1 SAMHSA Initiatives to Educate Prescribers and Consumers and Treatment Resources Nick Reuter Division of Pharmacologic Therapy Substance Abuse and Mental Health Services Administration 1
2 Overview National Survey Trends Reducing Demand Through Treatment Prevention-Related Activities Consumer Awareness - SMartRx Practitioner Education/Training Opioid Treatment Methadone Buprenorphine
3 Is prescription drug abuse a problem? National Survey on Drug Use and Health NSDUH, formerly national household survey. Drug Abuse Warning Network DAWN Emergency Department Medical Examiner Monitoring the Future
4 2007 NSDUH Highlights Among youth ages 12-17, there was a significant decline in overall past month illicit drug use, from 11.6 percent in 2002 to 9.5 percent in Reductions in youth drug use occurred for nearly every type of illicit drug, including marijuana, cocaine, hallucinogens, LSD, Ecstasy, prescription-type drugs used nonmedically, pain relievers, stimulants and methamphetamine. Despite many positive trends, the most recent NSDUH also reveals some less encouraging data. Among young adults ages 18 to 25, the level of current nonmedical use of prescription pain relievers has risen 12 percent (to 4.6 percent in 2007). In addition, the level of current illicit drug use among those aged 55 to 59 more than doubled, to 4.1 percent in 2007, confirming concerns that baby boomers have continued their higher levels of substance abuse as they age.
5 Fig 2.1 Past Month Illicit Drug Use among Persons Aged 12 or Older: 2007 Illicit Drugs 19.9 Marijuana Psychotherapeutics 6.9 Cocaine 2.1 Hallucinogens Inhalants Heroin Numbers in Millions 1 Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.
6 Fig 2.2 Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: Percent Using in Past Month Illicit Drugs Marijuana Cocaine Methamphetamine Difference between this estimate and the 2007 estimate is statistically significant at the.05 level Psychotherapeutics Pain Relievers
7 Past Month Nonmedical Use of Pain Relievers among Persons Aged 12 or Older, by Age: Percent Using in Past Month to to or Older Difference between this estimate and the 2007 estimate is statistically significant at the.05 level.
8 Fig 5.1 Specific Drug Used When Initiating Illicit Drug Use among Past Year Initiates of Illicit Drugs Aged 12 or Older: 2007 Pain Relievers 19.0% Marijuana 56.2% Inhalants 10.7% Tranquilizers 6.5% Stimulants 4.1% Hallucinogens 2.0% Cocaine 0.6% Sedatives 1.1% 2.7 Million Initiates of Illicit Drugs Note: The percentages add to greater than 100 percent because of a small number of respondents initiating multiple drugs on the same day.
9 Fig 5.2 Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: 2007 Numbers in Thousands 2,500 2,147 2,090 2,000 1,500 1, , Marijuana Cocaine Inhalants LSD Heroin Pain Tranquilizers Ecstasy Center Stimulants for Substance Sedatives Abuse Treatment PCP Relievers
10 Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or Older: Numbers in Thousands 3,000 2,500 2,000 2,320 2,196 2, ,973 2,422 2,142 2,193 2,114 2,150 2,063 2,147 2,090 Pain Relievers Marijuana 1,500 1, Difference between this estimate and the 2007 estimate is statistically significant at the.05 level.
11 Fig 5.3 Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to 49: 2007 Age in Years Inhalants LSD Ecstasy Heroin Sedatives PCP Marijuana Cocaine Pain Center for Substance Stimulants Abuse Tranquilizers Treatment Relievers
12 Fig 7.2 Dependence on or Abuse of Specific Illicit Drugs in the Past Year among Persons Aged 12 or Older: 2007 Marijuana 3,932,000 Pain Relivers 1,707,000 Cocaine 1,598,000 Tranquilizers Stimulants Hallucinogens Heroin Inhalants Sedatives 443, , , , , , ,000,000 2,000,000 Center for 3,000,000 Substance 4,000,000 Abuse Treatment 5,000,000 Substance Numbers Abuse of and Persons Mental with Health Drug Use Services Disorder Administration
13 Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006 Visits (thousands) CI upper bound estimate CI lower bound Fentanyl* Hydrocodone* Morphine* Oxycodone* * Single- & multi-ingredient formulations Source: National Substance estimates from Abuse DAWN, and Mental 2006 Health Services Administration
14 Nonmedical Use of Pharmaceuticals, Selected Opiates/Opioids, 2006 Visits (thousands) Opiates/opioids not specified CI upper bound estimate CI lower bound Methadone Buprenorphine* * Single- & multi-ingredient formulations Source: National Substance estimates from Abuse DAWN, and Mental 2006 Health Services Administration
15 Nonmedical Use of Pain Relievers in the Past Year among Persons Aged 12 or Older, by Substate Region*: Percentages, Annual Averages Based on 2004, 2005, and 2006 NSDUHs
16 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2007 Source Where Respondent Obtained Drug Dealer/ Stranger 4.1% More than One Doctor 2.6% One Doctor 18.1% Bought/Took from Friend/Relative 14.1% Bought on Internet 0.5% Other 1 4.2% Free from Friend/Relative 56.5% Source Where Friend/Relative Obtained One Doctor 81.0% More than One Doctor 2.9% Free from Friend/Relative 6.6% Other 1 1.8% Bought/Took from Friend/Relative 5.9% Drug Dealer/ Stranger 1.8% Bought on Internet 0.1% Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown. 1 The Other category includes the sources "Wrote Fake Prescription," "Stole from Doctor s Office/Clinic/Hospital/Pharmacy," and "Some Other Way."
17 Response to Rx Drug Abuse Substance abuse treatment Block Grant Treatment Vouchers Provider screening, intervention Opioid Assisted Treatment Methadone Buprenorphine Provider education/training Consumer education/awareness
18 Fig 7.7 Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2007 Did Not Feel They Needed Treatment (19.5 m) 93.6% 4.6% Felt They Needed Treatment and Did Not Make an Effort (955,000) 1.8% Felt They Needed Treatment and Did Make an Effort (380,000) 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use
19 Fig 7.8 Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment But Did Not Receive Treatment and Felt They Needed Treatment: Combined No Health Coverage and Could Not Afford Cost Not Ready to Stop Using Able to Handle Problem without Treatment No Transportation/Inconvenient Might Cause Neighbors/Community to Have Negative Opinion No Program Having Type of Treatment Might Have Negative Effect on Job Did Not Know Where to Go for Treatment Substance Abuse and Mental Percent Health Reporting Services Reason Administration
20 Reimbursing for SBI in Health Care Settings HCPCS Codes (Medicaid) - H0049: Alcohol &/or Drug Screening ($24) - H0050: Brief Intervention:15 mins. ($48) CMS G-Codes (Medicare) - G0396: mins ($29.42) - G0397: > 30 mins ($57.69) CPT Codes (Commercial Health Plans) : mins ($33.41) : > 30 mins ($65.51)
21 Treatment for Opioid Dependence Drug Free, residential, in patient, ambulatory Medication Assisted Treatment Clonidine Naltrexone Opioid Assisted Treatment Methadone Buprenorphine
22 Methadone Maintenance Regulated by DEA, State, local Treatment programs 1200 programs 260,000 patients Public non profit Private for profit Stigmatized
23 Risk Management for Methadone Pain Treatment no required Risk management plan FDA modified labeling, 2006 DEA voluntary restriction on distribution 2008 Addiction/Dependence Treatment Distribution limited to certified, accredited, registered programs Initial dose limit Restrictions on dispensing
24 Methadone In Opioid Dependence Treatment Risk Management Training Guideances to field New Guidelines Dear Colleague Letters Induction practices Patient death reporting State Activities West Virginia moratorium, PDMP check on all patients,
25 Office-based opioid addiction treatment - Buprenorphine 2000 Federal Law permits certain physicians to prescribe certain narcotic medications for opioid dependence
26 Physician Eligibility/Restrictions Physicians Medical license DEA Registration Qualifications Credentialing 8 hour training Restrictions Certain medications Suboxone/Subutex Patient limits 30 or 100
27 Total Number of Patients that Filled a Prescription for Suboxone and Subutex in U.S. Retail Pharmacies, Patient Count (Thousands) SUBOXONE SUBUTEX Year Source: Verispan Total Patient Tracker, Extracted Feb. 2008
28 Buprenorphine Treatment and Diversion 16,000 certified physicians more in 2008 then any other year 305,000 patients in 2007 Baltimore Sun Buprenorphine diverted Buprenorphine injected Buprenorphine and poison reports Buprenorphine related deaths French experience with buprenorphine
29 Prescriber Education and Training
30 Physician Education 4-8 Hour CME Problems we see with patients who are prescribed opioids for persistent pain Deciding whether or not to prescribe an opioid Pharmacology, emphasis on methadone Steps to take if you decide to use opioids in the treatment of persistent pain Steps to take if you decide NOT to use opioids in the treatment of persistent pain: The practical side of patient monitoring PMP, screening, lost Rx, etc. When, why and how to stop prescribing opioids and manage the patient with another treatment approach
31 Opioid Prescribing CME Planned with State Medical Society Pilot tested in Ohio, Virginia Offered in West Virginia (2), Massachusetts, Connecticut, North Carolina, Florida, Maine Integrate with online tie to registration renewal
32 Consumer Awareness/Prevention SmartRx risks, precautions, disposal information on controlled prescription medications distributed to patients point of sale (pharmacy)
33 Program Overview The program ran from 10/22/07 to 5/1/08. The core of the program sent targeted PatientLink messages to patients picking up the following categories of prescriptions: Select Hydrocodones, Benzodiazepines, Sleep Aids, and Oxycontin. The above messages were communicated with patients in the following states as per the government study on abuse rates: AR, AZ, CA, CO, ID, IN, KY, LA, MA, MI, MN, MT, NC, NH, NM, NV, OK, OR, RI, SC, TN, UT, WA, WI, WV, WY. This state criteria allowed Catalina to use approximately 6,300 of its 15,000 pharmacies for distribution (2007 count). In addition to the above prints, the program included a PharmAware message. This message was communicated to over 75,000 pharmacists in the network. The message printed six different times over 12 days to achieve this reach. This execution occurred during Center November for Substance Abuse Treatment 33
34 Program Overview SAMHSA PatientLi 34
35 PatientLink Delivers Trusted Results Based on the Catalina 2007 Readership Study Only physicians and pharmacists are seen as providing more trustworthy information than the PatientLink TM messages. Your physician A pharmacist Information attached to or included w/ prescription A nurse at your physician's office Web site about specific brand of medication Web site about specific med. condition from nonprofit/ govt. Web site about med. condition sponsored by pharma. co. Literature/brochures distributed in aisles of pharmacy Mail sent to my home, sponsored by a pharma. co. Info sent via , sponsored by a pharma. co. Ad in magazine about medication TV ad about medication
36 Summary Prescription drug abuse increasing public health problem Buprenorphine and methadone treatment expanding Rx Opioid/Methadone mortality Labeling, guidance, education, voluntary distribution restriction