A Multi-Systemic Approach for Addressing Arizona s Silent Epidemic Arizona Criminal Justice Commission Statistical Analysis Center

Transcription

1 The Arizona Rx Drug Misuse and Abuse Initiative A Multi-Systemic Approach for Addressing Arizona s Silent Epidemic Arizona Criminal Justice Commission Statistical Analysis Center

2 Conceptual Framework Targeted Increases (+) and Decreases (-) SUPPLY Attitudes & Awareness Use of the PDMP Scripts & Pills Dispensed Health ED visits Deaths NAS Tx Admissions DEMAND - Attitudes & Beliefs - Antecedent Behavior Availability Misuse and Abuse Consequences Crime & Delinquency Rx Drug Investigations DUI-D School Suspensions School Youth Arrests - Lack of LE Training Social Acceptance Perceived Low Risk Expectations of Health Consumer Unsafe Storage & Disposal Sharing Scripts Lack of Resistance Strategies Lack of Parent-Child Communication

3 The Opioid Influx A 4 fold increase in the quantity of Rx Pain Relievers sold in the U.S. in the last decade The United States makes up 4.6% of the world s population, but consumes 80% of its Rx opioids ~46 deaths per day!!!!!!!!!! Rx Pain Reliever deaths are greater than heroin and cocaine combined

4 The Problem? ~ 575 million Class II-IV pills were prescribed in Arizona in 2013 Percentage of Pills by Drug Type in Arizona (2013) Pain Relievers had the highest % of scripts, pills and average number of pills per day; accounting for 57.4% of all pills prescribed Hydrocodone and Oxycodone accounted for 82.6% of all pain relievers prescribed in Arizona Why it matters = probability and access! Benzodiazepine 24.3% All Other Rx Drugs 14.5% Other Rx Pain Relievers 10.0% Oxycodone 24.8% Hydrocodone 22.6%

5 Volume:Access Ratio Enough Rx pain relievers were dispensed last year to medicate every adult in Arizona around-the-clock for 2 weeks straight

6 WHO IS IT AFFECTING?

7 Percentage of Youth Reporting Rx Drug Misuse Past 30 Day Rx Drug Misuse Among Arizona Youth (2014) 10% 9% 8% 7% Arizona= 6.3% 6% 5% 8.9% 4% 3% 7.8% 7.7% 7.6% 7.6% 7.1% 6.8% 6.4% 6.3% 6.1% 6.1% 5.6% 5.5% 5.2% 2% 1% 1.9% 0% Greenlee Pinal Mohave Pima Gila Cochise Apache Santa Cruz CoconinoMaricopa La Paz Navajo Yavapai Yuma Graham *Y-axis altered for visual purposes; accurate representation is out of 100%

8 Percent (%) of Reported Use Rx Misuse and Abuse Among Arizona Adults (2010) 45% 40% 35% Arizona 33% 30% 25% 20% 15% Arizona 13% 10% 5% 0% 39% 13% Apache, Coconino, Mohave, Navajo, & Yavapai 13% 26% Cochise, Graham, Greenlee, & Santa Cruz 34% 29% 30% 25% 24% 15% 12% 5% Gila & Pinal La Paz & Yuma Maricopa Pima Past 12 Months (but not past 30 days) Past 30 Days

9 What Is It Costing Us? Mortality & Morbidity 9,860 cases of opioid-related abuse and dependency cases in the ED a 50% increase between Hospitalizations and emergency department visits for poisonings (Rx drugs are a leading cause) cost Arizona nearly a half a million dollars per day in ,099 drug-related deaths in AZ in % involved Opioids/Opiates Increase in Crime Narcotic drug possession increased 15% between Increase in DUI-D 4,073 DUI-D arrests in AZ a 99.4% increase over the past decade Increase in babies born with NAS 3 out of every 1,000 babies born between

10 CONTRIBUTING FACTORS i.e., What is Amplifying this Problem and What Can We Change?

11 Difficult Balancing Act Prescribers struggle with balancing the legitimate pain needs of their patients while ensuring their safety Prescribers were told over a decade ago that they weren t accessing pain well enough Pain became the 5 th Vital Sign Inconsistent Guidelines Unrealistic Expectations of the Health Consumer Uninformed Patients and lack of education tools/resources The Role of the CSPMP

12 Percent Signed Up 100 Percentage of Arizona Prescribers Signed Up to Use the CSPMP Arizona= 32.5%

13 Easy Access 78.9% of Arizona youth who have misused prescription drugs in the past 30 days report getting them from friends, family or right out of the home

14 Have fun Get high Deal with stress Keep from feeling sad Stop boredom Other Something new To focus Feel normal Because I needed it Lose weight Fit in Get back at parents Be more grown up Be like a famous person Percent (%) Youth Reporting Reasons 100 Reasons Past 30 Day Arizona Youth Rx Misusers Gave for Using (2014)

15 Diversion as a Business Oxy and Hydro generate between $20-$80 a pill on the street depending on dose and formulation

16 FINDING A SOLUTION The Arizona Rx Drug Misuse and Abuse Initiative A Multi-Systemic Approach: Medical/Treatment, Law Enforcement and Prevention

17 Initiative Ontology ASAP Leveraging existing resources and partners Data-driven-decision-making Expert Panel and Public Health vs. Public Safety: a multi-systemic approach Coalitions, Task Groups and Local Champions The vehicles of change Home Grown or Backyard approach

18 The Strategies 1. Reduce Illicit Acquisition and Diversion of Rx Drugs 2. Promote Responsible Prescribing and Dispensing Policies and Practices 3. Enhance Rx Drug Practice and Policies in Law Enforcement 4. Increase Public Awareness and Patient Education about Rx Drug Misuse 5. Enhance Assessment and Referral to Treatment

19 Reduce Illicit Acquisition and Diversion of Rx Drugs

20 Install and Promote Permanent Drop Boxes

21 Safe Storage

22 Promote Responsible Prescribing and Dispensing

23 Raise Awareness and Educate Provide education and resources to balance legitimate pain needs with patient safety (i.e., minimize highdose opioids, dangerous drug combinations and doctor shopping ) Self-monitoring of individual prescribing habits (e.g., report cards) Use of the PDMP Adopt statewide clinical guidelines for prescribing and dispensing controlled substances Opioids in smallest dose possible and shortest time necessary Encourage non-narcotic alternatives and/or combination of therapies

24 Enhance Rx Drug Practice and Policies in Law Enforcement

25 HIDTA Rx Diversion Crimes Training Strategies and step-by-step guidelines for helping law enforcement officers conduct pharmaceutical drug diversion investigations Topics include Rx drug trends Drug identification PDMP Internet Pharmacies Forged prescriptions Doctor Shopping Diversion in a medical facility Over-prescribing cases

26 Increase Public Awareness and Patient Education

27 Raise Awareness and Educate Create a sense of urgency about the Rx drug misuse problem Educate patients and the public about risks of misuse Taking more than prescribed Mixing with other drugs and/or alcohol Not sharing scripts with others and why Proper storage and disposal especially if kids are present in the home Get parents talking to their kids about risks, expectations and resistance strategies

28 The Rx360 Curriculums Research-based curriculum adapted from DrugFreeAmerica s Pact360 modules and localized to specific communities and populations in Arizona Raises awareness of the Rx problem, the risks of misuse, resistance strategies and methods of proper storage and disposal 3 modules: Youth (middle and high school); Parent; Community (e.g., senior citizens and childless adults)

29 Messaging & Patient Education

30 Increase Access and Referral to Substance Abuse Tx

31 Resource Information Screening, Brief Intervention and Referral to Treatment (SBIRT) Additional screening tools: SOAPP; Opioid Risk Tool Decision-trees (RHBA) for navigating Tx options and type Accessing Tx through AHCCCS and the Affordable Care Act MAT Training Promotion of the SAMHSA Tx Locator Tool

32 Did it WORK?

33 Evaluation Highlights Breadth, Depth and Efficacy Did We Change Knowledge, Attitudes, Awareness, Beliefs and BEHAVIOR?

34 Process Evaluation Highlights Cumulative Initiative Counties The initiative counties have 40 Rx drug drop boxes and have held 46 take back events 7 of 9 hospitals are implementing the ED Guidelines or equivalent Over 1,500 prescribers are receiving quarterly report cards 163 professionals have received comprehensive Best Practice training Over 300 Law Enforcement Officers have received the Rx Diversion Crimes curriculum 13,198 youth and 1,328 adults have received the Rx360 curriculum Over 26,000 people have been reached via community events Over 900,000 people have been reached via public messaging and media methods

35 Impact Evaluation

36 Strategy 1: Reduce Illicit Acquisition and Diversion of Rx Drugs

37 Goal: Install and Promote Permanent Drop Boxes 15,000 lbs. of unused, unneeded and expired medication are no longer available for potential diversion. 117 Rx drug boxes are now available in Arizona a 485% increase since June, 2012

38 Goal: Increase Knowledge and Awareness of Proper Disposal and Storage Methods There has been a 76.7% increase in community awareness of drop box locations in the pilot counties There has been a 55.6% increase in community awareness of take-back events in the pilot counties There has been a 64.7% increase in knowledge of proper storage methods in the pilot counties There has been a 179.3% increase in knowledge of proper storage methods in the pilot counties

39 Goal: Limit Youth Access Arizona has seen a 10% reduction in youth obtaining Rx drugs from the home. The Friends and Family plan has significantly decreased in Yavapai, Graham/Greenlee Counties and Casa Grande for past 30 day youth Rx drug misusers (range 29-68% reduction)

40 Strategy 2: Promote Responsible Prescribing and Dispensing

41 Goal: Encourage Sign Up and Use of the CSPMP Arizona has seen a 118% increase in prescribers signed up to use the CSPMP system 14.9% June 1, % January 1, 2014 Arizona has seen a 317% increase in pharmacists signed up to use the CSPMP system 14.7% June 1, % January 1, 2014

42 % Prescribers Signed Up Prescribers Signed up for the CSPMP 140 Pilot Period Cumulative CSPMP % Signed Up (pre) CSPMP % Signed Up (post) CSPMP % Signed Up Increase (pilot) CSPMP % Signed Up Current CSPMP % Signed Up Increase (current) Pilot Non-Pilot

43 Queries Run Arizona CSPMP Queries 2,000,000 1,800,000 1,600, % INCREASE between ,400,000 1,200,000 1,000, , , , ,

44 Queries Pilot CSPMP Queries Start of Yavapai Pilot Start of Pinal Pilot Start of Graham/Greenlee Pilot 116.7% Increase (Pre to Current Quarter) 230 Prescribers Made Queries Prescribers Made Queries 31.4% Increase (Pre to Post Quarter) 178 Prescribers Made Queries Q Q Q Q Q Q Q Q Q Q2 2014

45 Goal: Provide Education and Training and Increase Awareness of Individual Prescribing Habits

46 Prescriptions Dispensed per 100,000 People 45,000 Rate of Controlled Substance Prescriptions in Arizona Noted Decreases are Between , % Decrease 35,000 30, % Decrease 5.5% Decrease 25,000 20,000 15, % Decrease 10,000 5, % Decrease Oxycodone Hydrocodone Other Rx Pain Relievers Benzodiazepine Carisoprodol

47 Pills Dispensed per 100,000 People 3,000,000 Rate of Controlled Substance Pills in Arizona Noted Decreases are Between ,500, % Decrease 2,000, % Decrease 5.7% Decrease 1,500,000 1,000, % Decrease 500, % Decrease Oxycodone Hydrocodone Other Rx Pain Relievers Benzodiazepine Carisoprodol

48 Prescriptions per 100,000 People 250,000 Rates of Controlled Substance Prescriptions in Pilot Counties Noted Decreases are Between , % Decrease 150, % Decrease 6.4% Decrease 100, % Decrease 50, Graham/Greenlee Counties Pinal County Yavapai County Non-Pilot Counties

49 Pills per 100,000 People 16,000,000 Rates of Controlled Substance Pills in Pilot Counties Noted Decreases are Between ,000, % Decrease 12,000, % Decrease 10,000, % Decrease 8,000, % Decrease 6,000,000 4,000,000 2,000, Graham/Greenlee Pinal Yavapai Non-Pilot Counties

50 Awareness and Education Provide education and resources to balance legitimate pain needs with patient safety (i.e., minimize highdose opioids, dangerous drug combinations and doctor shopping ) Adopt statewide clinical guidelines for prescribing and dispensing controlled substances Opioids in smallest dose possible and shortest time necessary Encourage non-narcotic alternatives and/or combination of therapies CME opportunities for opioid-prescribing education Self-monitoring of individual prescribing habits (e.g., report cards)

51 PDMP Prescriber Report Card

52 Strategy 3: Enhance Rx Drug Practice and Policies in Law Enforcement

53 Goal: Increase Knowledge, Awareness and Use of the CSPMP Law Enforcement PDMP sign up has increased 115% in Arizona and 140% in our Initiative counties Awareness of the Rx problem significantly increased for officers who completed the Rx Drug Diversion Crimes training Beliefs that law enforcement officers play an important role in prescription drug diversion significantly increased Knowledge of specific information around Rx fraud investigation procedures significantly increased*

54 Strategy 4: Increase Public Awareness and Patient Education

55 The Demand Side Public Awareness of the Rx problem increased Awareness of the risks of Rx misuse and abuse increased Knowledge of proper storage and disposal increased Parents became more aware of the importance of talking to their kids about Rx misuse and developing resistance strategies Parents felt more equipped to have conversations with their kids about Rx misuse and developing resistance strategies

56 Goal: Increase Youth Perception of the Risks and Consequences of Rx Drug Misuse

57 Percentage of Youth Reporting Reason for Not Using 100 Reasons Non-Rx Youth Users in Yavapai County Gave for Not Using % Increase 6.9% Increase 7.1% Increase Physical Harm External consequences Parent Disapproval

58 Outcome Evaluation Rates of Misuse, Non-Fatal Poisonings and Opioid-Related Deaths

59 Percent (%) Use Past 30 Day Rx Drug Use Among Arizona Youth % REDUCTION 2012=

60 Percentage of Youth Reporting Misuse 14 Arizona Youth Past 30 Day Rx Drug Misuse: Pilot vs. Non-Pilot % Decrease 19.2% Decrease 36.8% Decrease % Decrease Yavapai Pinal Graham/Greenlee Non-Pilot Note: scale reduced for visibility; accurate depiction is out of 100%

61 Age adjusted rate per 100,000 people Non-Fatal Poisoning-Related Inpatient Hospitalizations in Arizona % REDUCTION % REDUCTION Pilot Counties Non-Pilot Counties

62 Cases per 100,000 people Opiate/Opioid Related Deaths in Arizona % INCREASE % REDUCTION Pilot Counties Non-Pilot Counties

63 Accomplishments Almost 500 new prescribers signed up for the CSPMP in MC Toolkit completed and dissemination has started Statewide Summit consensus and adaptation Coalition buy-in session Community Learning Collaborative Identifying Champions Pharmacy/Law Enforcement Partnership in progress

64 Future Plans Expansion of drop boxes in local pharmacies Sign up to Save Lives Campaign Promote Delegates Leveraging AHCCCS Health Plans Report cards and regulatory boards Key Stakeholders Group Hot-Spot Mapping to target resources

65 Contacts For additional information, please visit our website or contact: Karen Ziegler (initiative co-chair): Sheila Sjolander (initiative co-chair): Shana Malone (county-level strategies): Dean Wright (PDMP specifics): Shelly Mowrey (prevention): Tomi St. Mars (prescriber education): Sara Salek (AHCCCS): Jenna Jones (AZ D.O. Board): Carlena Orosco (coordination & TA): Danielle Dandreaux (coordination & TA): Kelly Charbonneau (DBHS): Kenneth Steel (Maricopa County Public Health): Kyle Gardner (Maricopa County Public Health): Tracy Cruickshank (Maricopa County Public Health): Jeanene Fowler (Maricopa County Public Health: Adonis Deniz Jr. (Mercy Maricopa): Heather Brown (Mercy Maricopa):