Prescription Drug Abuse and Overdose: Public Health Perspective

Prescription Drug Abuse and Overdose: Public Health Perspective [Residency educators may use the following slides for their own teaching purposes.] CDC s Primary Care and Public Health Initiative October 24, 2012

Overview of Presentation CDC prescription drug abuse and overdose goal Public health approach to prescription drug abuse and overdose Define the problem Identify risk and protective factors Develop and test prevention strategies Ensure widespread adoption Additional resources

CDC Goal Reduce abuse and overdose of opioids and other controlled prescription drugs while ensuring patients with pain are safely and effectively treated.

The Public Health Approach to Prevention Identify Risk and Protective Factors Develop and Test Prevention Strategies Ensure Widespread Adoption Define the Problem

Opioid Prescriptions Dispensed by Retail Pharmacies United States, 1991 2011 250 Number of Prescriptions (in millions) 200 150 100 50 76 78 80 86 91 96 100 109 120 131 139 144 151 158 169 180 192 201 202 210 219 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year IMS Vector One. From Prescription Drug Abuse: It s Not what the doctor ordered. Nora Volkow National Prescription Drug Abuse Summit, April 2012. Available at http://www.slideshare.net/opunite/nora-volkow-final-edits.

Emergency Department Visits Related to Drug Misuse or Abuse United States, 2004 2010 1,600,000 Illicit Drugs Pharmaceuticals Opioid Pain Relievers Benzodiazepines 1,400,000 1,200,000 Number of ED Visits 1,000,000 800,000 600,000 400,000 200,000 0 2004 2005 2006 2007 2008 2009 2010 Year SAMHSA. Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related ED Visits, 2011.

Primary Substance of Abuse at Treatment Admission United States, 2000 2010 18 Alcohol only Heroin Cocaine Stimulants Alcohol w/secondary drug Other opiates Marijuana/hashish Other drugs 16 Admissions per 10,000 Population 14 12 10 8 6 4 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year SAMHSA Treatment Episode Data Set, 2000-2010.

Motor Vehicle Traffic, Poisoning, and Drug Poisoning (Overdose) Death Rates United States, 1980 2010 Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose) 25 Deaths per 100,000 population 20 15 10 5 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Year NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data.

Number of Drug Overdose Deaths Involving Opioid Pain Relievers and Other Drugs United States, 1999 2010 Number of deaths 18,000 16,000 14,000 12,000 10,000 8,000 6,000 Any opioid analgesic Specified drug(s) other than opioid analgesic Only non-specified drug(s) 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CDC, National Center for Health Statistics, National Vital Statistics System. 10

Drug Overdose Deaths by Major Drug Type, United States, 1999 2010 18,000 Opioids Heroin Cocaine Benzodiazepines 16,000 14,000 Number of Deaths 12,000 10,000 8,000 6,000 4,000 2,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

Public Health Impact of Opioid Use For every 1 overdose death in 2010, there were Past Year Nonmedical Users 733 People with abuse/dependence 108 ED visits for misuse or abuse 26 Abuse treatment admissions 10 Treatment admissions are for primary use of opioids from Treatment Exposure Data set. Emergency department visits are from DAWN (Drug Abuse Warning Network), https://dawninfo.samhsa.gov/default.asp. Abuse/dependence and nonmedical use in the past month are from the National Survey on Drug Use and Health.

Economic Cost s $72.5 billion in health care costs 1 Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers 2 1. Coalition Against Insurance Fraud. Prescription for peril: how insurance fraud finances theft and abuse of addictive prescription drugs. Washington, DC: Coalition Against Insurance Fraud; 2007. 2. White AG, Birnbaum, HG, Mareva MN, et al. Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm 2005;11(6):469-479.

High Risk Populations People taking high daily doses of opioids People who doctor shop People using multiple abuseable substances like opioids, benzodiazepines, other CNS depressants, illicit drugs Low-income people and those living in rural areas Medicaid populations People with substance abuse or other mental health issues White AG, Birnbaum HG, Schiller M, Tang J, Katz NP. Analytic models to identify patients at risk for prescription opioid abuse. Am J Managed Care 2009;15(12):897-906. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300(22):2613-20. Paulozzi LJ, Logan JE, Hall AJ, et al. A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia. Addiction 2009;104(9):1541-8. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85-92. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-1321.

Rates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999 2010 8 Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 7 6 5 Rat e 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w. Updated with 2009 mortality and 2010 treatment admission data.

Drug Overdose Death Rate, 2008, and Opioid Pain Reliever Sales Rate, 2010 Kg of opioid pain relievers used per 10,000 Age-adjusted rate per 100,000 National Vital Statistics System, 2008; Automated Reports Consolidated Orders System, 2010.

Drug Overdose Death Rates by Age United States, 1999 2010 30 Deaths per 100,000 population 25 20 15 10 5 45 54 35 44 25 34 55 64 15 24 65 and over 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 CDC, NCHS, National Vital Statistics System.

High Opioid Dose and Overdose Risk 12 11.18 10 Adjusted Hazard Ratio 8 6 4 3.11 2 1.00 1.19 0 1-19 mg/d 20-49 mg/d 50-99 mg/d 100 mg/d Morphine MG Equivalent Dose * Overdose defined as death, hospitalization, unconsciousness, or respiratory failure. Dunn et al. Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92.

High Opioid Dose and Overdose Risk 5 4 Adjusted Odds Ratio 3 2 1.92 2.04 2.88 1 0 20-49 mg/d 50-99 mg/d 100-199 mg/d 200 m g/d Morphine MG Equivalent Dose * Overdose defined as defined cases as people who died of an opioid-related cause. Gomes et al, Opioid dose and drug-related mortality in patients with nonmalignant pain. Ann Int Med 2011;17197):686-691.

High Opioid Dose and Overdose Risk 14 Chronic Pain Acute Pain SUD Cancer 12 10 Hazard Rat io 8 6 4 2 0 1-19 mg/d 20-49 mg/d 50-99 mg/d 100 m g/d Morphine MG Equivalent Dose * Overdose defined as death with an underlying cause-of-death code from the ICD-10 of X42, X44, Y12, or Y14 Bohnert et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-1321.

CDC in Context of National Response Blueprint for federal government Focus areas I. Education II. III. IV. Monitoring Disposal Enforcement CDC role : fits within our mission and complements other federal agencies

CDC Strategic Focus Areas Enhance surveillance Inform policy Improve clinical practice

Intervention Points Pill mills Problem prescribing General prescribing EDs and hospitals Insurer and pharmacy benefit managers General patients & the public People at high risk of overdose Pharmacies

Intervention Recommendations Prescription drug monitoring programs Patient review and restriction programs Laws/regulations/policies Insurers and pharmacy benefit managers mechanisms Clinical guidelines

Prescription Drug Monitoring Programs (PDMPs) Operational in 42 states Focus PDMPs on Patients at highest risk of abuse and overdose Prescribers who clearly deviate from accepted medical practice Implement PDMP best practices

Patient Review and Restriction Programs (aka Lock-In Programs) Applies to patients with inappropriate use of controlled substances 1 prescriber and 1 pharmacy for controlled substances Improve coordination of care and ensure appropriate access for patients at high risk for overdose Evaluations show cost savings as well as reductions in ED visits and numbers of providers and pharmacies

Laws/Regulations/Policies Some states have enacted laws and policies aimed at reducing diversion, abuse, and overdose Policies can strengthen health care provider accountability Safeguard access to treatment when implementing policies Rigorous evaluations to determine effectiveness and identify model aspects

Insurer/Pharmacy Benefit Manager (PBM) Mechanisms Reimbursement incentives/disincentives Formulary development Quantity limits Step therapies/prior authorization Real-time claims analysis Retrospective claims review programs

Clinical Guidelines Improve prescribing and treatment Basis for standard of accepted medical practice for purposes of licensure board actions Several consensus guidelines available Common themes among guidelines

Additional Information http://www.cdc.gov/homeandrecreationalsafety/pdf/ PolicyImpact-PrescriptionPainkillerOD.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm604 3a4.htm http://www.cdc.gov/mmwr/preview/mmwrhtm l/mm6126a5.htm?s_cid=mm6126a5_w

The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.