PRESCRIPTION NATION ADDRESSING AMERICA S PRESCRIPTION DRUG ABUSE EPIDEMIC. from the National Safety Council

PRESCRIPTION NATION ADDRESSING AMERICA S PRESCRIPTION DRUG ABUSE EPIDEMIC from the National Safety Council

Working together to address the prescription drug overdose epidemic As the National Safety Council celebrates 100 Years of Safety, the Council has been examining how it can better address the urgent and emerging issues that are confronting our nation today and into the future. Drug overdoses have now surpassed traffic crashes as the leading cause of injury death in America. More than 38,000 people died of drug overdoses in 2010. The class of drugs that contributed to the largest number of these deaths is prescription pain medications. Prescription pain reliever abuse is now a national epidemic, affecting millions of Americans and killing more than 16,000 in 2010. Since 1999, the number of people who have died from prescription drug overdoses each year has more than doubled. Forty-five people die every day from overdoses of prescription pain relievers. This is about twice the number of fatal overdoses from illegal drugs. At NSC, we have taken on this issue as one of our five strategic initiatives, with a goal of substantially reducing injuries and deaths associated with it. We are confronting this epidemic nationally and in states and communities. We ask you to learn more about this issue and join us. This report documents the current status of laws and practices in the states and makes recommendations, based on research evidence, for additional actions. This comparison of current laws and practices with research evidence suggests: coordinated state action is needed to optimize prescription drug monitoring programs (PDMP) to identify misuse and fraud; education of prescribers is necessary to support responsible prescribing practices; enhanced enforcement should be undertaken to reduce pill mills, doctor and pharmacy shopping; and programs should be expanded to treat opioid drug overdoses by increasing access to naloxone, a safe effective treatment to reverse an overdose. Countless lives have been lost and many more will be lost in this epidemic without concerted action. I invite you engage with us on this important issue so together we can save lives and prevent injuries. Sincerely, Janet Froetscher President & CEO National Safety Council 2 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

Table of Contents America s Prescription Drug Epidemic... 1 Rating the States... 9 Detailed Review of the Rating... 14 Additional Related Reports available by download: Summary by State Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives About the National Safety Council The National Safety Council is a nonprofit organization whose mission is to save lives by preventing injuries and deaths at work, in homes and communities and on the road through leadership, research, education and advocacy. NSC advances this mission by partnering with businesses, government agencies, elected officials and the public to make an impact where the most preventable injuries and deaths occur, in areas such as workplace, distracted driving, teen driving, prescription drug overdoses and Safe Communities. Founded in 1913 and chartered by Congress, the National Safety Council relies on research to determine optimal solutions to safety issues. Its educational efforts aim to change behaviors by building awareness, providing training and sharing best practices. The Council recognizes organizations that have focused on safety as a critical part of their operational excellence with the Robert W. Campbell Award, safety s most prestigious honor. The NSC Congress & Expo is the world s largest annual event dedicated to safety and Safety+Health magazine is a leading source of occupational safety and health information. Offering a variety of learning options, NSC is a world leader in Defensive Driving, First Aid and Workplace Safety training. Each year the Green Cross for Safety medal from NSC salutes a company and its CEO for exceptional safety leadership. NSC is the International Support Center for the Safe Communities America program, guiding community stakeholders to reduce injuries and promote safety for the residents of their communities. The National Safety Council is committed to helping its members and the public prevent unintentional injuries and deaths through a wide variety of benefits that advance them on their Journey to Safety Excellence. This Journey outlines a process of continuous improvement in leadership and employee engagement, safety management systems, risk reduction and performance measurement. With local Chapters and global networks, NSC is the leading advocate for safety and promotes June as National Safety Month. National Safety Council 3

America s growing prescription drug epidemic Prescription pain medications, including opioid pain relievers, are commonly used in an effort to improve lives by reducing pain and suffering. Prescription pain medications are used to help in recovery and rehabilitation from injuries, surgeries and various ailments. Along with the pain relieving benefits are the risks of misuse, addiction and death when the use of these drugs is not carefully prescribed and monitored by health professionals. The Centers for Disease Control and Prevention (CDC) reports year-over-year increases in prescription drug overdoses for the past 11 years. 1 In 2010, 38,329 people died from drug overdoses. 2 The majority of these deaths involved prescription medications. Opioid pain relievers, alone or in combination with other prescription medicines or alcohol, were involved in 16,651 deaths 3 approximately 45 deaths per day. In fact, more people died from opioid pain reliever drug overdoses than from heroin and cocaine combined. Admissions for opioid treatment in emergency rooms and rehabilitation centers also have increased substantially in recent years. In 2011, 1.4 million emergency department visits were related to the misuse or abuse of prescription medicines an increase of 114% since 2004. 4 Drug treatment admissions for prescription opioids increased seven-fold between 1998 and 2010, from 19,941 to 157,171. 5 The CDC has termed our current problem with opioid abuse an epidemic. There are nearly 2 million people in the United States who are currently addicted to opioid pain relievers. 6 One in six teens have misused or abused prescription pain relievers in their lifetime according to a recent study. 7 The rapid increase in opioid deaths and opioid treatment admissions correspond with the increase in sales of opioid pain relievers (see figure 2). Further underscoring this connection, states with the highest drug overdose death rates also have among the highest sales per capita of prescription pain relievers. 8 A number of factors have contributed to the increase and widespread availability of these powerful medications. In the mid 1990s, several professional medical organizations reported that physicians were not adequately treating pain and recommended that physicians be more attentive in identifying pain and more aggressive in treating it. 9 New extended-release opioid pain relievers were introduced and approved by the FDA for the treatment of moderate to severe pain. Deemed to have a higher abuse potential which may lead to psychological or physical 4 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

States with the largest sales of opioid painkillers also have the highest mortality rates Kg of NPR used per 1M 3.7-5.9 6.0-7.2 7.3-8.4 8.5-12.6 Age-adjusted rate per 100,000 5.5-9.4 9.5-12.3 12.4-14.8 14.9-27.0 Figure 1: States with highest rates of drug overdose fatalities also reported higher sales of opioid pain relievers. dependence 10 opioid pain relievers such as oxycodone and hydrocodone gained widespread acceptance by the medical community. Through the latter half of the 1990s and into the last decade, doctors, dentists and other providers prescribed opioid pain relievers more frequently as a part of patient care. From 2000 to 2009, the number of opioid prescriptions per 100 people increased by 35.2 percent and the number of morphine milligrams equivalents (MME) prescribed doubled. 11 Now, approximately, 1 in 25 adults are receiving treatment of chronic pain with opioid pain relievers. 12 It is clear that the increase and availability in opioid prescribing parallels an increase in addiction and overdose deaths. 13 There are many factors related to the increase in opioid addiction and why some people may be at greater risk than others. We do know that opioids have very powerful antidepressant and antianxiety properties. 14 People with depression who receive a prescription for an opioid medication are much more likely to misuse it. 15 There are others who are genetically predisposed to addiction and can easily have problems with the pain pills. One study showed that as many as 43 percent of those being treated for chronic back pain with opioids may also have a substance use disorder. 16 National Safety Council 5

rates of opioid overdose deaths, sales and treatment admissions, US 1999-2010 8 7 6 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Figure 2: As opioid sales increased, the rates of opioid deaths and opioid treatment admissions also increased. The increases in prescriptions for pain medications resulted in many more of these medicines being kept in home medicine cabinets. The accessibility to these drugs has increased the opportunity for theft or misuse. Nearly, 70 percent of people who misuse prescription medicines report getting the drugs or taking them without asking from family members or friends. 17 As a person falls more deeply into addiction, he or she begins to seek the medications from multiple doctors and/or purchase drugs from friends and illegal dealers. A person who tries to obtain medications from multiple doctors, without the prescriber s knowledge of the other prescriptions, is considered to be engaged in doctor shopping. This is illegal in 16 states. In addition, 34 states have general provisions that ban the use of deceit, misrepresentation or fraud to obtain controlled substances. 18 Another source contributing to the over-supply of prescription opioid pain relievers are pill mills. 19 At 6 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

How different misusers of pain relievers get their drugs Methods and sources for obtaining pain relievers 9% 17% 68% 13% 17% 64% 28% 26% 41% Key Bought from friend/ relative, dealer, or internet Prescribed from 1 or more doctors Obtained from friend/relative for free or w/o asking Figure 3: Most people who misuse prescription medicines get them from a friend or family member. Recent Initiaters Occasional Users Frequent/Chronic Users Types of past-year users pill mills, which provide little or no medical care, clinic physicians issue prescriptions for large quantities and high dosages of opioid pain relievers and other prescription drugs frequently abused. People seeking drugs willingly traveled hundreds of miles to purchase a supply of pills to use for themselves and sell to others. Largely unregulated, these facilities minimally adhere to accepted standards of medical practice. Florida, Kentucky and 8 other states have enacted legislation that significantly reduced or eliminated pill mills in those states. 20 However, many of these businesses have moved to other, less regulated, states. Federal agencies, in coordination with the White House Office of National Drug Control Policy (ONDCP), have mobilized to reduce overdoses from opioid pain relievers and other prescription medications. ONDCP published a national strategy Epidemic: Responding to America s Prescription Drug Abuse Crisis in 2011 that outlines specific tactics to reduce by 15 percent the non-medical use of prescription drugs among people 12 years of age and older. The plan outlines specific actions to be taken by federal agencies, including the CDC, Drug Enforcement Agency (DEA), Bureau of Justice Assistance (BJA), Substance Abuse and Mental Health Services Administration (SAMHSA), and Food and Drug Administration (FDA) to achieve this goal. 21 Strategies identified in the ONDCP plan include: education of patients, prescribers and the general public; expansion of prescription drug monitoring programs (PDMP) to identify misuse and fraud; enforcement initiatives to reduce pill mills, doctor and pharmacy shopping, criminal prescribers and drugged driving; and programs to encourage proper medication disposal. National Safety Council 7

CDC reported that wide variation among states in the nonmedical use of opioid pain medications and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in opioid prescribing. 22 States with the highest sales of opioid pain relievers report a greater number of drug overdose deaths. The presence of high-volume prescribers and pill mills within a state can contribute to increased drug overdose deaths. Differences between states laws and regulations might also contribute to this national epidemic. State leadership and action is needed to implement many of these strategies and promising approaches. As evidenced in this report, states have begun to take action but more work is needed in order to save lives. In this report, the National Safety Council examines state progress in four areas: state leadership and action, prescription drug monitoring programs, responsible opioid prescribing and overdose education and prevention programs. NSC recognizes that access to substance abuse treatment is an important part of a comprehensive strategy to address this problem, however, it is not addressed in this report. For this report, NSC established standards for performance in each of these four areas, based on the best available research evidence. 8 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

State Leadership and Action State plan addressing prescription drug misuse and overdoses State taskforce or workgroup addressing prescription drug misuse and overdoses The Association of State and Territorial Health Officials (ASTHO) in summary findings from a multistate meeting Preventing Prescription Drug Abuse Across the Continuum 26 and a National Governors Association (NGA) issue brief Six Strategies for Reducing Prescription Drug Abuse 27 identified that high level state leadership is essential in order to develop and implement a coordinated and effective state response to prescription drug abuse. Prescription drug Monitoring Programs PDMPs are state operated databases that collect prescription information from pharmacies and dispensers of controlled substances. The Prescription Drug Monitoring Program Center of Excellence at Brandeis University (COE) identified in its white paper 35 recommended best practices. 28 The research base supporting these practices is developing. The scientific support includes research evidence, cases studies and a consensus of expert opinion. The National Alliance of Model State Drug Laws (NAMSDL) conducted a review of recommended practices promoted by NAMSDL, COE and four other organizations. 29 The report identifies areas of agreement and compares states, current implementation of those practices. NSC examines how states have enacted legislation authorizing five of these recommended practices. PDMP data can be accessed by a variety of professionals and state agencies including: - Prescribers and dispensers - Law enforcement, coroners or medical examiners and licensing boards with probable cause or active investigation - State insurance programs such as Medicaid, etc. PDMP allows dispenser and prescriber delegates PDMP moving towards realtime data collection and, at a minimum, collects data from dispensers at least weekly State PDMP shares data with other states PDMP proactively alerts following user groups: prescribers, dispensers, law enforcement and licensing boards. Insufficient data exist for a comparison of states on a number of recommended practices such as prescriber utilization of the PDMP or integration of PDMP data with electronic health records. Responsible Opioid Prescribing Based on recommendations identified in ONDCP national strategy, Institute of Medicine report 30 and experiences of states leading the effort to reduce prescription drug overdoses, this report examined states efforts to support responsible prescribing practices. State has regulations that deter the formation of pill mills and interstate trafficking of opioid pain relievers. State medical boards and licensing agencies provide rules or guidance to all prescribers on responsible prescribing of opioid pain relievers. State medical boards and licensing agencies require or recommend education regarding responsible prescribing of controlled substances, pain management, screening for substance use disorders and state prescription monitoring program. A number of states are requiring certain prescribers such as pain management professionals and other high volume prescribers of opioid medications to obtain mandatory education. State PDMP use by requiring prescriber utilization of the state PDMP. A number of states are requiring certain prescribers such as pain management or other high volume prescribers to utilize the PDMP. National Safety Council 9

Ooverdose Education and Prevention Programs The ONDCP, American Medical Association (AMA), Harm Reduction Coalition and others recommend increased access to naloxone. Studies have shown that programs that provide overdose education and increase access to naloxone are safe and cost effective. 31 A report by the Network for Public Health Law 32 compiling relevant state law supplemented by a review of recent state legislation was used as basis for the state rating. State has an overdose education and prevention program to increase access to naloxone or allows licensed healthcare professionals to prescribe naloxone for third party use to prevent drug overdose. Good Samaritan provisions protecting first responders and others from criminal and/or civil liability for possessing and administering naloxone. Laws providing immunity or special consideration at sentencing for bystanders who call 911 or provide medical assistance. Summary of State action Twenty-three states were identified as partially meeting the standard but needing improvements in at least one areas. Fourteen states met the standards in two or more of the four areas. The one area in which many states require improvement is in supporting responsible prescribing practices. Twenty-five states did not meet the standards for responsible prescribing practices. While 16 states require or recommend education for prescribers on the treatment of pain, 23 only 13 states have strengthened their laws to deter pill mills 24 or to establish rules addressing responsible prescribing. States with the most overdose fatalities and/or highest rates of prescription drug misuse were more likely to have to implemented changes in laws, regulations and programs. Following the lead of New Mexico, 13 states have increased access to naloxone, a drug that reverses opioid overdoses or passed laws to encourage bystander action. 25 Overall, states had conducted the most work in areas of state leadership and action and establishing prescription drug monitoring programs. Two states, Kentucky and Washington, met the standards in all four areas. Vermont provisionally met the standards, pending the outcome of the state s rule-making process for legislation passed in 2013. Ten states partially met the criteria, demonstrating progress, by meeting or partially meeting the standards in all four areas. 10 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

State overview Rating Indicators Meets Standards Partially Meets Standards, Making Progress Partially Meets Standards, Improvements Needed Does Not Meet Standards Rating the States The attached table lists each state s overall rating and its rating for each area using the described criteria on page 9 and 10. To receive a meets rating, the state met all indicators for an area; partially met if the state met at least one of the indicators and does not meet if the state met none of the indicators. States were rated based on best available information as of April 30, 2013. new or pending state legislation or changes to programs after this date may not be reflected in these ratings. The District of Columbia and other U.S. territories are not included in this report. National Safety Council 11

Overall state ratings overall rank state action & Leadership Prescription Drug monitoring responsible prescribing overdose prevention Kentucky Washington Vermont Massachusetts New York Tennessee California New Mexico Colorado Florida North Carolina Virginia Rhode Island Illinois Montana North Dakota Wisconsin Connecticut Minnesota New Jersey Oregon West Virginia Oklahoma Maryland Indiana NR Alabama Arkansas This report provides a detailed review of the four areas examined. See report appendix for a summary by state of report findings and recommendations. 12 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

overall rank state action & Leadership Prescription Drug monitoring responsible prescribing overdose prevention Louisiana Michigan Mississippi Ohio Texas Utah Nevada Alaska NR Georgia NR Arizona New Hampshire Idaho Kansas Missouri Delaware NR Iowa Maine South Carolina Wyoming Hawaii NR Nebraska Pennsylvania South Dakota NR Rating Indicators Meets Standards Partially Meets Standards, Making Progress Partially Meets Standards, Improvements Needed NR Does Not Meet Standards Not Reported National Safety Council 13

detailed review of four ratings State Action and Leadership State action and leadership is necessary to effectively address prescription drug misuse and overdoses. Coordination across state agencies and the ability to bring together diverse stakeholders is required. 33 A 2012 survey of state alcohol and drug addiction directors reported that most states had a state plan that addressed prescription drugs and/or convened a taskforce to address the issue. 34 In addition, several states reported previously convened taskforce that is no longer active. It should be noted that states may have convened a taskforce for a specific purpose such as a study or to develop a plan. That taskforce may be dismissed upon completion of the task. Forty-one states were rated as meets or partially meets by having a state plan and/or an active task force. Three states did not meet the standard. Six states could not be rated as meeting the standard as data were not available. As this report shows, while many states have plans or taskforces addressing prescription drug misuse and overdoses, more work is needed to save lives from drug overdoses and reduce the nonmedical use of prescription drugs. ASTHO and NGA have learning collaboratives in fifteen states to develop comprehensive, coordinated strategies to prevent injuries and deaths, prescription drug misuse and abuse. 35 These efforts led by governors, the chief state health officials and other key state leaders (i.e. state agency directors, public safety and Attorney General) ensure that the strategies identified have the support necessary to be implemented across state government. State Leadership and Action Criteria State plan addressing prescription drug misuse and overdoses State taskforce or workgroup addressing prescription drug misuse and overdoses It is important that these learning collaboratives work be expanded to more states. One of the more troubling aspects of the current prescription drug epidemic is how quickly it has expanded from one or two isolated states to become a regional problem and now, a national epidemic. The well-documented experiences of states such as Florida and Kentucky demonstrate how the movement of prescription drugs across state lines can contribute to problems in nearby states. Unless all states have in place similar controls and the ability to share critical data - such as PDMPs - and strong standards guiding the prescribing and dispensing of scheduled II, III and IV substances, states risk becoming a safe harbor for those engaged in the trafficking of prescription medications. ASTHO, NGA and other national organizations have identified state leadership and coordinated a comprehensive approach essential to reducing prescription drug overdose deaths. 14 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

Improve State Prescription DRUG Monitoring Programs Experts from the field and research have identified PDMPs as an effective tool in preventing the misuse and diversion of prescription medications. 36 PDMPs are state operated databases that collect prescription information from pharmacies and dispensers of controlled substances. Fortynine states have operating PDMPs or have enacted PDMP legislation to establish their program. Missouri is the lone state without legislation authorizing PDMP. The PDMP Center for Excellence at Brandeis University identified more than 35 best and promising practices for state prescription monitoring programs. 37 The scientific support includes research evidence, case studies and a consensus of expert opinion. The National Alliance of Model State Drug Laws conducted a comparison of published PDMP best-practice recommendations and existing state PDMP legislation and policies. Based on this report, the National Safety Council rated state PDMPs on five recommended practice indicators. 1 Make the PDMP Easy to Access by Adding Authorized Users Each state determines who is authorized to access the PDMP database. Nearly all states allow pharmacists and prescribers access to the PDMP. Other authorized users may include officials from other state agencies such as the Medicaid, Medicare and health insurance programs, health department and workers compensation boards. Most states allow access to PDMP data to aid law enforcement officers or medical licensing boards in their investigations. Forty-seven states require a court order, probable cause or active investigation in order for law enforcement officials to access PDMP information. To protect patient privacy, thirty-five states have laws prohibiting unlawful access and/or disclosure of patient information. An analysis revealed that some states very narrowly define who is authorized to use the PDMP. In many cases, restrictions written into state law prevent professionals and state agencies that need PDMP data from carrying out their responsibilities. For example, a coroner may find it helpful to check the PDMP when conducting an investigation to determine cause of death. State Medicaid programs could use PDMP information to detect suspicious activity indicating fraud or doctor shopping. 2 Prescription Monitoring Programs 1. PDMP data can be accessed by a variety of professionals and state agencies including: - Prescribers and dispensers - Law enforcement, coroners or medical examiners and licensing boards with probable cause or active investigation - State insurance programs such as Medicaid, etc. 2. PDMP allows dispenser and prescriber delegates 3. PDMP moving towards realtime data collection and collects data from dispensers at least weekly 4. PDMP shares data with other states 5. PDMP proactively alerts following user groups: prescribers, dispensers, law enforcement and licensing boards Allow Prescribers and Dispensers the Ability to Delegate PDMP Access Many states limit access to the PDMP only to the licensed prescriber or pharmacist who is registered with the state PDMP. This adds an unnecessary obstacle for prescribers and dispensers that may significantly decrease utilization of the PDMP. The ability to delegate PDMP access allows prescribers and dispensers to assign the task of checking National Safety Council 15

the PDMP to other medical professionals making it a part of their clinical and office workflows. Further, state PDMPs which allow delegation and the creation of institutional accounts report higher utilization rates by prescribers and dispensers. 3 Move to Real-Time Data Collection Prescribers and pharmacists need easy-to-use reports with real-time information. Most state PDMPs collect prescription information from pharmacies weekly, a few PDMPs collect bi-weekly or monthly. The Oklahoma PDMP is the first to offer real-time data reports to pharmacists and physicians to assist them in making clinical decisions on whether to issue a prescription or dispense medication to a patient. Today, an Oklahoma emergency department physician can use his or her PDMP to identify a patient who recently received prescriptions from multiple doctors or pharmacies from anywhere in the state, or to obtain a more accurate list of recent prescriptions for a patient confused about their medication and the amounts he or she is taking. Recently, New York, Minnesota and Kentucky began the first steps towards real-time data by enacting legislation to collect prescription data within 24 hours. Since many who obtain prescription drugs illicitly will utilize providers in multiple states, it is important that those providers have access to the PDMP in other states. 4 Share PDMP Data with Other States State boundaries present an opportunity for those actively seeking prescription drugs to misuse or divert to others. The Kentucky Attorney General s office reported that 60 percent of the prescription medications seized by law enforcement were prescribed, dispensed and brought to Kentucky from Florida and neighboring states. 38 16 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

Since many who obtain prescription drugs illicitly will utilize providers in multiple states, it is important that those providers have access to the PDMP in other states. and dispensers who receive proactive alerts and are prompted to review the patient record, may change clinical decisions regarding the prescribing of controlled substances and more likely to utilize the state PDMP after receiving an alert. 40 State PDMPs should be authorized to issue proactive alerts to prescribers, dispensers, drug diversion officers and licensing officials. States should allocate the necessary funding to support staffing to conduct these analyses and to make revisions to PDMP software. Forty-four states currently authorize their PDMPs to share data either with other state PDMPs and/or their authorized PDMP users. 39 Although changing state laws may be a difficult task amid individual concerns about the privacy and security of personal information, states should allow other states to access their PDMP. By doing so, it will be easier for states to monitor and stop the movement and diversion of prescription drugs across state lines. 5 Issue Proactive Alerts PDMP officials analyze prescription data to look for suspicious patterns that may indicate doctor shopping or pill mill operations and in some states may issue alerts to prescribers, dispensers, law enforcement and licensing officials. Studies have shown that prescribers Responsible Opioid Prescribing The amount of prescription painkillers sold to pharmacies, hospitals, and doctors offices was four times larger in 2010 than in 1999. Enough pain killers were prescribed in 2010 to medicate every American adult with a 5mg dose of hydrocodone, four times a day for a month. 41 Yet, according to a recent Institute of Medicine (IOM) report, the overall treatment of pain in the United states has not improved. Based on recommendations identified in ONDCP national strategy and experiences of states leading the effort to reduce prescription drug overdoses, NSC examined states efforts to support responsible prescribing practices. Responsible Opioid Prescribing 1. State has regulations that deter the formation of pill mills and interstate trafficking of prescription pain medications. 2. State medical boards and licensing agencies provide rules or guidance to all prescribers on responsible prescribing of opioid medications and/or schedule II, III and IV controlled substances. 3. State medical boards and licensing agencies require or recommend education regarding responsible prescribing of controlled substances, pain management, screening for substance use disorders and state prescription monitoring program. At a minimum, certain prescribers such as pain management professionals and other high volume prescribers of opioid medications are required to obtain mandatory education. 4. State increases PDMP use by requiring prescriber utilization of the state PDMP. At a minimum certain prescribers such as pain management or other high volume prescribers are required to utilize the PDMP. National Safety Council 17

Pill mills are clinics that overprescribe pharmaceuticals inappropriately for nonmedical use. Ohio: a case study in what happens when pill mills are reduced Prior to 2011, Ohio was above the national prescription drug overdose death rate. PERCENTAGE Reduction of prescription OF PRESCRIPTION painkillers PAINKILLER sold in REDUCTION hardest hit counties IN HARDEST-HIT COUNTIES Following the passage of Ohio s Pill Mill Bill, 13 illegal pill mills were closed in the first year. The bill was a success, as it drastically reduced prescriptions in counties that had the biggest problems. 1 2 Adams County Scioto County -5.3% -19.6% 3 Jackson County -8.65% 4 Gallia County -11% 1 2 4 1 2. Support safe prescribing. Pill Mills predominantly serving drug-seeking consumers. Primary care physicians and hospital emergency departments are the Florida, Doctors Kentucky and and other Ohio prescribers have seen success need clear with pill guidelines mill to determine the appropriate amount of painkillers needed. first place those in acute pain turn to for treatment. legislation that regulates pain clinics and pain management services. Ohio and Florida saw Washington: significant decreases responsible prescribing Primary care physicians have a difficult job balancing in the amount of opioid pain relievers prescribed after their efforts to provide adequate pain relief with their implementing pill mill regulations. After passage of Ohio s In 2007, the state of Washington issued desire voluntary to prevent prescribing drug diversion, guidelines. addiction and death. It is law, 13 pill mills closed in the Passed first year. into In Scioto law in County, 2010, the guidelines often reversed difficult a to decade-long keep up with the trend latest recommendation of one of Ohio s hardest hit counties, increasing nearly fatal 2 million prescription fewer opioid overdoses. and tools available to help them in this challenging task. doses were prescribed, a 19.6 percent decrease. 42 Pill mill Washington has seen success in reducing overdose deaths legislation Number typically of regulates deaths pain or wellness clinics not and the amounts of opioid pain relievers 23% prescribed through covered under other state medical practice statutes, defining the implementation of prescribing reduction guidelines. In 2007, ownership 600 requirements and establishing educational voluntary guidelines were introduced deaths in Washington to qualifications and the clinical oversight responsibilities of guide physicians on responsible opioid prescribing for the medical 500 director. Eleven states have enacted these laws. non-cancer pain. Following introduction of the guidelines Pill mill legislation frequently require use of the state PDMP it reported increases in prescriber awareness of safer prior to prescribing controlled substances to patients. 400 opioid prescribing practices and subsequent decreases in overdose deaths. 43 In 2010, Washington state law required 2300 all licensing boards to establish rules and adopt one set of Prescribing Guidelines evidence-based prescribing guidelines. The state developed a Pill mill 200 legislation only addresses one part of the number of tools and resources to support responsible opioid prescribing problem: that of high volume prescribers prescribing practices. In addition, it increased training and 100 18 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic 0

support for prescribers to recognize substance abuse and make referrals to treatment. Following Washington State s efforts, it reports a 23 percent reduction in drug overdose death rate since 2008. 44 Vermont and Indiana recently passed legislation that requires licensing boards to develop and adopt evidence-based prescribing guidelines. 3 Prescriber Education IOM report recommends that all healthcare providers keep their knowledge of pain management current by engaging in continuing education programs. Licensure, certification, and recertification examinations should include assessments of providers pain education. 45 A Johns Hopkins review of medical school curricula determined that pain education was limited and that the risks of opioid treatment were underrepresented. 46 Sixteen states currently require or recommend education for physicians and other professionals who prescribe controlled substances to treat pain. 47 State medical boards and medical societies should increase medical education offerings and resources to support responsible prescribing. 48 Washington has created a number of resources to support prescribers including pain assessment tools and continuing medical education (CME) on pain management and addiction. Project ECHO offers CMEs for participation in weekly TelePain video conferences with University of Washington specialists that provide case consultation and answer prescriber clinical and practice based questions. 49 In addition to state efforts, the National Institute on Drug Abuse (NIDA) and the AMA have also released free online training courses for prescribers to address this need. 4 Increase Utilization of State PDMP State PDMPs provide prescribers with additional information about a patient s prescribing history and assist prescribers in making prescribing and other treatment decisions. However, PDMPs are underutilized by most prescribers. The majority of state PDMPs report low utilization rates. Seven states, Kentucky, Massachusetts, New Mexico, New York, Tennessee, West Virginia and Vermont - have all moved to increase utilization of the PDMP by requiring prescribers to access the PDMP prior to prescribing a schedule II, III or IV controlled substance and at specified time intervals (6 or 12 months) if treatment is on-going. Since implementing this legislation, KASPER, the Kentucky PDMP, saw prescriber s registrations triple and information requests increase from 3,000 to 18,000 each day. In order to increase prescriber utilization of these systems, PDMPs need to simplify the registration process and make querying the PDMP easy for medical professionals to incorporate into their clinical workflows. Kentucky PDMP processes the majority of PDMP queries within 15 seconds or less. 50 This report was unable to rate state PDMPs on ease of use and prescriber utilization - two key metrics to ensure widespread adoption of PDMPs by prescribers and dispensers. Overdose Education and Naloxone to Distribution Opiate overdoses, typically from opioid pain relievers or heroin, are reversible with the timely administration of the drug naloxone. Naloxone, available by prescription, can be administered as an injection or nasal spray. It is not a controlled substance and has no abuse potential. Physicians can provide a prescription for naloxone to a person at risk of overdose similar to prescribing an EpiPen for people with severe allergies. However, unlike in some types of allergic reactions, with an opioid overdose, it is unlikely the person at risk would be responsive and able to self-administer this medication. States have increased access to and use of naloxone by amending medical practice laws and regulations to allow a licensed healthcare professional to presribe naloxone for use by a third-party such as a family member. Massachusetts allows community programs to provide naloxone to trained individuals with a standing order from the health department. 51 These programs provide naloxone to the people most likely to witness and intervene in an overdose, law enforcement officers, users of drugs and their friends and family members. Other policy interventions which support increased naloxone access are two categories of laws loosely termed Good Samaritan provisions. The first category protects first responders and other bystanderes from criminal or civil liability for possessing and administering naloxone. The second category provides limited immunity from prosecution or mitigation at sentencing fro crimes such as possession of drugs or drug paraphernalia to overdose bystanders who call 911 or provide medical assistance. 52 National Safety Council 19

Overdose Education and Prevention Criteria State has an overdose education and prevention program to increase access to naloxone or allows licensed healthcare professionals to prescribe naloxone for 3rd party use to treat drug overdose. Good Samaritan provisions protecting first responders and others from criminal and/or civil liability for possessing and administering naloxone. Laws providing immunity or special consideration at sentencing for bystanders, often also drug users, who call 911 or administer naloxone. Overdose education and prevention programs distribute naloxone overdose prevention kits and provide training. The people most likely to witness an overdose - law enforcement officers, people who use drugs and their friends and family members - may be in the best position to intervene and treat an overdose by administering naloxone. Education includes how to recognize the signs of an overdose, when and how to administer naloxone and the importance of rescue breathing until 911 first responders arrive. State program requirements may include logging distribution of kits, educating kit recipients and requiring hospital emergency departments to report if naloxone was administered prior to arrival at ER and record patient outcomes. Studies have shown that programs that provide overdose education and increase access to naloxone are safe and cost-effective. The use of naloxone has reversed more than 10,000 overdoses. 53 This report rates state efforts to expand access to naloxone. Following the lead of New Mexico, 13 states have increased access to naloxone by amending state law. Sixteen states have added Good Samaritan provisions to provide protection from civil or criminal liability for possessing or administering naloxone and offer limited immunity or special consideration at sentencing to bystanders who provide medical assistance. North Carolina recently authorized creation of a state-wide program that would increase access to naloxone and extend Good Samaritan and limited liability provisions. Thirty-four states have to yet to change laws to increase access to naloxone or begin these life-saving programs. States should allocate the necessary resources and funding to support effective implementation of overdose prevention programs. Conclusion Drug overdose is a national epidemic, contributing to the deaths of more than 300,000 people from 1999 to 2010. The leading class of drugs responsible for these deaths is opioid prescription pain relievers, which were involved in more than 16,000 deaths in 2010, or about 45 deaths every day of that year. 54 This report demonstrates that many states have made great strides in addressing this problem. However, evidence-based practices, documented by multiple sources and presented in this report, indicate that preventing prescription drug misuse and overdose deaths requires significant state actions that are far more extensive than most states have engaged thus far. The ultimate success of state actions is also linked to improved support for individuals affected by addiction. Although not addressed in this report, improved access to substance abuse prevention, treatment and recovery services is critical to states efforts to effectively address prescription drug misuse and prevent further drug overdoses. NSC looks forward to working with the treatment, prevention and recovery service community as this work moves forward. The National Safety Council is hopeful that governors, legislators, public health officials, the medical community and the pharmaceutical industry, among many interested parties, will find this report useful in identifying the needs that exist in each state and the evidence-based strategies that should be considered to stop this national epidemic and save thousands of lives each year. 20 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

REFERENCES 1 Jones, C. M., Mack, K. A., & Paulozzi, L. J. (2013). Pharmaceutical Overdose Deaths, United States, 2010. JAMA: Journal Of The American Medical Association, 309(7), 657-659. 2 Jones, C. M., Mack, K. A., & Paulozzi, L. J. (2013). Pharmaceutical Overdose Deaths, United States, 2010. JAMA: Journal Of The American Medical Association, 309(7), 657-659. 3 Jones, C. M., Mack, K. A., & Paulozzi, L. J. (2013). Pharmaceutical Overdose Deaths, United States, 2010. JAMA: Journal Of The American Medical Association, 309(7), 657-659. 4 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013) The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD. Retrieved from http://www. samhsa.gov/data/2k13/dawn127/sr127-dawn-highlights.htm 5 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2012) Treatment Episode Data Set (TEDS): 2000-2010. State Admissions to Substance Abuse Treatment Services, (DASIS Series: S-63, HHS Publication No. SMA-12-4729). Rockville, MD. Retrieved from http://www.samhsa.gov/data/2k13/ TEDS2010/TEDS2010StWeb.pdf 6 Substance Abuse and Mental Health Services Administration, (2012) Results from The 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD. Retrieved from http://www.samhsa.gov/data/ nsduh/2k11results/nsduhresults2011.htm 7 The Partnership at Drugfree.org. (April 2013). 2012 Partnership Attitude Tracking Study. Retrieved from http:// www.drugfree.org/wp-content/uploads/2013/04/pats-2012- FULLREPORT2.pdf 8 Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers -- United States, 1999-2008. MMWR: Morbidity & Mortality Weekly Report, 60(43), 1487-1492. 9 Manchikanti, L., Fellows, B., Ailinani, H., & Pampati, V. (2010). Therapeutic Use, Abuse, and Nonmedical Use of Opiods: A Ten-Year Perspective. Pain Physician, 13(5), 401-435. 10 Drug Enforcement Agency website retrieved from: http:// www.deadiversion.usdoj.gov/schedules/ 11 Kenan, K., Mack, K., & Paulozzi L. (2012). Trends in Prescriptions for Oxycodone and Other Commonly Used Opioids, 2000 10, United States. Open Medicine, 6(2), 41 47. 12 Kenan, K., Mack, K., & Paulozzi L. (2012). Trends in Prescriptions for Oxycodone and Other Commonly Used Opioids, 2000 10, United States. Open Medicine, 6(2), 41 47. 13 Paulozzi, L. J. (2012). Prescription Drug Overdoses: A review. Journal of Safety Research, 43(4), 283-289. 14 Tenore, P. L. (2008). Psychotherapeutic Benefits of Opioid Agonist Therapy. Journal Of Addictive Diseases, 27(3), 49-65. 15 Grattan, A., Sullivan, M. D., Saunders, K. W., Campbell, C. I., & Von Korff, M. R. (2012). Depression and Prescription Opioid Misuse Among Chronic Opioid Therapy Recipients With No History of Substance Abuse. Annals of Family Medicine, 10(4), 304-311. 16 Breckenridge, J. & Clark, J. D. (2003). Patient Characteristics Associated with Opioid Versus Nonsteroidal Anti-inflammatory Drug Management of Chronic Low Back Pain. Journal of Pain, 4(6), 344-350. 17 Substance Abuse and Mental Health Services Administration, (2012) Results from The 2011 National Survey on Drug Use and Health: Summary of National Findings (NSDUH Series H-44, HHS Publication No. (SMA) 12-4713). Rockville, MD. Retrieved from http://www.samhsa.gov/data/nsduh/2k11results/ nsduhresults2011.htm 18 Centers for Disease Control and Prevention. Law: Doctor Shopping retrieved from http://www.cdc.gov/ HomeandRecreationalSafety/Poisoning/laws/dr_shopping.html 19 Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers -- United States, 1999-2008. MMWR: Morbidity & Mortality Weekly Report, 60(43), 1487-1492. 20 National Alliance for Model State Drug Laws, National Safety Council. (May 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 2: State Regulation of Pain Clinics. Retrieved from http://namsdl. org/library/7c4c8b13-1c23-d4f9-74dc1e8e771e451a/ 21 Executive Office of the President of the United States, Office of National Drug Control Policy, (2011) Epidemic: Responding to America s Prescription Drug Abuse Crisis. Retrieved from http:// www.whitehouse.gov/sites/default/files/ondcp/issues-content/ prescription-drugs/rx_abuse_plan.pdf 22 Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers -- United States, 1999-2008. MMWR: Morbidity & Mortality Weekly Report, 60(43), 1487-1492. 23 National Alliance for Model State Drug Laws, National Safety Council. (May 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 3: Prescribing of Controlled Substances for Non Cancer Pain. Retrieved from http://www.namsdl.org/library/8595cdba- 65BE-F4BB-AA4136217F944FE7/ 24 National Alliance for Model State Drug Laws, National Safety Council. (May 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 2: State Regulation of Pain Clinics. Retrieved from http://namsdl. org/library/7c4c8b13-1c23-d4f9-74dc1e8e771e451a/ 25 Network for Public Health Law. (July 2013) Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. Retrieved from http://www.networkforphl. org/_asset/qz5pvn/network-naloxone-10-4.pdf 26 Association of State and Territorial Health Officials (2012) Preventing Prescription Drug Misuse, Abuse and Diversion Across the Continuum. Retrieved from http://www.astho.org/ WorkArea/DownloadAsset.aspx?id=7535 27 National Governors Association. (2012) Issue Brief Six Strategies for Reducing Prescription Drug Abuse. Retrieved from http://www.nga.org/files/live/sites/nga/files/ pdf/1209reducingrxdrugsbrief.pdf 28 Clark T, Eadie J, Knue P, Kreiner P, & Strickler, G. (2012) Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy and Management, Brandeis University National Safety Council 21

REFERENCES (continued) 29 National Alliance for Model State Drug Laws, National Safety Council. (July 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 1: State Prescription Drug Monitoring Programs. Retrieved from http://www.namsdl.org/library/e2d59d38-1372-636c- DDA22C690DB0056A/ 30 National Research Council. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011. 31 Coffin, P. O., & Sullivan, S. D. (2013). Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Annals Of Internal Medicine, 158(1), 1-9. 32 Network for Public Health Law. (July 2013) Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. Retrieved from http://www.networkforphl. org/_asset/qz5pvn/network-naloxone-10-4.pdf 33 National Governors Association. (2012) Issue Brief Six Strategies for Reducing Prescription Drug Abuse. Retrieved from http://www.nga.org/files/live/sites/nga/files/ pdf/1209reducingrxdrugsbrief.pdf 34 National Association of State Alcohol and Drug Abuse Directors, (2012) State Substance Abuse Agencies and Prescription Drug Abuse Initial Results from a NASADAD Membership Inquiry. Retrieved from http://nasadad.org/wp-content/uploads/2010/12/ NASADADPrescription-Drug-Abuse-Inquiry-FINAL-04-2012-3. pdf 35 Association of State and Territorial Health Officials (2012) Preventing Prescription Drug Misuse, Abuse and Diversion Across the Continuum. Retrieved from http://www.astho.org/workarea/ DownloadAsset.aspx?id=7535 36 Clark T, Eadie J, Knue P, Kreiner P, & Strickler, G. (2012) Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy and Management, Brandeis University 37 Clark T, Eadie J, Knue P, Kreiner P, & Strickler, G. (2012) Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy and Management, Brandeis University 38 Congressional Testimony: Prescription Drug Abuse.( 2013, June 6) Retrieved from http://blog.governor.ky.gov/lists/posts/post. aspx?id=107 39 National Alliance for Model State Drug Laws, National Safety Council. (July 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 1: State Prescription Drug Monitoring Programs. Retrieved from http://www.namsdl.org/library/e2d59d38-1372-636c- DDA22C690DB0056A/ 40 Clark T, Eadie J, Knue P, Kreiner P, & Strickler, G. (2012) Prescription Drug Monitoring Programs: An Assessment of the Evidence for Best Practices. The Prescription Drug Monitoring Program Center of Excellence, Heller School for Social Policy and Management, Brandeis University 41 Paulozzi, L. J., Jones, C. M., Mack, K. A., & Rudd, R. A. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers -- United States, 1999-2008. MMWR: Morbidity & Mortality Weekly Report, 60(43), 1487-1492. 42 Hall, Orman. (March 2013) Little Pill, Big Problem: Ohio s Opiate Story presented at meeting of National Safety Council, Atlanta GA. 43 Glass, Lee. (March 2013) Washington State and Opioids: Making Safety First presented at meeting of National Safety Council, Atlanta GA 44 Washington Department of Health TakeAsDirected retrieved from http://www.doh.wa.gov/youandyourfamily/ PoisoningandDrugOverdose/TakeAsDirected/DataSummary. aspx 45 National Research Council. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011. 46 Mezei, L. & Murinson, B. B. (2011). Pain Education in North American Medical Schools. Journal of Pain, 12(12), 1199-1208. 47 National Alliance for Model State Drug Laws, National Safety Council. (May 2013) Prescription Drug Abuse, Addiction and Diversion: Overview of State Legislative and Policy Initiatives Part 3: Prescribing of Controlled Substances for Non Cancer Pain. Retrieved from http://www.namsdl.org/library/8595cdba- 65BE-F4BB-AA4136217F944FE7/ 48 Executive Office of the President of the United States, Office of National Drug Control Policy, (2011) Epidemic: Responding to America s Prescription Drug Abuse Crisis. Retrieved from http:// www.whitehouse.gov/sites/default/files/ondcp/issues-content/ prescription-drugs/rx_abuse_plan.pdf 49 Glass, Lee. (March 2013) Washington State and Opioids: Making Safety First presented at meeting of National Safety Council, Atlanta GA 50 Office of Drug Control Policy (2013,June 6) Retrieved from http://odcp.ky.gov/default.htm 51 Walley, A. Y., Ziming, X., Hackman, H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., &... Ozonoff, A. (2013). Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: Interrupted Time Series Analysis. BMJ: British Medical Journal, 346(7894), 13. 52 Network for Public Health Law. (July 2013) Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. Retrieved from http://www.networkforphl. org/_asset/qz5pvn/network-naloxone-10-4.pdf 53 Coffin, P. O., & Sullivan, S. D. (2013). Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Annals of Internal Medicine, 158(1), 1-9. 54 Wheeler, E., Davidson, P. J., Jones, T., & Irwin, K. S. (2012). Community-Based Opioid Overdose Prevention Programs Providing Naloxone United States, 2010. MMWR: Morbidity & Mortality Weekly Report, 61(6), 101-105. 55 Jones, C. M., Mack, K. A., & Paulozzi, L. J. (2013). Pharmaceutical Overdose Deaths, United States, 2010. JAMA: Journal Of The American Medical Association, 309(7), 657-659. 22 Prescription Nation: Addressing America s Prescription Drug Abuse Epidemic

Acknowledgements The National Safety Council wishes to acknowledge and thank the NSC Board of Directors and Delegates who have led the Council s entry into this issue. In addition, NSC wishes to thank these volunteers and organizations that comprise the Expert Panel that has reviewed and provided feedback on NSC strategies and this report: Rodney Bragg State of Tennessee, Department of Mental Health, Division of Alcohol and Drug Abuse Services Terry Cline State of Oklahoma Department of Health Steve Haught Employee Assistance Professionals Association Paul Jarris, MD, MBA Association of State and Territorial Health Officials Elizabeth Walker Romero Association of State and Territorial Health Officials Sharon Moffat Association of State and Territorial Health Officials William Reay, Pharm.D., MS, MHA Sherry Green National Alliance of State Model Drug Laws Christopher Jones, PharmD, MPH, LCDR Centers for Disease Control and Prevention Leonard J. Paulozzi, MD, MPH Centers for Disease Control and Prevention Clarion Johnson, MD Exxon Mobil, Medicine and Occupational Health Brian Richard Walmart Michael Ayotte, R.Ph. CVS Caremark Tasha Polster Walgreens Company Kathryn Mueller, MD, MPH Colorado Division of Workers Compensation John Klimek, R.Ph. National Council for Prescription Drug Programs Barry Dickinson, Ph.D. American Medical Association Rene Hanna Office of National Drug Control Policy Thomas MacLellan National Governors Association Brian Rosen Pharmacuetical Research and Manufacturers Association Purdue Pharma Robert Cowan National Association of Boards of Pharmacy David Hopkins Kentucky Office of Inspector General, Cabinet for Health and Family Services Constantine Gean, MD, MBA, MS, FACOEM Liberty Mutual Insurance Darci Beacom CNA Insurance Lucy Gee, MS Florida Department of Health Robert Forney, Ph.D., DABFT NSC Alcohol, Drugs and Impairment Division Chief Toxicologist, Office of Lucas County Coroner Brenda Gray, RN Marriott International, Inc. John Eadie PDMP Center of Excellence Rob Morrision National Association of State Alcohol and Drug Abuse Directors Whitney Englander Harm Reduction Coalition Corey Davis Harm Reduction Coalition Sharon Stancliff, MD Harm Reduction Coalition Cheryl Wittke Safe Communities of Madison-Dane County Adam Pomerleau, MD Emory University National Safety Council 23

0613 90000XXXX 2013 National Safety Council