Emerging Issues

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Adverse Childhood Experiences

Adverse Childhood Experiences

ACEs research continues, and some of the key issues identified include:

  • Toxic stress from ACEs impacts brain development as well as physical and emotional health
  • High levels of trauma over time can alter DNA and be passed from generation to generation
  • Trauma-informed care and resiliency-building interventions are both healing and preventative of future problems

Issues you may wish to consider include:

  • Diabetes self-management education and support (DSMES) is available as a benefit through nearly all health insurance plans, but few clients use it. Some regions are working on DSMES access to improve referrals and quality of care.
  • Short-term outcomes, including cost savings, may be more quickly achieved with interventions that decrease A1c levels in people with diagnosed diabetes. Assessing and addressing cardiovascular risk factors, including blood pressure and high blood cholesterol, are also important in preventing poor outcomes in people with diabetes. Implementing interventions that prevent diabetes, particularly with those experiencing prediabetes, may also help achieve long term cost reduction.
  • New interventions, such as group self-management support or engagement of community health workers, may be more effective with some populations than older models of self-management education. However these new models are either not covered by health insurance or not paid for equally.
  • Evidence in both clinical trials and studies finds that the onset of type 2 diabetes can be prevented or delayed with lifestyle change support by trained coaches and peer groups over the course of one year. As of April 2018, Medicare began to cover qualified Diabetes Prevention Programs (DPP) for eligible enrollees. Several programs in Washington state have met the criteria to qualify.
  • Other insurers in Washington state, including those providing benefits for state and higher-education employees and retirees, cover DPP through specific contracts.
  • Obesity is a health issue with a complex web of causes and co-morbidities. Generally speaking, obesity is the result of social, cultural, and physical environmental factors patients experience throughout their lives, genetic factors, and the interaction between those factors.
  • The environment where patients live, learn, work and play can increase or decrease risk of obesity. For instance, a community without safe areas for kids to play will make it harder to be physically active, which will increase risk for obesity.
  • Studies have shown that trauma experienced during childhood, as well as experiencing racism in daily life, are part of the complex set of causes of obesity.
  • Epigenetics is increasingly seen as a mechanism for obesity passing down through generations, as well as adult obesity and co-morbidities.
  • Increasing evidence shows a connection between maternal nutrition during pregnancy and adult obesity.


  • Synthetic opioids including illicit fentanyl and fentanyl-type drugs have been appearing in other drugs sold as pain pills or heroin, contributing to Fentanyl Overdose Deaths in Washington State.
  • Jail and prison inmates with opioid use disorder often lack access to Medication Assisted Treatment (MAT) and social services while incarcerated.
  • There is a need to transform care for pregnant and new mothers with opioid use disorder, including stigma reeducation.
  • Rising rates of homelessness are creating a crisis in some communities. Trying to address housing and opioid issues is taxing limited resources.

* Sources:

Alcohol and Drug Abuse Institute, University of Washington, 2018

Centers for Disease Control, Drug Overdose Deaths 2013

Binswager, NEJM 2017

Oral Health

Oral Health

Dental providers screen for oral cancers and recommend HPV vaccinations; as well as provide screening for melanoma/skin cancer lesions on the face and neck. 

Oral surgeons are reducing opioid prescriptions in favor of NSAIDs for oral surgery post-op pain.

Antibiotic stewardship to reduce the problem of antibiotic resistant infections is gaining momentum in the dental field.


The availability of vapor products (also known as e-cigarettes, electronic nicotine delivery systems or ENDS, and JUUL) has caused serious concern among health advocates.

  • A growing body of research indicates electronic cigarettes and vapor products have unique health risks that are not yet completely understood. The National Academies of Sciences, Engineering and Medicine published a consensus study report in January 2018, "Public Health Consquences of E-Cigarettes," that outlines some of these conclusions.
  • A major concern of stakeholders is that these products may again normalize smoking in public places.
  • According to the U.S. Surgeon General there are strong associations between use of e-cigarettes and other tobacco products.
  • While cigarette smoking has decreased overall, persistent tobacco-related disparities still exist.

Vapor products are the most commonly used nicotine product among youth. One product increasingly popular among youth is JUUL. This product currently represents 75 percent of teh e-cigarette market. These devices emit little to know odor or aerosol and can be easily concealed. They closely resemble a USB flash drive and can be charged as such, so while they are hard to detect, teachers find students using them in classrooms and bathrooms.

JUULs come in an assortment of flavors that appeal to youth and the amount of nicotine in one pod is equivalent to one pack of cigarettes. The products are under investigation by the U.S. Food and Drug Administration. In October 2019, the Washington State Board of Health issued an emergency rule banning all flavored vapor products at the request of the Governor's Office.

The findings of the 2018 National Youth Tobacco Survey highlight a disturbing and growing trend of youth using vapor products. According to these data, use of vapor products by high school and middle school students jumped by nearly 80 percent and 50 percent, respectively, since 2017. 2018 Washington State Healthy Youth Survey results indicated that 10 percent of 8th graders, 21 percent of 10th graders, and 30 percent of 12th graders are using vapor products.

Additionally, with the legalization of recreational marijuana in 2012 (Washington Initiative 502 (PDF)), more youth are reporting using tetrahydrocannabinol (THC), the main psychoactive compound in marijuana, in their vapor products. According to the 2018 Healthy Youth Survey, 21 percent of 10th graders reported vaping THC (marijuana). Poly-substance use is also of concern, as 41 percent of teens who used tobacco in 2018 used two or more tobacco products, including vapor products. For more information, see the Youth Substance Use: Tobacco, E-Cigarette/Vape, Alcohol, Opioid and Marijuana Use report (2018). 

The use of vapor products recently became so widespread that in September 2018, the U.S. Surgeon General and U.S. Food and Drug Administration labeled use by youth an “epidemic.”

According to the Centers for Disease Control and Prevention:

  • E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.
  • People who have never smoked or used other tobacco products or e-cigarettes should not start doing so.
  • E-cigarettes have the potential to benefit adults who smoke cigarettes and are not pregnant, if used as a complete substitute for regular cigarettes and other smoked tobacco products.
  • While e-cigarettes have the potential to benefit some people and harm others, scientists still have much to learn about whether or not e-cigarettes are effective for quitting smoking.
  • Additional research is needed to understand long-term health effects.

More information about vapor products can be found on the Department of Health website.

Well Child Visits

There is an increase in the number of children with insurance coverage, and in many parts of the state there are not enough providers to meet the demand.

Some families are reluctant to access healthcare due to their nationality and citizenship status. Anecdotally, clinics report experiencing this even with immigrant patients who are legal residents. There may also be barriers due to language and/or comfort level.

There is increasing awareness of the need to address Adverse Childhood Experiences (ACEs) as part of preventive care. Some healthcare systems are implementing a Trauma Informed Approach to interactions with children and parents/caregivers. This has created demand for ACEs related training and tools.