Dr. Volkow underscored that tobacco and alcohol are the two drugs causing the greatest mortality, largely because these drugs are legal and readily available. Tobacco use is the leading preventable cause of death in the United States. According to a CDC Fact Sheet on Tobacco Related Mortality, tobacco use results in 278,544 deaths among men and 201,773 deaths among women annually. Dr. Volkow reported that strong tobacco prevention efforts focused on men have resulted in declining death rates from tobacco among men. Unfortunately, fewer efforts have targeted women with smoking prevention and cessation. Now that we are seeing a narrowing of the differences in smoking patterns between females and males, more smoking prevention and cessation efforts need to aggressively target women.
The fourth leading cause of preventable death in the United States is alcohol, which causes 62,000 deaths among men and 26,000 deaths among women annually. These alcohol-related deaths are the result of acute events (falls, car accidents, and poisoning) as well as chronic disease (liver disease cirrhosis, and cancer). Dr. Volkow noted that alcohol abuse is a significant problem among elderly women, resulting in a large number of fatal falls. This pattern needs to be understood and prevented.
Dr. Volkow explained that prescription drug misuse and abuse is a major and growing concern in the US Almost one in four persons (23.9 percent) report use of illicit drugs: marijuana is the most commonly used illicit drug (18.9 percent), followed by psychotherapeutics (6.8 percent) (SAMHSA 2012 National Survey on Drug Use and Health). Since 1990, death rates from drug overdoses (prescription opioids, benzodiazepines, antidepressants, cocaine, and heroin) have tripled overall with a five-fold increase in death rates from opioids for women. Among women, overdose deaths from prescription opioids are greatest among those between the ages of 35 and 55.
Dr. Volkow said that women are more likely than men to report chronic pain, to be prescribed prescription painkillers, to be given higher doses, and to use them for longer time periods. Also, women may become dependent on prescription painkillers more quickly than men. Citing a study prepared by the Institute of Medicine, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, Dr. Volkow reported that there are more than 100 million people in the U.S. with chronic pain. Women appear to suffer pain in more categories in comparison with men: For example, in 2008, more than twice as many women as men reported severe headaches or migraines (21.9 percent vs. 10.1 percent). Summing up, Dr. Volkow said that research is needed on disparities in the experience of pain among subgroups of Americans. It is especially important to focus research on what makes women particularly vulnerable to pain and the adverse effects of painkillers on women so that women can be treated properly.
Debbie Chapman Bryant, Nurse Practitioner, Health Care Provider
Debbie Chapman Bryant
Ms. Bryant explained that her decision to become a health care provider stemmed from growing up in a small rural community in South Carolina where women often put their own health care needs on hold due to limited time, money, and access to health care. As a result, many women succumbed to preventable and manageable diseases. Ms. Bryant described one woman who repeatedly returned to the hospital with complications from diabetes; neither she nor her family understood how to prevent or manage diabetes.
Today, Ms. Bryant directs a mobile screening van and navigation program, which serves as a safety-net system to address cancer disparities among racially diverse and medically underserved populations in South Carolina. This important screening and navigation program provides a continuum of services starting with prevention and early detection of cancer, and including diagnosis and treatment. The program utilizes highly trained 'lay' navigators who are experienced with local ethnic and rural cultures, as well as low health literacy among clients. These navigators help clients overcome the contextual and systemic barriers to health care. Ninety-two percent of the clients in this mobile screening and navigation program are women, 57 percent are African American, and five percent are Hispanic. Almost one in five (19 percent) clients report having less than a high school degree, and 60 percent report having inadequate health insurance. In addition, 80 percent of the clients report that they would not have sought cancer screening services in the absence of the services provided through the mobile van.
Ms. Bryant described several women served by her program. One 35 year old, uninsured African American woman was six months pregnant with her fifth child at the time of her breast cancer diagnosis through the screening and navigation program. Unfortunately, cancer treatment was delayed because the pregnancy-related Medicaid coverage provided to this woman did not cover other medical conditions and the required documentation for a separate new Medicaid application process was not readily available. Although the navigation team assisted this woman through the birth of her new baby and cancer treatment, the cancer was aggressive and she passed away.
Ms. Bryant described another woman who experienced a more positive outcome. This uninsured, 46 year old machine operator, who had gone without a mammogram for many years, received a screening mammogram from the mobile van that proved to be abnormal. A navigator with the program helped this woman through the biopsy and successful surgery to remove the cancer while in its early stage. This navigator offered emotional support and guided the client through the complex health care system — helping her complete financial paperwork, arrange reliable transportation, schedule appointments, and communicate with her primary provider. Because she returned each year for the recommended follow-up care, a recurrence of cancer was caught early. This woman was able to receive the necessary treatment and enroll in a clinical trial.
Ms. Bryant emphasized that data demonstrates the importance of the navigation program, showing a decrease in the proportion of at-risk patients who do not return for care following an abnormal mammogram from 11 percent in 2009 to fewer than five percent since 2010. This shows that, despite the many factors behind women's mortality (e.g., stress, poverty, fear, and a complex health care environment), results can improve when adequate infrastructures are designed and put into place to addresses the unique situations and challenges faced by women.
Discussion
Susan Dentzer summarized some of the primary points made by Dr. Volkow and Ms. Bryant. Dr. Volkow emphasized the need to consider how biology, social structure, and gender affect drug and substance abuse, as well as women’s vulnerability to chronic pain and opiate addiction. Ms. Bryant described a key public health crisis of our time, which manifests in poor health for so many disadvantaged women with inadequate health insurance. After Ms. Dentzer posed a question about next steps to both panelists, Dr. Volkow pointed to the importance of evidence-based interventions to prevent a range of medical conditions and Ms. Bryant called for policies to expand the health care workforce in order to address health literacy and health care navigation.
Questions and discussion focused on the possible role of teen pregnancy in predisposing women to higher mortality, the adverse effects of smoking on fetuses and newborns, and the provision in the Affordable Care Act that allows all pregnant women covered by Medicaid to access free smoking cessation without cost sharing. Discussion also focused on the role of mental health problems in rising mortality among women, including the role of depression during pregnancy and postpartum.
Ms. Dentzer concluded the briefing by thanking the panelists, Cindy Hall at WPI, members of Congress, and the attendees. She said that we need to ask ourselves how such a great country can sit by and allow so many women to have so many health problems. She said that we truly need a culture of health, for both genders, and particularly for women — and pointed to hopeful signs showing that there is much that can be done to improve women’s health.
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