Interstate Variation in Prescribing of Opioid Pain Relievers and Benzodiazepines Karin A. Mack, PhD Associate Director for Science

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1 Interstate Variation in Prescribing of Opioid Pain Relievers and Benzodiazepines Karin A. Mack, PhD Associate Director for Science National Center for Injury Prevention and Control Division of Analysis, Research, and Practice Integration

2 cdc.gov/vitalsigns

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4 Prescription painkiller overdoses are a serious problem among women About 18 women died every day in 2010 of a prescription painkiller overdose. For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse. Women ages 45 to 54 are at the highest risk of dying of a prescription painkiller overdose. Non-Hispanic white and American Indian or Alaska Native women have the highest risk of prescription painkiller overdose death.

5 Prescription opioid painkiller deaths are a growing problem among women

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7 Key Findings In 2010, drug overdoses in the United States caused 15,323 deaths among women. Opioid pain relievers prescription painkillers were involved in 6,631 deaths. Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men

8 Vital Signs: Interstate Variation in Prescribing of Opioid Pain Relievers and Benzodiazepines United States, 2012

9 National Vital Statistics System Drug overdose death rate by state,

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11 Prescriptions per 100 people, 2012

12 Prescriptions per 100 people, 2012

13 Opioid prescribing can vary 3-fold between states Number of painkiller prescriptions per 100 people HI

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15 Regional Patterns in Prescribing, 2012 South highest OPR and benzodiazepines Alabama highest OPR West Virginia highest benzodiazepines Northeast highest rates for long-acting/extended-release OPR and high-dose OPR Maine highest for long-acting OPR Delaware highest for high-dose OPR Adjacent states vary widely New York 2/3 of OPR and benzodiazepine rates of Pennsylvania Illinois 60% of the OPR rate in Indiana

16 Reasons for Interstate Prescribing Variation State prevalence of painful conditions Northeast oldest, 14.1% aged 65+ years; Midwest second, 13.5% Poverty rates South highest rates of poverty Proportion of minorities Minorities represent larger proportion in south and west Prescribing rates lower among minorities Other reasons for variation Prescriber norms Rates of misuse and abuse State policies

17 Key Findings In 2011, opioid pain relievers (OPR) caused 16,917 overdose deaths in the United States Benzodiazepine sedatives were involved in 31% of those deaths Use of these drugs varied greatly among states in 2012 Highest prescribing rates were found in the southern region

18 Decline in Drug Overdose Deaths After State Policy Changes Florida,

19 Florida and the Epidemic % increase in prescription drug overdoses 264% increase in oxycodone overdoses In 2009, 8 people died of overdoses every day 2010: 90 of the top 100 oxycodone purchasing physicians in US were in Florida 900+ pain clinics

20 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 ; 40(3):

21 16 Florida opioid overdoses fell sharply between 2010 and Opioid pain reliever overdoses Oxycodone overdoses 6 4 Benzodiazepine overdoses Johnson H; Paulozzi L; Porucznik C. Mack K. Herter B. Decline in Drug Overdose Deaths After State Policy Changes Florida, MMWR. 63(26) July 2014.

22 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

23 Drug overdose death rates and selected prescription drug diversion and misuse actions taken Florida, A B C D E F G Oxycodone Alprazolam Methadone Morphine Hydrocodone Heroin 0.0 Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec Jan Jun Jul Dec A. January 4, Pain clinics must register. B. February, Operation Pill Nation: DEA, state and local law enforcement begin investigation of unscrupulous pain clinics. C. October 1, Pain clinic regulation expanded. D. February 23, Operation Pill Nation: joint law enforcement raids begin. E. July 1, Physician dispensing prohibited and statewide regional strike forces activated. F. September 1, Mandatory reporting to prescription drug monitoring program begins. G. July 1, Wholesale distributor regulations expanded.

24 To Work with Providers, States Can Take steps to improve prescription drug monitoring programs Consider setting up programs for Medicaid, workers compensation programs, and state-run health plans that identify and address improper patient use of painkillers Make it easier for prescribers to use PDMPs by providing them unsolicited reports and making data available in real-time

25 To Reverse this Epidemic, States Can Consider Pill mill, doctor shopping, and other laws that can reduce prescription painkiller abuse Universal prescriber use of PDMPs when prescribing controlled substances Enhanced coverage for non-drug treatments for chronic pain Increased access to substance abuse treatment (including immediate access to treatment for pregnant women)

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27 For more information, please contact the Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The presenter has no conflicts of interest to report. National Center for Injury Prevention and Control Division of Analysis, Research, and Practice Integration