The Prescription Drug Overdose Epidemic Rita Noonan, PhD National Center for Injury Prevention and Control Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Unintentional Injury Prevention
Dramatic increase in overdose deaths related to opioid pain relievers since 1999 18,000 16,000 opioid pain relievers 14,000 12,000 10,000 8,000 6,000 cocaine 4,000 2,000 heroin 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 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 % change in number of deaths, United States, 2000-2010 Rx opioid overdose Alzheimer's Hypertension Parkinson's Disease Nephritis Suicide Liver Disease Chronic Lower Respiratory disease Septicemia HIV Malignant Neoplasms Pneumonitis Diabetes Mellitus Homicide Perinatal Period Heart disease Motor vehicle traffic Cerebro-vascular Influenza & Pneumonia Aortic Aneurysm -34% -22% -23% -23% -14% -16% 0% -3% 7% 4% 2% 13% 11% 20% 36% 31% 40% 47% 68% 276% -50% 0% 50% 100% 150% 200% 250% 300% WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System
Middle-aged adults are at greatest risk for drug overdose in the United States Death rates by age Deaths per 100,000 population 30 25 20 15 10 5 0 45-54 35-44 25-34 55-64 15-24 65 + 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CDC/NCHS, National Vital Statistics System
Rate per 100,000 Males, American Indians/Alaska Natives, and Whites at highest risk for opioid overdose deaths Females Males 10 9 8 7 6 5 4 3 2 1 0 5.3 8.7 American Indian or Alaska Native 0.4 0.8 Asian or Pacific Islander 1.9 2.3 Black or African American 4.6 White 7.1 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 Rates of hydrocodone and/or oxycodone filled by NYC neighborhood Rates of unintentional opioid pain reliever overdose deaths by NYC neighborhood *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
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 Pain specialists prescribe opioids most frequently IMS Health, National Prescription Audit, United States, 2012
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
Percent Patients receiving high doses of opioid pain relievers account for disproportionate share of overdoses 100% 90% 80% multiple doctors, high doses one doctor, high dose multiple doctors, high doses 70% 60% 50% 40% one doctor, lower dose one doctor, high dose 30% 20% 10% one doctor, lower dose 0% patients receiving opioid pain relievers patients overdosing with opioid pain relievers CDC Grand Rounds: Prescription Drug Overdoses a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);10-13.
Rate of long-term incident opioid use per 1000 noncancer patients, 2005 Patients with depression 3x more likely to be prescribed long-term opioid therapy 25 20 15 10 Patients with depression 5 Patients without depression 0 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.
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
National Vital Statistics System Overdose deaths continue to climb
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 8 7 6 5 Sales (kg per 10k) Deaths (per 100k) 4 3 2 1 0 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
Risk For every Rx opioid overdose death in 2011, there were... 12 treatment admissions for opioids 25 emergency department visits for opioids 105 people who abused or were dependent on opioids 659 nonmedical opioid users 0 100 200 300 400 500 600 700 SAMHSA NSDUH, DAWN, TEDS data sets.
Risk Policy & the Continuum of 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) Status of PDMPS September 2013 Source: PDMP Training and Technical Assistance Center. http://www.pdmpassist.org/pdf/pmpprogramstatus2013_a.pdf
PDMP Promising Practices Epidemiological analysis Increasing utilization Unsolicited reporting Interstate data-sharing Criteria for questionable Interagency collaboration activity Improving data quality Integrating with EHRs and Conducting evaluation HIEs Source: ASTHO, Brandeis PDMP Center of Excellence: Prescription Drug Monitoring Programs: Tools for Education, Epidemiological Surveillance, Prevention, and Early Intervention
Example of Innovation: PDMP Report Cards to Outliers Source: Arizona Prescription Monitoring Program, Arizona State Board of Pharmacy
Washington State Rules Prescribing 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.
Louisiana Anatomy of a Pain Clinic Law 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 2010: 90 of the top 100 oxycodone purchasing physicians in US were in Florida 900+ pain clinics MMWR. Drug overdose deaths Florida, 2003 2009. 869-72. 60(26). July 8 2011.
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
16 Florida opioid overdoses fell sharply between 2010 and 2012 14 Opioid pain reliever overdoses 12 10 8 Oxycodone overdoses 6 4 Benzodiazepine overdoses 2 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 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.
Naloxone & Good Samaritan Laws
Naloxone Access Naloxone Access Laws April 2014 Source: Public Health Law Research - phlr.org
Good Samaritan Laws Good Samaritan Laws April 2014 Laws that explicitly limit criminal liability in some way for an overdose bystander who summons help in good faith. PHLR, Law Atlas. April 2014.
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