CDC s Prevention Efforts to Address Prescription Opioid Epidemic

CDC s Prevention Efforts to Address Prescription Opioid Epidemic Jan Losby, PhD, MSW Lead, Prescription Drug Overdose Health Systems and State Support Team Division of Unintentional Injury Prevention NASBO Spring Meeting April 1, 2016 National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

Today s Topics Public Health Burden Prescription Opioids Heroin Fentanyl CDC s Prevention Work Supply healthcare providers with resources to improve patient safety Improve data quality and track trends Strengthen state efforts through effective public health interventions

Quarter billion opioid prescriptions in 2013

Opioid prescribing can vary 3-fold across states Number of painkiller prescriptions per 100 people 52 71 HI 72 82.1 82.2 95 96 143

States with more opioid pain reliever sales tend to have more drug overdose deaths Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA s Automation of Reports and Consolidated Orders System

Sharp increases in opioid prescribing coincides with sharp increases in Rx opioid deaths 8 7 6 Opioid Sales (kg per 10k) Rx Opioid Deaths (per 100k) 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 National Vital Statistics System, DEA s Automation of Reports and Consolidated Orders System.

2002 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

2007 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

2014 Rapid Increase in Drug Overdose Death Rates by County SOURCE: NCHS Data Visualization Gallery

Risk of opioid-related overdose increases with increased regularity of opioid use 100% 90% 10% 1% 25% 80% 70% 60% Daily users 50% 40% 89% 44% Other users Non-users 30% 20% 10% 31% 0% All patients (N=7,405,800) Opioid overdoses (N=188) Source: Paulozzi et al. Risk of adverse health outcomes with increasing duration and regularity of opioid therapy. J Am Board Fam Med. 2014 May-Jun;27(3):329-38

RX Opioids As Dose Goes Up Risk Goes Up Source: Bohnert, Amy SB, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. Jama 305.13 (2011): 1315-1321.

Majority of opioid overdose deaths associated with multiple sources and/or high dosages 100% 6% 90% 80% 70% 60% 50% 94% 55% multiple sources (> 3 prescribers or pharmacies) and/or high dosages (>100 MME) of opioids fewer sources and dosages of opioids 40% 30% 20% 45% 10% 0% control patients patients with fatal overdose Source: Baumblatt JAG et al. High Risk Use by Patients Prescribed Opioids for Pain and its Role in Overdose Deaths. JAMA Intern Med 2014; 174: 796-801.

Longer durations and higher doses of opioid treatment are associated with opioid use disorder 140 adjusted OR for opioid use disorder (abuse or dependence) compared with no opioid use 120 122 100 adjusted OR 80 60 90 or fewer days more than 90 days 40 20 0 29 15 3 3 3 Low (36 mg or less) Medium (36 to 120 MME) High (120 MME or more) opioid dose Edlund, MJ et al. The role of opioid prescription in incident opioid abuse & dependence among individuals with chronic noncancer pain. Clin J Pain 2014; 30: 557-564.

Half of US Opioids Market is Treatment for Chronic, Non-Cancer Pain U.S. opioids market revenues 7 leading indications - 2010 Fibromyalgia Neuropathic Pain Cancer { 50% Osteoarthritis Post Operative Care Rheumatoid Arthritis Low Back Pain Source: GBI Research. Opioids Market to 2017. June 2011

Rise in Rx overdose deaths since 2000 and recent increase in heroin & fentanyl deaths 5 Deaths per 100,000 population 4 3 2 1 0 Commonly Prescribed Opioids like oxycodone or hydrocodone Methadone Heroin Synthetic opioids like fentanyl 2000 2002 2004 2006 2008 2010 2012 2014 SOURCE: National Vital Statistics System Mortality File.

Prescription opioid misuse is a major risk factor for heroin use 3 out of 4 people who used heroin in the past year misused opioids first 7 out of 10 people who used heroin in the past year also misused opioids in the past year Jones, C.M., Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers United States, 2002 2004 and 2008 2010. Drug Alcohol Depend. (2013).

Fentanyl Synthetic and short-acting opioid analgesic 100X more potent than Morphine 50X more potent than Heroin Primary use is for managing acute or chronic pain associated with advanced cancer

Illicitly-Made Fentanyl (IMF) Illicitly-made fentanyl and fentanyl analogs Most recent increases in nonfatal and fatal fentanyl-involved overdoses linked to IMF Often mixed with heroin or sold as heroin Algren D, Monteilh C, Rubin C, et al. Fentanyl-associated fatalities among illicit drug users in Wayne County, Michigan (July 2005-May 2006). Journal Of Medical Toxicology: Official Journal of the American College Of Medical Toxicology [serial online]. March 2013; 9(1):106-115. U. S. Department of Justice, Drug Enforcement Administration, DEA Investigative Reporting, January 2015

Increases in Fentanyl Drug Confiscations and Fentanyl-related Overdose Fatalities October 26, 2015 Source: http://emergency.cdc.gov/han/han00384.asp

More than 80% of 2014 Fentanyl Seizures Occurring in 10 States CDC Health Advisory on fentanyl available at: http://emergency.cdc.gov/han/han00384.asp

CDC Health Advisory on fentanyl available at: http://emergency.cdc.gov/han/han00384.asp

Three Pillars of CDC s Opioid Prevention Work 1. Improve data quality and track trends 2. Supply healthcare providers with resources to improve patient safety 3. Strengthen state efforts by scaling up effective public health interventions

Improve data quality & track trends

Data Sources Fatal overdoses: Mortality (death certificate) data, medical examiner records Non-fatal overdoses: ED data, hospitalization data, syndromic data, EMS data Drug use, dependence, treatment: Non-medical use, abuse, dependence, treatment admissions Available supply of drugs, drug exposure: Prescription data, claims data, drug supply data

Supply healthcare providers with resources to improve patient safety CDC Guideline for Prescribing Opioids for Chronic Pain

Purpose of CDC Guideline for Prescribing Opioids for Chronic Pain (released March 15, 2016) Support informed clinical decision making Help providers offer safer, more effective care for patients with chronic pain Help reduce misuse, abuse, and overdose from opioids Encourage improved communication between providers and patients about the benefits and risks of opioid therapy Improve provider confidence regarding when and how to use opioids in management of chronic pain Benefit patient health

Organization of Recommendations 12 recommendations are grouped into three conceptual areas: Determining when to initiate or continue opioids for chronic pain Opioid selection, dosage, duration, follow-up, and discontinuation Assessing risk and addressing harms of opioid use http://www.cdc.gov/drugoverdose/prescribing/guideline.html

Primary Audience Primary care providers (e.g., family physicians, internists) Treating patients with chronic pain (i.e., lasting > 3 months or past time of normal tissue healing) Treating patients > 18 years In outpatient settings Outside of active cancer treatment, palliative care, and endof-life care

CDC Guideline for Prescribing Opioids for Chronic Pain + Tools and Support Materials http://www.cdc.gov/drugoverdose /prescribing/guideline.html

Strengthen state efforts by scaling up effective public health interventions CDC-Funded Prescription Drug Overdose Prevention for States Program

CDC s Prescription Drug Overdose Prevention For States (PDO PfS) Program Launched in 2015 4-year cooperative agreement 29 states funded Average award $750K each year Focus on high impact, data driven activities and give states flexibility to tailor their work

CDC s Prescription Drug Overdose Prevention For States (n=29 states in 2015) Arizona California Colorado Connecticut Delaware Illinois Indiana Kentucky Maine Maryland Massachusetts Nebraska Nevada New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Utah Vermont Virginia Washington West Virginia Wisconsin

1 2 Enhance and Maximize PDMPs Insurer or Health System Interventions PDO Prevention for States Strategies State Policy Evaluation Rapid Response Projects 3 4

Prescription Drug Monitoring Programs (PDMPs) State run database 49 states + DC + Guam Pharmacies submit dispensing information on controlled substance prescriptions to a centralized database Operating agency varies Optimal components: Universal registration/use Real-time reporting Actively managed Under used resource

State-based interventions are improving outcomes

1 2 Enhance and Maximize PDMPs Insurer or Health System Interventions PDO Prevention for States Strategies State Policy Evaluation Rapid Response Projects 3 4

Prevention for States: Insurer/Pharmacy Benefit Manager Strategies Prior authorization Coverage requires review to ensure criteria met Drug utilization review Retrospective claims review to identify inappropriate prescribing Patient review and restriction Require patients to use one prescriber and/or pharmacy for controlled substance prescriptions

Primary Prevention Preventing a problem from occurring in the first place Provider guideline Patient and provider education Insurance strategies prior authorization, quantity limits Secondary Identify risk for the problem in the earliest stage so that prompt and appropriate management can be instituted Prescription drug monitoring programs (PDMPs) Legislation: pain clinic, doctor shopping, Good Samaritan Coordinated Care Plan Insurance strategies drug utilization review Tertiary Reducing or minimizing consequences of a problem once it has developed Naloxone distribution Medication-assisted treatment Insurance strategies patient review and restriction

www.cdc.gov/drugoverdose/index.html

Jan Losby JLosby@cdc.gov 770-488-8085 For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.