State-Level Strategies for Reducing Prescription Drug Overdose Deaths: Utah s Prescription Safety Programpme_

Pain Medicine 2011; 12: S66 S72 Wiley Periodicals, Inc. SECTION 2: FINDING SOLUTIONS State-Level Strategies for Reducing Prescription Drug Overdose Deaths: Utah s Prescription Safety Programpme_1126 66..72 Erin M. Johnson, MPH,* Christina A. Porucznik, PhD, MSPH, Jonathan W. Anderson, MPH,* and Robert T. Rolfs, MD, MPH* *Prescription Pain Medication Program, Utah Department of Health, Salt Lake City, Utah, USA; Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA Reprint requests to: Erin M. Johnson, MPH, P.O. Box 142104, Salt Lake City, UT 84114, USA. Tel: 801-538-6542; Fax: 801-538-9923; E-mail: erjohnso@utah.gov. Abstract Introduction. The Utah Department of Health created a program to decrease deaths and other harm from prescription pain medication. Program goals included educating the public, providers, and patients on prescription safety and creating guidelines for providers on prescribing opioids. Program Interventions. The department s Prescription Pain Medication Program was organized in collaboration with many state agencies as well as public and private organizations. The program developed a statewide media campaign, running messages using the slogan Use Only As Directed from May 2008 to May 2009. The program facilitated the publication and distribution of opioid prescribing guidelines. Program Outcomes. Collaboration among stakeholders to develop educational materials furthered use of the materials. The program distributed more than 2,800 copies of the prescribing guidelines and more than 120,000 copies of print materials, including bookmarks, patient information cards, and posters. Statewide Data. In 2008, unintentional overdose deaths from prescription opioids dropped 14.0% compared with the number of deaths in 2007. In 2009, the number of deaths remained stable from 2008. The campaign funding ended in May 2009. State agencies have continued collaborating and have pooled money to renew the media campaign in 2011. Evaluation of the impact of the prescribing guidelines is ongoing. Conclusions. The state-funded educational campaign may have contributed to a reduction in overdose deaths. Collaboration among state agencies and a sustained educational effort are important aspects of a successful prevention campaign. Key Words. Opioids; Prescription Medication; Death Prevention; Education Campaign; Media Campaign; Intervention Introduction Unintentional prescription pain medication overdose deaths increased by more than 500% in Utah, between 1999 to 2007 [1]. The Utah medical examiner noticed the increase in deaths early in 2000 and brought this to the attention of the state epidemiologist. To better understand these deaths and begin efforts to prevent future deaths, the medical examiner and the state epidemiologist began meeting with stakeholders to identify funding for research and education on the topic of prescription opioid overdose death. After several years of petitioning for funding, legislation was passed granting funds to the Utah Department of Health (UDOH) to investigate prescription pain medication deaths. During the 2007 general session, the Utah State Legislature passed House Bill 137 (H.B. 137), establishing funding for 2 years for an effort by the UDOH to reduce deaths and other harm from prescription opioids utilized for chronic pain. As a result of this legislation, the Prescription Pain Medication Program (PPMP) was established at UDOH. The legislation mandated that UDOH accomplish four objectives: 1. Educate four specific groups to recognize and prevent medication-related harms: health care providers, patients, insurers, and the public. S66

2. Conduct research to improve understanding of why deaths related to prescription pain medications occur and the factors that increase risk of death. 3. Provide recommendations for utilizing the controlled substances database, the state prescription monitoring program, to identify risk factors for prescription pain medication overdose to potentially prevent deaths. 4. Create medical treatment and quality care guidelines for use of prescription opioids. The goal of the PPMP was to reduce the number of unintentional and intent-undetermined prescription opioid overdose deaths by 15% by 2009 compared with 2007 deaths. The remainder of this manuscript describes the organization and interventions of the PPMP, including the educational media campaign, and the creation of Utah s clinical opioid prescribing guidelines. Provider education, also a part of this effort, is discussed in a separate manuscript [2]. Program Organization Collaboration Leaders from related state agencies were invited to provide oversight of the program through participation in a steering committee. The agencies included the following: the Utah Division of Occupational and Professional Licensing; HealthInsight, the Agency for Health Research and Quality designee; the Utah Poison Control Center; the Utah Labor Commission; the Utah Medicaid Program; the Utah Department of Human Services, Division of Substance Abuse; and the Utah Attorney General s Office. The committee met monthly and made decisions about program goals, research topics to pursue, and areas for allocating funds. In addition to the steering committee, an advisory committee was established to provide a way to collaborate with the many stakeholders interested in the issue of prescription medication. The advisory committee was divided further into work groups that met on the topics of patient and community education, provider behavior change, guideline recommendations, guideline tools, and data/research. The advisory committee was open to any interested parties, resulting in a Listserv of nearly 150 individuals, 50 of them in regular attendance at quarterly meetings. The committee included pharmacists, practitioners from a variety of health care fields, government officials, public health professionals, law enforcement officers, pharmaceutical representatives, and other interested members of the community. Funding Table 1 Funding sources for the Prescription Pain Medication Program in Utah After the passage of H.B. 137, various opportunities for additional funding presented themselves. The Utah Labor Commission approached the PPMP with the proposal of contributing $250,000 to the PPMP on the condition that we could find $250,000 in matched funding. Through the collaboration set up by the advisory committee and steering committees, we were made aware of grants and other agencies with funding for this type of program. Some funding was obtained through grants. Other funding came from agencies who saw that they could contribute to an existing effort to leverage the funding from H.B. 137 in order to have a unified, statewide effort (Table 1). The transparency with which the PPMP worked and the desire for input from other agencies while maintaining our balance between the benefits of prescription pain medications against the risks helped instill trust in the PPMP by other agencies. Program Interventions Media Campaign Utah s Rx Safety Program Fiscal Year 2008 Utah Labor Commission $250,000 Legislative Appropriation $150,000 Workers Compensation Fund of Utah $77,000 University of Utah, Research Center for $23,000 Excellence in Public Health Informatics Total $500,000 Fiscal Year 2009 Utah Labor Commission $250,000 Legislative Appropriation $150,000 Utah Division of Substance Abuse $88,954 and Mental Health Utah Commission of Criminal and $37,142 Juvenile Justice Total $526,096 A statewide media campaign using the slogan, Use Only As Directed, ran from May 2008 to May 2009. The campaign targeted adults between the ages of 25 and 54, who account for the majority of prescription overdose deaths in Utah [3]. The total amount allocated to the marketing agency for the media campaign was $300,000. Educational materials, including a TV spot, a radio spot, 10,000 posters, 30,000 patient information cards (Figure 1), and 80,000 bookmarks were developed and introduced to the community during the campaign beginning in May 2008. The TV spot aired on five different broadcast stations, as well as on channels available through a local cable TV provider, during two separate time periods: May to September 2008 and January to April 2009. In addition, eight news releases and media advisories were distributed, and several interviews were granted S67

Johnson et al. with local media, resulting in several TV and print news stories. Of the $300,000 allocated to the media campaign, $109,000 was used to air the TV spots, $15,000 to air radio spots, and $15,000 on online advertising. All campaign materials referred the public to the Use Only As Directed Website (Figure 2) [4], which was developed to provide information regarding safe use of prescription pain medications. Proper disposal of medications was a recommended measure for reducing misuse and abuse in the community [5,6]. Key messages of the education campaign included the following: 1. Never take prescription pain medication that is not prescribed to you. 2. Never adjust your own doses. 3. Never mix with alcohol. 4. Taking with other depressants such as sleep aids or anti-anxiety medications can be dangerous. 5. Always keep your medications locked in a safe place. 6. Always dispose of any unused or expired medications. As part of the media campaign contract, the marketing agency conducted two telephone-based public opinion Figure 1 Front and back views of the patient information card [4]. surveys to obtain information for guidance of efforts and evaluation of the Use Only As Directed public awareness campaign. A pre-campaign survey generated information that guided development of program goals and campaign materials, and also established baseline data for future comparisons. The main objective of the post-campaign survey was to evaluate any changes in public awareness, opinions, and behaviors related to prescription pain medications in Utah over the course of the campaign. The primary survey audience consisted of residents of Utah, age 18 and older, derived from a comprehensive database of Utah residents used to develop a random sample. The number of respondents surveyed represents the population distribution across the state. The sample size for the pre- (N = 413) and post-campaign (N = 410) surveys allowed for an accurate extrapolation of responses to the entire population of the state with a margin of error of plus or minus 4.8% and a 95% level of confidence. An experienced team of telephone interviewers contracted by Vanguard Media, Salt Lake City, Utah, conducted the data collection. Calling hours for the surveys were between 9 AM and 9 PM. on weekdays and between 9 AM and 4 PM on Saturdays. The survey was S68

Utah s Rx Safety Program Figure 2 Screen shot of the original* Use Only As Directed Website home page [4]. *The relaunch of the Use Only As Directed campaign in February 2011 included a redesign of the Website. programmed in computer-assisted telephone interviewing format with interviewers entering survey responses directly into the database during the interview. Data were collected for approximately 1 week for each survey until the desired number of respondents had completed the interviews. The pre-campaign survey took place in February 2008. The campaign was launched in May 2008. The post-campaign survey took place in May 2009. Responses from identical questions on the pre- and postcampaign were compared using tests of proportions. Additional questions were added to the post-campaign as well. A substantial amount of time and effort was spent in developing and distributing press releases throughout the year as well as visiting with the media prior to Prescription Safety Awareness Week (October 20 26, 2008) in order to generate coverage of the topic of prescription pain medication. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain As part of the legislative mandate for H.B. 137, the UDOH was asked to create guidelines for Utah on the proper prescribing of opioids. The Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain were published and made available to providers in March 2009. The guidelines provide clinical recommendations for the use of opioids for management of pain that are intended to be useful to practitioners and to balance the benefits of use against the risks to the individual and society. The target audience was all clinicians who prescribe opioids in their practice. The guidelines were intended to give guidance but not carry the force of law. The PPMP developed the guidelines in partnership with two multidisciplinary panels of physicians. The panels reviewed existing evidence-based guidelines and compiled common recommendations as a starting point for the content of the guidelines. Additional recommendations specific to Utah were added. Key recommendations include the following: Alternatives to opioid treatment should be tried or previous treatment failures documented before initiating opioid treatment for chronic pain. Providers should screen for risk of abuse or addiction before initiating opioid treatment. Methadone should only be prescribed by clinicians who are familiar with its risks and appropriate uses, and who are prepared to conduct the necessary careful monitoring of patients. In general, long-acting opioids should not be used to treat acute pain. Methadone should rarely, if ever, be used to treat acute pain. The patient should be informed of the risks and benefits of opioid treatment. Also included in the guidelines are 20 separate clinical tools selected to help providers implement the recommendations. Included are tools for screening for risk of opioid-related abnormal behaviors and monitoring patients on opioids, sample treatment plans, dosing guidelines, and more. Utah s quality improvement agency, HealthInsight, was engaged to conduct provider education, distribute the opioid prescribing guidelines, and help providers adopt the principles laid out in the guidelines [2]. A postcard was sent to each controlled substances licensee in Utah (~12,000 practitioners) to inform them of the guidelines and how to request a hard copy or print their own copy from the campaign Website. S69

Johnson et al. Table 2 Respondent knowledge, attitudes, and behaviors regarding prescription pain medications before and after the Utah media education campaign Response Number (%) Pre-Campaign N = 413 Number (%) Post-Campaign N = 410 P Value Respondent felt that most Utahns take their prescription pain medications EXACTLY as prescribed by a doctor Respondent took own prescription pain medication and provided it to a friend, family member, or loved one Respondent took prescription pain medication that was not prescribed to him/her Respondent felt that sharing prescription pain medication among family, friends, and loved ones is very dangerous Respondent felt it is wrong to take prescription pain medications that were not prescribed to him/her by a physician Respondent felt that prescription pain medications are misused Respondent knows someone who has misused or abused a prescription pain medication Respondent disposed of prescription pain medication by flushing it down the toilet Respondent disposed of prescription pain medication at a drop box or collection event Program Outcomes Media Impact and Public Opinion Surveys The Use Only As Directed Website served as a mechanism for tracking public awareness of the campaign. Peaks in Website visits were associated with the release of state opioid prescribing guidelines, media stories on various topics, and media air schedules. The post-campaign telephone survey revealed that while 48% of respondents recalled seeing the campaign s TV commercial, only 16% of respondents recognized the campaign slogan, Use Only As Directed. Approximately half (52%) of respondents said that media messages they saw made them less likely to share their prescription medications, and 51% said that media messages made them less likely to take prescription medications not prescribed to them. Nearly one third (29%) of respondents reported that their understanding of the dangers of prescription pain medication had changed during the past year. There was no change in reported beliefs regarding medication sharing or the burden of misuse in the community (Table 2). Reported behaviors regarding disposal of prescription medications improved significantly among the fraction of respondents aware of the disposal issue. The number of respondents who were familiar with how to dispose of expired prescription pain medications remained unchanged from pre- to post-survey at less than half (43%). 143 (34.6) 107 (26.1) 0.0078 70 (16.9) 51 (12.4) 0.0677 78 (18.9) 51 (12.4) 0.0110 238 (57.6) 246 (60.0) 0.4892 368 (89.1) 363 (88.5) 0.7961 384 (93.0) 385 (93.9) 0.5924 226 (54.7) 267 (65.1) 0.0023 199 (48.1) 137 (33.4) <0.0001 1 (<1) 22 (5.4) <0.0001 However, 18% of respondents reported that they disposed of leftover medications as a result of the media messages they saw during the past year. The most common reasons for keeping medication were simply not bothering to dispose of it (32%), keeping it for a possible future need (31%), and keeping it in case of an emergency (15%). The majority of respondents (59%) in the post-survey recalled seeing the TV spots, while fewer reported seeing messages on the Internet (24%) and hearing them on the radio (30%), where minimal funds were allocated (Figure 3). No media funds were allocated to print media, but campaign messages were picked up by print news agencies, and respondents recalled prescription drug safety messages in these media. The estimated value of the news stories, interviews, and unpaid advertising for the campaign was $298,561. This value is based on what it would have cost the marketing agency to purchase time slots and newspaper space for stories that were covered. In addition, all of the print materials (120,000 items) have been distributed throughout the state. This includes 10,000 posters, 30,000 patient information cards (Figure 1), and 80,000 bookmarks. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain The postcards sent to each controlled substances licensee in the state generated 2,804 requests for copies of S70

Utah s Rx Safety Program Figure 3 Percent of respondents who heard, saw, or read information about prescription pain medication by source*. *All respondents on the follow-up survey were asked specifically about seeing media messages from each of the different sources. However, on the initial survey, only those who responded yes to the question, Do you recall hearing, seeing, or reading any advertisements about safely using prescription pain medications?, were asked about the specific sources. the opioid prescribing guidelines from more than 300 hospitals, clinics, and providers. The complete set of guidelines is available at the Website of the Use Only As Directed campaign [4]. To request either the complete (92 pages) or summary (15 pages) version, e-mail useonlyasdirected@utah.gov. The guidelines were also published in the Journal of Pain and Palliative Care Pharmacotherapy in September 2010 [1]. Statewide Data Prescription Drug Deaths The PPMP elected to use the number of prescription drug deaths cited by the medical examiner as one quantifiable metric to evaluate the impact of the guidelines, provider education [2], and the educational campaign. The goal for the PPMP was to see a 15% decrease in the number of unintentional, opioid-related drug deaths by 2009 based on 2007 numbers. In 2008, there was a 14.0% reduction in the number of unintentional, opioid-related drug overdose deaths, from 301 deaths in 2007 to 259 in 2008 (Figure 4). This remained relatively stable during 2009 at 265 unintentional, opioid-related deaths. Discussion Process outcomes, such as increased collaboration and strengthened relationships among stakeholders, demonstrate qualitative success of the PPMP. Distribution of guidelines and Use Only As Directed materials demonstrates quantitative success. The collaboration among local and state organizations caused the PPMP materials to be well accepted and dispersed throughout the state. Requests for materials and opioid prescribing guidelines came from pharmacies, county health departments, clinics of a variety of specialties, treatment centers, grocery stores, and individuals. Federal and state agencies including the Department of Environmental Quality, the Drug Enforcement Agency, the Department of Human Services, the Department of Commerce, and the UDOH have continued meeting to ensure that all efforts at education are done collaboratively. More than $800,000 has been pooled to resume the Use Only As Directed statewide media campaign in Utah during 2011. In 2010, Utah was awarded funding by the Centers for Disease Control and Prevention to conduct a complete evaluation of the impact of the opioid prescribing guidelines. Results of the evaluation are anticipated in 2012. The reported drop in prescription drug deaths, the first significant decrease since 1994, was based on medical examiner records, which included a literal field called cause of death. Cause of death fields were manually reviewed for all intent-undetermined and unintentional deaths. Any mention of a drug was coded under the specific drug. The medical examiner investigation and cause of death determination protocol did not change in 2008 compared with 2007, nor had it changed during the time of increasing deaths. Fatality is the most severe outcome associated with prescription drug use. It is not reasonable to expect sustained change in this metric with a short-term intervention. Given a limited time period for a funded intervention and the devastating impact this problem was having in lives lost, Utah chose to implement several interventions as research on the problem was being conducted. This choice meant that the research findings were not available to guide interventions. It also compromised our ability to evaluate the impact of the individual interventions. Funding for the media campaign ended in May 2009. The decrease in the number of unintentional, opioid-related drug deaths remained stable in 2009 (Figure 4). A causal Figure 4 Number of unintentional drug overdose cases involving at least one prescription opioid by year: Utah, 2000 2009. S71

Johnson et al. link cannot be drawn between the annual decrease in deaths related to prescription opioids reported in 2008 and 2009, and the efforts of the PPMP. The drop in deaths should reinforce the need for sustained effort in educating on safe use of prescription drugs. Potential for Replication Other organizations are welcome to modify or adopt the Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain [1]. While these guidelines were not written to be mandated or legally binding, certain agencies in Utah have adopted the guidelines as official practice. Utah is working with other states who have expressed interest in modifying, merging, or adopting the Utah guidelines. An obstacle in replicating the guidelines is that permission was obtained for each of the tools included in the guidelines; any modification or merging of the guidelines may require obtaining separate permission for any of the tools included. To facilitate replication of the media campaign materials, print and media materials are available upon request [4]. Several states have requested permission to modify Utah s materials for use in their own state prescription awareness programs. Some obstacles to consider in replicating the media materials include adjusting the materials with state-specific data, costs for talent fees if using radio or TV spots, and replacing the Use Only As Directed logo with a personalized logo. Also, laws regarding sharing, disposing of, and using prescription drugs vary from state to state, so interested states would need to review the materials for applicability. Limitations Several limitations exist for this prevention program. First, there was no true monitoring or evaluation framework to assess program impact; thus, there is no basis to assess the program outcomes except as mere descriptions. This lack of framework limits any definitive conclusions about the impact of the program interventions on reducing death and harm from prescription pain medication. The second limitation is that the duration of the program was insufficient to monitor output or consequences to establish any longitudinal trends. The third limitation, inherent to many public health interventions, is that the program interventions lacked a method to demonstrate a causal linkage between the program and improvements in public health. Conclusions Utah has used a multipronged approach to address problems related to prescription opioid use by educating providers, patients, and the general public to increase knowledge about potential dangers of prescription pain medication. Approaches included a media awareness campaign, opioid prescribing guidelines, provider education via small group sessions [2], and collaboration among state agencies and interested parties. The media campaign materials and guidelines were well accepted in the state and are available for other states to use, adapt, and distribute. To sustain a reduction in deaths, a continuing effort to educate the public and providers is needed. It is hoped that the lessons learned from this program can help inform other programs at the local and state levels. Disclosures The authors have no relevant financial relationships to disclose. References 1 Rolfs RT, Johnson E, Williams NJ, Sundwall DN. Utah clinical guidelines on prescribing opioids for treatment of pain. J Pain Palliat Care Pharmacother 2010;24(3):219 35. 2 Cochella S, Bateman K. Provider detailing: An intervention to decrease prescription opioid deaths in Utah. Pain Med 2011;12:S73 6. 3 Centers for Disease Control and Prevention. Increase in poisoning deaths caused by non-illicit drugs Utah 1991 2003. MMWR Morb Mortal Wkly Rep 2005;54(02):33 6. 4 Utah Department of Health. Website of the Use Only as Directed campaign. 2008. Available at: http:// www.useonlyasdirected.org (accessed December 7, 2010). 5 Inciardi JA, Surratt HL, Cicero TJ, Beard RA. Prescription opioid abuse and diversion in an urban community: The results of an ultrarapid assessment. Pain Med 2009;10(3):537 48. 6 The White House. National drug control strategy. 2007. Available at: http://www.ncjrs.gov/pdffiles1/ondcp/ 216431.pdf (accessed September 30, 2010). S72