The Prescription Drug Overdose Epidemic Noonan, PhD National Center for Injury Prevention and...
Transcript of The Prescription Drug Overdose Epidemic Noonan, PhD National Center for Injury Prevention and...
Rita Noonan, PhD
National Center for Injury
Prevention and Control
Centers for Disease Control and Prevention
The Prescription Drug
Overdose Epidemic
National Center for Injury Prevention and Control
Division of Unintentional Injury Prevention
Dramatic increase in overdose deaths related to opioid pain relievers since 1999
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
opioid pain relievers
heroin
cocaine
CDC, National Center for Health Statistics, National Vital Statistics System
Opioid pain reliever-related overdose deaths increasing
at a faster rate than deaths from any major cause
-34%
-23%
-23%
-22%
-16%
-14%
-3%
0%
2%
4%
7%
11%
13%
20%
31%
36%
40%
47%
68%
276%
-50% 0% 50% 100% 150% 200% 250% 300%
Aortic Aneurysm
Influenza & Pneumonia
Cerebro-vascular
Motor vehicle traffic
Heart disease
Perinatal Period
Homicide
Diabetes Mellitus
Pneumonitis
Malignant Neoplasms
HIV
Septicemia
Chronic Lower Respiratory disease
Liver Disease
Suicide
Nephritis
Parkinson's Disease
Hypertension
Alzheimer's
Rx opioid overdose
% change in number of deaths, United States, 2000-2010
WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System
Middle-aged adults are at greatest risk for drug overdose in the United States
0
5
10
15
20
25
30
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010De
ath
s p
er
10
0,0
00
po
pu
lati
on
CDC/NCHS, National Vital Statistics System
Death rates by age
45-54
35-44
25-34
55-64
15-24
65 +
Males, American Indians/Alaska Natives, and Whites at
highest risk for opioid overdose deaths
5.3
0.4
1.9
4.6
8.7
0.8
2.3
7.1
0
1
2
3
4
5
6
7
8
9
10
American Indian or Alaska Native
Asian or Pacific Islander
Black or African American
White
Ra
te p
er
10
0,0
00
Females Males
National Vital Statistics System; crude rates, 2009
Opioid pain reliever prescribing
rates vary by state
CDC Vital Signs, July 2014. Rates per 100 people in 2012
Opioid prescribing rates correlate with
drug overdose death rates
Kg of opioid pain
relievers used per
10,000
Age-adjusted rate
per 100,000
Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System
Opioid prescribing rates correlate with
opioid overdose death rates
*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and mortality update. Epi Data Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf
Rates of unintentional opioid pain reliever
overdose deaths by NYC neighborhood
Rates of hydrocodone and/or
oxycodone filled by NYC neighborhood
Opioid -related overdose death rates and treatment
admissions increased over time along with opioid sales
United States, 1999-2011. National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS. Treatment admission rates are per 10,000 people ages 12+.
Half of United States opioids market is
treatment for chronic, non-cancer pain
Primary care providers prescribe the most opioids
IMS Health, National Prescription Audit, United States, 2012
Pain specialists prescribe opioids most frequently
Doctors most common source of opioids
for most frequent nonmedical users
Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. JAMA Internal Medicine. 2014
JAMA 2011;305:1315-1321
Patients receiving high doses of opioid pain relievers
account for disproportionate share of overdoses
Perc
en
t
CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);10-13.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
patients receiving opioid pain relievers patients overdosing with opioid pain relievers
one doctor, high dose
one doctor, lower dose
multiple doctors,
high doses
multiple doctors,
high doses
one doctor, high dose
one doctor, lower dose
Patients with depression 3x more likely to be prescribed long-term opioid therapy
0
5
10
15
20
25
Braden JB et al. Trends in long-term opioid therapy for noncancer pain among persons with a history of depression. General
Hospital Psychiatry. 31 (2009); 564-570.
Patients with depression
Patients without depression
Rate
of
lon
g-t
erm
in
cid
en
t o
pio
id u
se p
er
10
00
no
ncan
cer
pati
en
ts,
20
05
Opioid pain reliever overdose deaths: summary of epidemiology
• Increasing at a faster rate than deaths from any
major cause in the United States
• Correlation between opioid prescribing rates
and drug overdose death rates
• Patients receiving opioids from multiple
prescribers and at high doses at highest risk
Prevention Policies & Interventions
Overdose deaths continue to climb
National Vital Statistics System
“It is one of the happy incidents
of the federal system that a
single courageous state may, if
its citizens choose, serve as a
laboratory; and try novel
social and economic
experiments without risk to the
rest of the country.”
–Justice Louis Brandeis
Opioid prescribing is the key driver
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS
Sales (kg per 10k)
Deaths (per 100k)
For every Rx opioid overdose death in 2011,
there were...
SAMHSA NSDUH, DAWN, TEDS data sets.
0 100 200 300 400 500 600 700
12 treatment admissions for opioids
25 emergency department visits for opioids
105 people who abused or were dependent on opioids
659 nonmedical opioid users
Risk
Policy & the Continuum of Risk
Risk
Prescription Drug Monitoring Programs & Prescribing Rules
What Are Prescription Drug Monitoring Programs?
Source: PDMP Center of Excellence at Brandeis University.
Prescription Drug Monitoring Programs (PDMPs)
Source: PDMP Training and Technical Assistance Center. http://www.pdmpassist.org/pdf/pmpprogramstatus2013_a.pdf
Status of PDMPS – September 2013
PDMP Promising Practices
Epidemiological analysis
Unsolicited reporting
Criteria for questionable
activity
Integrating with EHRs and
HIEs
Increasing utilization
Interstate data-sharing
Interagency collaboration
Improving data quality
Conducting evaluation
Source: ASTHO, Brandeis PDMP Center of Excellence:
Prescription Drug Monitoring Programs: Tools for Education, Epidemiological Surveillance, Prevention, and Early
Intervention
Source: Arizona Prescription Monitoring Program, Arizona State Board of Pharmacy
Example of Innovation:PDMP Report Cards to Outliers
Prescribing Rules
Washington State Rules
Washington Agency Medical Directors’
Opioid Dosing Guidelines
Pain Management Rules
ED prescribing guidelines
Other measures
Good Samaritan Law
PDMP
Medicaid Narcotic Review Program
Expanded Patient Review and
Coordination program
Insurer/Pharmacy Benefit Manager (PBM) Mechanisms
Reimbursement
incentives/disincentives
Quantity limits
Step therapies/Prior
Authorization
Real-time claims analysis
Retrospective claims review
programs
Pain Clinic Laws
The Problem of “Pill Mills”
“You just walk in, they ask you what hurts, they take
your blood pressure, they weigh you, and they say
actually – literally sometimes, ‘What do you want?’…
‘How many do you take a day?’ You could be
ridiculous and say 40. I mean, I could get 200 of
each, Roxi's and Oxy's at the same time, which
makes no sense, and Xanny bars (Xanax) at the
same time. They just ask you what you want.”
—White female, 41
Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681–702.
Anatomy of a Pain Clinic Law
Louisiana
Statute passed in ‘05; rules in Jan. ‘08
Passes a pain management clinic law
Brings heightened scrutiny to pain
clinics
Requirements:
Pain specialist physician ownership
Licensure from Department of Health and Hospitals
Inspections
50% on-site requirement
Urine drug screen for each patient
30-day supply limit
Florida and the Epidemic
2003-2009 (CDC MMWR)
84% increase in prescription
drug overdoses
264% increase in oxycodone
overdoses
In 2009, 8 people died of
overdoses every day
MMWR. Drug overdose deaths — Florida, 2003–2009. 869-72. 60(26). July 8 2011.
2010:
90 of the top 100 oxycodone purchasing physicians in US were
in Florida
900+ pain clinics
Florida’s Policy Response
Jan. 2010: State legislature required pain clinics register with the state
Feb. 2010: DEA and various Florida law enforcement agencies began to work
together in Operation Pill Nation
Late 2010: Pain clinic regulations further expanded
Feb. 2011: Law enforcement conducted statewide raids
July 2011: State legislature prohibited physician dispensing of schedule II or
III; activated regional strike forces to address the emergency.
Sept. 2011: Mandatory dispenser reporting to the newly established PDMP
2012: State legislature expanded regulation of wholesale drug distributors
Florida opioid overdoses fell sharply between 2010 and 2012
Johnson H; Paulozzi L; Porucznik C. Mack K. Herter B. Decline in Drug Overdose Deaths After State Policy Changes —Florida,
2010–2012. MMWR. 63(26). 569-74. July 2014.
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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Oxycodone overdoses
Opioid pain reliever overdoses
Benzodiazepine overdoses
Naloxone & Good Samaritan Laws
Naloxone Access
Source: Public Health Law Research - phlr.org
Naloxone Access Laws
April 2014
Good Samaritan Laws
PHLR, Law Atlas. April 2014.
Good Samaritan Laws
April 2014
Laws that explicitly limit criminal liability in some way for an
overdose bystander who summons help in good faith.
Three Pillars of CDC’s PDO Prevention Work
Improve data quality and track trends
Strengthen state efforts by scaling up effective public health
interventions
Supply healthcare providers with resources to improve
patient safety
Example Program:Boost for State Prevention
Advance and evaluate comprehensive
state-level interventions for preventing
prescription drug overdose in 3 areas:
• Enhancing and maximizing PDMPs
• Improving and evaluating public insurer mechanisms
• Evaluating state-level laws, policies, and regulations
The findings and conclusions in this report are those of the author and do not
necessarily represent the views of the Centers for Disease Control and
Prevention.
National Center for Injury Prevention and Control
Division of Unintentional Injury Prevention