ages 12 and older reported using alcohol within the previous month. For adolescents aged 12 - 17, the same survey indicates that 8.08% used alcohol within the previous month, and for young adults ages 18 - 25, approximately 50.76% used alcohol within the previous month. Approximately 4.16% of Alabamians ages 12 and over were reported to suffer from alcohol use disorder in 2015 - 2016, with adolescents aged 12 - 17 being affected at a rate of 1.67% and young adults aged 18 - 25 affected at a rate of 9.08%^[5]. All of these rates are reported as being lower than the national and regional averages for both alcohol use and alcohol use disorder.

(16)Tobacco

a. More people die every year from smoking than from murder, AIDS, suicide, car crashes, and alcohol combined.^[6] Alabama has the 8^th highest adult smoking prevalence rate in the nation.

b. ADPH reports that 21.5% of adults in Alabama are current cigarette smokers. An estimated 23.3% of males and 20.0% of females smoke. From 1996 to 2016 adult smoking prevalence fell on average only 0.2% per year and 10.9% of high school students are current smokers. ^[7] According to the 2018 National Center for Health Statistics, 10.1% of mothers reported smoking during pregnancy.

c. A key focus area for the state should be the impact of smoking on Alabama's youth. According to the 2016 Youth Tobacco Survey (YTS), 10.9% of high school students are current smokers. There was a significant difference in smoking prevalence between males (12.9%) and females (8.8%) in high school whereas the prevalence in middle school were very similar (3.4%). Also, the smoking disparity among racial/ethnic groups increased in high school where white students (14.3%) were twice as likely to smoke compared to African American (5.4%) and Hispanic students (7.5%).

d. Additionally, secondhand smoke creates significant problems for Alabama citizens. Secondhand smoke kills over 750 nonsmoking Alabamians each year. Children exposed to secondhand smoke are at an increased risk for Sudden Infant Death Syndrome, acute respiratory infections, ear problems, severe asthma, and reduced lung function.

e. The use of tobacco creates an economic burden on the State as well. ADPH estimates that $5.16 billion in excess personal medical care expenditures were attributable to smoking. There are an estimated $887.9 million in productivity losses as a result of smoking-attributable premature death. An additional $1.33 billion in productivity losses were estimated as a result of smoking-attributable illnesses. And $187.5 million in economic costs were attributed to personal medical costs and productivity losses associated with secondhand smoke. The total annual economic impact of smoking in Alabama is estimated to^[8] be $7.6 billion.

f. Recent research has shown that youth prevalence rates in Alabama have decreased substantially, although this is known to be somewhat offset by a rise in the use of e-cigarettes among young people in particular. The increase in the state's tobacco tax rate is expected to continue to help reduce young people's initiation of tobacco use and will likely generate an estimated $62 million of revenue annually.

g. Efforts to address the tobacco problem in Alabama have been led by ADPH. The Alabama State Plan for Tobacco Prevention and Control is the result of the efforts of the Alabama Tobacco Use Prevention and Control Task Force. The task force is composed of agents of ADPH and its national, state, and local partners. Representatives of task force partner organizations met in March of 2015 to review the state's progress regarding tobacco prevention and control and update the previous plan drafted in 2010.

h. One of the key partners ADPH is coordinating with is the Tobacco Prevention and Control (TPC) Branch of North Carolina Department of Health and Human Services. The TPC works with local coalitions, community agencies, and state and national partners to implement and evaluate effective tobacco prevention and cessation activities that meet the following goals:

1. Eliminating environmental tobacco use exposure.

2. Promoting quitting among adults and youth.

3. Preventing youth initiation.

4. Identifying and eliminating disparities among populations.

i. Another initiative that Alabama should support is the Federal Drug Administration's Youth Tobacco Prevention Plan, a series of actions to stop youth use of tobacco products, especially e-cigarettes, with special focus on three key areas:

1. Preventing youth access to tobacco products.

2. Curbing marketing of tobacco products aimed at youth.

3. Educating teens about the dangers of using any tobacco product, including e-cigarettes, as well as educating retailers about their key role in protecting youth.

j. While the ADPH efforts have had some minor success, the state still trails the country in its efforts to reduce tobacco related illness and death. The State Plan for Tobacco Prevention and Control may be seen as an important step in the process of moving the state along the right track toward reaching those goals.

(17)Vaping

a. E-cigarettes are battery-powered devices that allow users to inhale aerosolized liquid. E-cigarettes are also called vapes, vape or hookah pens, electronic nicotine delivery systems (ANDS), mods, vaporizers, and tank systems. Even though e-cigarettes do not contain any tobacco, the Food and Drug Administration (FDA) classifies them as "tobacco" products. The amount of nicotine provided by e-cigarettes varies by device.

b. These devices have become the most used tobacco product among Alabama youth in the past few years. Until recently these devices were not regulated as typical tobacco products. In fact, the e-cigarettes are not currently listed in any sections of the State's statutes included in the definition of "Tobacco Products." Originally e-cigarettes were offered as an alternative to regular tobacco products as a means of assisting in smoking cessation. Their popularity, especially among youth, has overtaken any effort to reduce smoking and tobacco addiction.

c. According to the American Cancer Society the possible long-term health effects of e-cigarettes aren't yet clear, but there have been recent reports of serious lung disease in some people using e-cigarettes or other vaping devices. Symptoms have included:

1. Cough, trouble breathing, or chest pain;

2. Nausea, vomiting, or diarrhea; and

3. Fatigue, fever, or weight loss

d. Furthermore, recent reports show nicotine exposure can harm brain development and as a result is more harmful to adolescents. Nicotine can also cause harmful physical effects to the cardiovascular and central nervous system. Eating, drinking, or absorbing nicotine in any way can lead to nicotine poisoning, especially in children. If used during pregnancy, nicotine may also cause premature births and low birthweight babies.

e. Nicotine, the main drug in tobacco products and ecigarettes, is known to be highly addictive. Developing adolescent and young adult brains are even more susceptible. In addition to being highly addictive, the American Cancer Society reports that nicotine is a major carcinogen and can cause lung disease, heart disease, and cancer.

f. Besides nicotine, e-cigarettes and e-cigarette vapor contain propylene glycol and/or vegetable glycerin. These are substances which have been found to increase lung and airway irritation after concentrated exposure.

g. In addition, e-cigarette and e-cigarette vapor may contain the chemicals or substances listed below:

1. Volatile organic compounds (VOCs): at certain levels, VOCs can cause eye, nose and throat irritation, headaches and nausea, and can damage the liver, kidney and nervous system.

2. Flavoring chemicals: some flavorings are more toxic than others. Studies have shown that flavors contain different levels of a chemical called diacetyl that has been linked to a serious lung disease called bronchiolitis obliterans.

3. Formaldehyde: this is a cancer-causing substance that may form if e-liquid overheats or not enough liquid is reaching the heating element (known as a "dry-puff").

h. The FDA does not currently require e-cigarette manufacturers to stop using potentially harmful substances. And, it is difficult to know exactly what chemicals are in an e-cigarette because most products do not list all of the harmful or potentially harmful substances contained in them.

i. The Stringer-Drummond Vaping Act, HB41, passed in May 2019. It requires the Alabama Alcoholic Beverage Control Board to regulate retail sales of alternative nicotine devices like sales of tobacco products and prohibits the sale or transfer of alternative nicotine products to minors. The law also prohibits retailers and manufacturers of alternative nicotine products and electronic nicotine delivery systems from advertising the products near schools; and to prohibit specialty retailers of electronic nicotine delivery systems from opening new places of business near schools, child care centers, churches, and other facilities. The law prevents retailers and manufacturers of alternative nicotine products or electronic nicotine delivery systems from advertising those products as tobacco cessation devices as a healthy alternative to smoking. E-cigarettes may only be sold in tobacco, mint, or menthol flavors.

j. The Stringer-Drummond Act also requires retailers of alternative nicotine products or electronic nicotine delivery systems to obtain a tobacco permit, to comply with FDA regulations governing the retail sale of alternative nicotine products and electronic nicotine delivery systems. Vendors must post warning signs in their stores regarding the dangers of nicotine use and potential risks associated with vaping.

k. Under the Act, anyone selling e-cigarettes is prohibited to sell or transfer alternative nicotine products or electronic nicotine delivery systems to minors; and in connection therewith would have as its purpose or effect the requirement of a new or increased expenditure of local funds within the meaning of Amendment 621 of the Constitution of Alabama of 1901, now appearing as Section 111.05 of the Official Recompilation of the Constitution of Alabama of 1901, as amended.

l. ADPH recently recommended that all consumers consider refraining from the use of electronic cigarette and vape products until national and state investigations into vaping-related deaths and illnesses are complete. This recommendation came after the Centers for Disease Control and Prevention reported a cluster of severe pulmonary disease among people who use e-cigarettes or vape products, with more than 800 cases of lung injury reported from forty-six states and one U. S. territory. Two-thirds of cases are 18 - 34 years old, and twelve (12) deaths had been confirmed by September 2019 in ten (10) states.

^[1]2018 National Survey of Drug Use and Health, Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services (HHS). 2018.

^[2]State of Alabama Opioid Action Plan, produced by the Alabama Opioid Overdose and Addiction Council, 2017.

^[3] Rawson RA, Gonzales R, McCann MJ, Obert J. Methamphetamine use among treatment-seeking adolescents in Southern California: participant characteristics and treatment response. Journal of Substance Abuse Treatment. 2005; 29:67-74.

^[4] Downloaded from Addictionrecovery.net, November 11, 2019.

^[5]Alabama Drug Abuse Statistics, 2019, www.recoveryconnection.com: owned and operated by Lakeview Health.

^[6] Alabama Department of Public Health. 2019

^[7] 2016 Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control.

^[8] Dunlap, S.T. & McCallum, D. (2019). Update: The Burden of Tobacco in Alabama, 2019. Tuscaloosa, AL: Institute for Social Science Research, University of Alabama.

Ala. Admin. Code r. 410-2-2-.07

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 03, December 31, 2014, eff. 1/6/2015.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 06, March 31, 2020, eff. 5/15/2020.

Adopted by Alabama Administrative Monthly Volume XLII, Issue No. 07, April 30, 2024, eff. 6/14/2024.

Author: Statewide Health Coordinating Council (SHCC)

Statutory Authority:Code of Ala. 1975, § 22-21-260(4).