Addressing the Substance Abuse Epidemic in Tennessee

John J. Dreyzehner Commissioner

A Rising Tide

2011 OD Deaths (U.S.): • 41,340 Any

Drug• 22,810 Rx

drug• 16,917 Rx

opioid• 4,397

HeroinSources: National Vital Statistics System, DEA Automation of Reports and Consolidated Orders System, SAMHSA TEDS

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8 Opioid Sales (Kg/10,000) Opioid-Related Deaths/100,000 Opioid Treatment Admissions /10,000

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Rate

Near Tripling in Opioid-related Deaths (in parallel with opioid sales and Rx opioid

treatment admits)

The Numbers in Tennessee

Data source: Tennessee Department of Health, Office of Health Statistics, Death Statistical System. Overdose deaths were defined as having underlying cause of death ICD-10 codes X40-X44 (accidental), X60-X64 (intentional suicide), X85 (intentional homicide), and Y10-Y14 (undetermined).

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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Deaths Due to Drug Overdose by IntentTennessee, 1999-2011

Accidental

Intentional

Undetermined

Data source: Tennessee Department of Health, Office of Health Statistics, Death Statistical System. Overdose deaths were defined as having underlying cause of death ICD-10 codes X40-X44, X60-X64, X85, and Y10-Y14.

342391 422

484

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868

963 972924 929

1,059 1,062 1,094

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1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Deaths Due to Drug OverdoseTennessee, 1999-2012

The Numbers in Tennessee

Deaths by Age Group, TN

Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

2007

2008

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2010

2011

Opioid Prescription Rates by CountyTN, 2007-2011

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EmptyBox Feeding

Di Chiara et al.

FOOD

These prescription drugs, like other drugs of abuse (cocaine, heroin, marijuana) raise brain dopamine levels Dopamine

Neurotransmission

Why Do People Abuse Prescription Drugs?

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AMPHETAMINE

“Ask your doctor if taking a pill to solve all your problems is right for you.”

How We got Here

A PAIN-DRUG CHAMPION HAS SECOND THOUGHTS

“Dr. Portenoy and other pain doctors who promoted the drugs say they erred by overstating the drugs’ benefits and glossing over risks.”

“…urged tackling what they called an epidemic of untreated pain…[and]…campaigned to make pain…’the fifth vital sign’ that doctors should

monitor, alongside blood pressure, temperature, heartbeat and breathing.”

“In 1998, the Federation of State Medical Boards released a recommendation policy reassuring doctors they wouldn’t face regulatory action for prescribing even large amounts of narcotics…In 2004, the group called on state medical boards to make undertreatment of pain punishable

for the first time…That policy was drawn up with the help of several people with links to opioid makers…the federation said it received nearly

$2 million from opioid makers since 1997.”

“In 2001, the Joint Commission, which accredits U.S. hospitals, issued new standards telling hospitals to regularly ask patients about pain and to make treating it a priority…The Joint Commission published a guide sponsored by

Purdue Pharma. ‘Some clinicians have inaccurate and exaggerated concerns’ about addiction, tolerance and risk of death, the guide said. ‘This

attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.’”

TN’s Prescription Drug Problem

Data source: CDC, Vital Signs: Opioid Painkiller Prescribing. July 2014. Available at: http://www.cdc.gov/vitalsigns/opioid-prescribing/

Prescription Painkillers Sold By State, 2012TN: Tied for 1st in country for kilograms of prescription painkillers sold per 100 people

Source of Opiates for Non-Medical Use

Friend or Relative

71%

Dealer4%

Internet0%

Other5%

One Doctor18%

More than One Doctor

2%

Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings. SAMHSA

Transmission in the substance abuse epidemic- How did we get here?

Abuse

Misuse

Misuse Abuse

Misuse

Abuse

Abuse

Abuse

Misuse Misuse

Misuse Abuse-Pregnancy

NAS

Overdose

Resistant (Religious)

Resistant (Recovery)

Resistant (Bad

Relationship)

Supply and Demand: The Substance Abuse/Misuse Market

PDMP Addresse

s All Three

Substance Abuse/Misuse: Constraining the Market

Steady reduction in the number of high-use patients since third quarter of 2012.

Survey of 800 CSMD users found:

• 71 percent had changed a treatment plan after viewing the patient’s information on the CSMD

• 73 percent said they are now more likely to discuss substance abuse issues with a patient

• 57 percent said they are now more likely to refer a patient for substance abuse treatment

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Fig 1. Number of High Utilization Patients* in CSMD 2012-2014

2012

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2014

*Individual who obtained controlled substance prescriptions from five or more prescribers and utilized five or more pharmacies within the quarter

Prescription Safety & Population Protection

Cumulative milligram morphine equivalent dispensed shows decline in year-to-year comparison since CSMD became mandatory:

• 0.7 percent in 2013

• 6.7 percent thus far in 2014

Effective July 1, 2014 Licensed practitioner in Tennessee can

prescribe

A New Tool To Combat Overdose Deaths: Naloxone

The Prescription for Success Plan

Plan for the Future:

1. Decrease the number of Tennesseans that abuse controlled substances.

2. Decrease the number of Tennesseans who overdose on controlled substances.

3. Decrease the amount of controlled substances dispensed in Tennessee.

4. Increase access to drug disposal outlets.

5. Increase access and quality of early intervention, treatment and recovery services .

6. Expand collaborations among state agencies.

7. Expand collaboration with other states.

REMEMBER

Doctor shopping is associated with a 5-fold higher risk of death.An MME of 100 or more is associated with an 11-fold higher risk of death.

Image credit: Naypong, FreeDigitalPhotos.net

Source: “High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths” by Baumbatt, et al, JAMA Internal Medicine, May 2014

Thank you for your partnership.

There’s a lot more for us to do together.