Prescription Opioid Overdose & Misuse in Oregon Mel Kohn, MD MPH Public Health Director and State Public Health Officer Oregon Health Authority Oregon In-State Policy Workshop NGA Policy Academy: Reducing Prescription Drug Abuse February 7, 2013, Salem, Oregon 1
Drug Poisoning Deaths Are Going Up Prescription Opioid Deaths the Primary Driver Number of deaths 450 Unintentional drug poisoning deaths by year and drug type, Oregon 2000-2011 Death rate per 100,000 population 12 400 350 10 300 8 250 200 150 6 4 Cocaine Heroin Prescription opioids Rate of drug poisoning 100 50 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Source: Oregon Vital Records 0 2
More Drug Overdose Deaths than Motor Vehicle Crash Deaths 16.0 Unintentional drug overdose and motor vehicle death rates, Oregon 2000-2011 14.0 12.0 10.0 8.0 6.0 Unintentional drug overdose Motor vehicle crash 4.0 2.0 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Source: Oregon Vital Records 3
Working-age Adults Most at Risk Percentage of total deaths Percentage of prescription opioid related deaths by age group, Oregon 2007-2011 35 31.99 30 25 22.9 20 18.87 15 14.73 10 9.67 5 0 0.23 1.27 0.35 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Group Source: Oregon Vital Records 4
Many Deaths Involve More Than One Drug Number of Drugs Listed as Cause of Death in Unintentional Drug Overdose Deaths, Oregon 2007-11 9% 4% 1% 0% 1 24% 62% 2 3 4 5 6 Source: Oregon Vital Records
Methadone Involved in Over Half of Prescription Opioid Deaths Number 400 Unintentional drug poisoning, prescription opioid and methadone deaths, Oregon, 2000-2011 350 300 250 200 150 All drug related deaths Prescription opioid related deaths Methadone related deaths 100 50 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 6
Methadone Death Rates Parallel Methadone Sales Retail distribution of methadone in Oregon and poisoning mortality rate asociated with methadone in Oregon, 1999-2006 Grams methadone sold per 100,000 persons 6000 5000 4000 3000 2000 1000 0 Grams sold/100,000 population Methadone death rate Oregon Public Health Division- Injury Prevention Program 1999 2000 2001 2002 2003 2004 2005 2006 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Rate of methadone-associated poisoning deaths per 100,000 persons Note: grams sold on left axis, death rate on right axis Sources: US Dept. of Justice, Drug Enforcement Administration, Office of Diversion Control, Automation of Reports and Consolidated Orders System (ARCOS); Oregon Center for Health Statistics mortality data files. Includes unintetnional and undetermined intent deaths. 7
Opioids Dispensed in Oregon in 2012 Drug or drug type Rx Recipient Count in 12 months Number of Rx dispensed in 12 months Number of Rx dispensed per recipient in 12 months Number of people receiving Rx per 1,000 residents Number of Rx dispensed per 1,000 residents Methadone Oxycodone Hydrocodone All opioids 17,350 127,600 354,881 1,161,145 716,753 2,021,962 970,576 3,717,145 7.4 4.5 33.1 3.3 92.0 301.0 2.8 185.8 524.1 3.8 251.6 963.6 Source: Oregon Prescription Drug Monitoring Program, 1/1-12/31/2012
Why is Methadone Especially Dangerous? For the same reason it is useful for treating pain: Long half-life Delayed onset Narrow therapeutic window Respiratory depression Cardiac arrest Interactions with other commonly used drugs Benzodiazepines Alcohol 9
Circumstances of Methadone Deaths, Oregon, 2010, N=56 41% prescribed methadone; 30% no Rx Prescriptions: 43% pain; 26% methadone maintenance In 77%, misuse or abuse contributed to death 75% history of substance abuse 21% history of substance abuse treatment 52% history of mental illness Source: Oregon Injury and Violence Prevention Program, unpublished review of Medical Examiner data 10
Some Potential Prevention Approaches and Policy Changes Utilize CCO structures and health system transformation Addiction and mental health treatment access Provider education on opioid use for pain Practice guidelines for dosing and patient management Single copy, serialized paper prescription forms E-prescribing Lock-in programs in Medicaid Naloxone programs Drug courts Drug Take Back events Prescription Drug Monitoring Programs Pain management specialty clinics LEA efforts to combat drug crime 11
Oregon s #1 Oregon first in the nation for non-medical use of prescription pain relievers in 2010-11 6.4% of those aged 12 or older compared to 4.6% nationally 7/10 states with highest rates in the West 12
Indications for Pain Treatment 760,000 live with chronic pain (20% of Oregonians) 100,000+ are treated for injury in ED annually 213,000 have surgical visits each year (5.5%) Uncounted dental encounters 20,000 new cases of cancer each year 8,000 die of cancer Source: Oregon Prescription Drug Monitoring Program Annual Report 2012 13
Doctor Shopping Uncommon Patients filling prescriptions from multiple prescribers at multiple pharmacies, Oregon 10/2011-3/2012 Patients* Providers/Pharmacies 895,982 1 4 providers and pharmacies 1,746 5-9 providers and pharmacies 69 10-14 providers and pharmacies 18 15 or more providers and pharmacies Source: Oregon Prescription Drug Monitoring Program, 1-3/2012
Opioid overdose: factors among decedents Washington: Medicaid population at high risk - 5.7 times higher risk of death* Utah: 40% of decedents had history of substance abuse; 49% diagnosed with mental illness** Sources: *Centers for Disease Control and Prevention (CDC). Overdose deaths involving prescription opioids among Medicaid enrollees - Washington, 2004-2007. MMWR Morb Mortal Wkly Rep. 2009 Oct 30;58(42):1171-5 **Utah Drug Overdose Mortality Project: http://www.health.utah.gov/prescription/ 15
Oregon s Prescription Drug Monitoring Program (PDMP) Created by legislature to: Support access to legitimate use of controlled substances Deter drug misuse and diversion Support identification and treatment of people addicted to prescription drugs Inform policymaking and educate the public about the problem of prescription drug abuse Launched in 2011 Secure, web-based system that collects data from pharmacies Authenticated providers can query system 16
Providers Using PDMP Find it Useful 65% say it is very helpful to monitor patients prescriptions for controlled substances 64% report it is very helpful to control doctor shopping 78% have spoken with patient about controlled substance use after using system 59% reduced or eliminated prescriptions for a patient after using system 49% contacted other providers or pharmacies Source: Oregon Prescription Drug Monitoring Program Evaluation 17
Improving PDMP Enroll providers Currently only 5,270/approximately 20,000 enrolled Focus especially on top volume prescribers Facilitate use by promoting toolkit and outreach by local public health SB 470 18
Acknowledgements Lisa Millet MSH, Injury and Violence Prevention Program Manager, Public Health Division, Oregon Health Authority Dagan Wright, PhD, Lead Research Analyst, Public Health Division, Oregon Health Authority Heidi Murphy, MPH, Research Analyst, Public Health Division, Oregon Health Authority Bruce Gutelius, MD, MPH, Administrator Center for Prevention & Health Promotion, Oregon Health Authority Katrina Hedberg, MD, MPH, Chief Science Officer, Public Health Division, Oregon Health Authority Todd Beran, MA, Prescription Drug Monitoring Program Coordinator, Public Health Division, Oregon Health Authority David Dowler, PhD, MPH, Research Analyst, Program Design and Evaluation Services, Public Health Division, Oregon Health Authority Data workgroup for the PDMP Gary Schnabel, RN, RPh, Executive Director, Board of Pharmacy Brad Anderson, MD, Kaiser Permanente, Chief Department of Addiction Medicine Wayne Wakeland, PhD, Associate Professor, Systems Science Program, Portland State University Ted Williams, Pharm.D, Pharmacy Director for Oregon Health Plan, and Oregon State University College of Pharmacy Rick Deyo, MD, Professor, Department of Family Medicine, Oregon Health Sciences University Sally Logan, RPh, Kaiser Permanente, Outpatient Pharmacy Quality Coordinator 19
Contact Information Me: Melvin.a.kohn@state.or.us PDMP staff: Lisa.m.millet@state.or.us Dagan.wright@state.or.us Todd.beran@state.or.us 20