The Arizona Rx Drug Misuse and Abuse Initiative A Multi-Systemic Approach for Addressing Arizona s Silent Epidemic Shana Malone Arizona Criminal Justice Commission Statistical Analysis Center
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 Drunk/High @ 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
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
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%
Volume:Access Ratio Enough Rx pain relievers were dispensed last year to medicate every adult in Arizona around-the-clock for 2 weeks straight
WHO IS IT AFFECTING?
Apache Cochise Coconino Gila Graham Greenlee LaPaz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma 5.2 *Percent (%) of Reported Use 6.3 6.7 6.2 6.9 7.9 7.5 7.0 7.7 7.7 8.1 8.2 9.2 8.7 11.1 Past 30 Day Rx Drug Misuse Among Arizona Youth (2012) 12.0 10.0 8.0 Arizona 7.9% 6.0 4.0 2.0 0.0 *Y-axis altered for visual purposes; accurate representation is out of 100%
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
What Is It Costing Us? Mortality & Morbidity 9,860 cases of opioid-related abuse and dependency cases in the ED a 50% increase between 2008-2013 1,099 drug-related deaths in AZ in 2013 41% involved Opioids/Opiates Increase in Crime Narcotic drug possession increased 15% between 2010-2012 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 2008-2013
3 Groups to Keep in Mind Opioid-Naïve Individuals Those who have never taken narcotics and have minimal experience with controlled substances Chemically Dependent Individuals who have developed symptoms of tolerance or physiological and/or psychological withdrawal if use of the Rx drug (legitimately or illegally acquired) is reduced or discontinued Diverters Individuals seeking controlled substances for the purpose of selling them to others or healthcare professionals engaged in fraudulent prescribing practices
CONTRIBUTING FACTORS i.e., What is Amplifying this Problem and What Can We Change?
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
Percent (%) of Youth Risk Factors for Arizona Youth 100 90 80 70 60 50 40 30 20 32.7 33.7 45.9 48.3 49.6 33.2 33.1 31.4 10 0 Never Used Resistance Strategy Did Not Talk to Parents About Drugs or Alcohol Attitudes Favorable to Drug Use 2008 2010 2012
Percent (%) at Risk 100 Risk Factor: Early Initiation of Substance Use 90 80 70 60 50 40 30 69.9 66.1 65.9 20 10 28.0 27.2 22.2 0 2008 2010 2012 Rx Users Non-Users
Percent (%) Rx Users Reporting Reasons Arizona Youth with Current Rx Use Reported Using ATODS (2012) 100 90 80 70 60 50 40 30 59.4 20 10 46.5 13.6 25.3 30.6 0 Have fun Deal with stress Addicted Feel normal Other
Percent (%) Non-Rx Users Reporting 100 Reasons Arizona Youth with No Rx Use Reported not Using ATODs (2012) 90 80 70 60 50 40 30 20 54.9 49.3 36.9 69.0 10 0 External Consequences Disapproval Against beliefs Not interested
Diversion as a Business Oxy and Hydro generate between $20-$80 a pill on the street depending on dose and formulation
The Pill Mill
The Stereotype Dealer
The Kindergarten Teacher????
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 PDMP
14.17 17.39 14.77 16.92 13.00 27.63 35.69 31.51 26.09 33.95 30.70 42.17 41.88 41.18 Percent (%) Signed Up 80.00 Percentage of Arizona Prescribers Signed Up to Use the PDMP (09/01/2014) 100 90 80 70 60 50 40 30 Arizona, 29.56 20 10 0 APACHE COCHISE COCONINO GILA GRAHAM GREENLEE LA PAZ MARICOPA MOHAVE NAVAJO PIMA PINAL SANTA CRUZ YAVAPAI YUMA
FINDING A SOLUTION The Arizona Rx Drug Misuse and Abuse Initiative A Multi-Systemic Approach: Medical/Treatment, Law Enforcement and Prevention
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
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
Reduce Illicit Acquisition and Diversion of Rx Drugs
Install and Promote Permanent Drop Boxes
Safe Storage
Promote Responsible Prescribing and Dispensing
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
PMDP Prescriber Report Card
Enhance Rx Drug Practice and Policies in Law Enforcement
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
Increase Public Awareness and Patient Education
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
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)
Increase Access and Referral to Substance Abuse Tx
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
Did it WORK?
Preliminary Evaluation Results Breadth, Depth and Efficacy Did We Change Knowledge, Attitudes, Awareness, Beliefs and BEHAVIOR?
Process Evaluation Highlights Cumulative Initiative Counties 39 drop boxes are operational in the Initiative sites; together with take-back events, our counties have collected ~8,000 lbs of unused/unneeded Rx 7 of 9 hospitals are implementing ED Guidelines Over 1,500 prescribers are receiving quarterly report cards 147 professionals have received comprehensive Best Practice training or door-to-door approach 237 Law Enforcement Officers have received Rx Crimes curriculum 12,221 youth and 976 adults have received the Rx360 curriculum 53,884 people have been reached via community events Over 360,000 people have been reached via public messaging and media methods
Preliminary Impact Evaluation Pilot Results
The Supply Side PDMP sign up has increased in our pilot counties Cumulative increase: 125% (prescribers) and 225% (pharmacists) PDMP use has increased 56% in our pilot counties (as high as 104% in one county) and the number of prescribers making the queries has increased 31% Number of prescriptions and pills for Oxycodone, Hydrocodone, Other Pain Relievers, Benzodiazepine, and Carisoprodol have decreased The percentage of doctors deemed outliers (>1 SD above the mean) has decreased by 12%
% Prescribers Signed Up Prescribers Signed up for the PDMP 140 Pilot Period Cumulative 120 100 80 60 125.29 40 82.38 92.87 20 0 18.59 14.93 PDMP % Signed Up (pre) 33.90 22.55 PDMP % Signed Up (post) 51.00 PDMP % Signed Up Increase (pilot) 41.88 28.80 PDMP % Signed Up Current PDMP % Signed Up Increase (current) Pilot Non-Pilot
Queries Run Arizona PDMP Queries 2,000,000 1,800,000 1,600,000 82.51% INCREASE between 2012-2013 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 2009 2010 2011 2012 2013
Prescriptions per 1,000 People Rates of Controlled Substance Prescriptions Dispensed in Pilot Counties 1,800 1,600 1,400 1,200 4.71% REDUCTION 2012-2013 1,000 800 600 400 200 0 2010 2011 2012 2013
Pills per 1,000 People Rates of Controlled Substance Pills Dispensed in Pilot Counties 120,000 100,000 80,000 6.19% REDUCTION 2012-2013 60,000 40,000 20,000 0 2010 2011 2012 2013
71,995 71,868 68,738 40,616 41,723 39,547 115,959 111,676 105,956 125,942 123,185 114,194 21,516 18,741 16,274 Prescriptions Dispensed 459,262 451,938 424,789 500,000 Controlled Substance Prescriptions - Yavapai County 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 Oxycodone Hydrocodone Other Rx Pain Relievers Benzodiazepine Carisoprodol All Controlled Prior Year July 2011-June 2012 Pilot Year July 2012-June 2013 Post Year July 2013-June 2014
6,198,099 6,299,522 5,987,052 8,172,012 7,972,830 7,470,927 2,743,077 2,740,790 2,576,611 6,476,572 6,391,034 5,935,582 1,656,585 1,483,103 1,284,417 28,766,919 28,388,142 26,548,736 Pills Dispensed 35,000,000 Controlled Substance Pills - Yavapai County 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 Oxycodone Hydrocodone Other Rx Pain Relievers Benzodiazepine Carisoprodol All Controlled Prior Year July 2011-June 2012 Pilot Year July 2012-June 2013 Post Year July 2013-June 2014
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
Law Enforcement Law Enforcement PDMP sign up has increased 140% in our Initiative counties Awareness of the Rx problem significantly increased 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
Preliminary Outcome Evaluation Pilot Results
Percent (%) Use 30 Day Rx Drug Use Among Arizona Youth 100 90 80 70 60 50 40 30 20 10 10.7 10.4 7.9 20.25% REDUCTION 2012=-2014 6.3 0 2008 2010 2012 2014
Age adjusted rate per 100,000 people Non-Fatal Poisoning-Related Inpatient Hospitalizations in Arizona 140 120 100 8.21% REDUCTION 80 17.97% REDUCTION 60 40 20 0 2008 2009 2010 2011 2012 2013 Pilot Counties Non-Pilot Counties
Cases per 100,000 people Opiate/Opioid Related Deaths in Arizona 10 9 8 4.09% INCREASE 7 6 5 28.29% REDUCTION 4 3 2 1 0 2008 2009 2010 2011 2012 2013 Pilot Counties Non-Pilot Counties
Lessons Learned and Next Steps PDMP needs improvement SB1124 Need for Community Prescriber Guidelines & Training Need for Patient Education Referral to Tx methods challenging RMS systems problematic for Rx crimes flagging system Need for earlier prevention strategies Need for targeted approach around DUI-D, NAS and high risk groups
High-Risk Groups Youth and young adults Women of child-bearing age Senior citizens American Indians Polypharm patients Specifically those combining opioids with benzodiazepines and/or muscle relaxers Medicaid patients
Additional Challenges and Managing Unintended Consequences
Shift to Heroin Economics Reduced Access Cartels
Malpractice Suits on the Rise
Walgreens and CVS Crack Down
AMA Resolution 218 (A-13) Calls from pharmacists to doctors offices to verify prescriptions will be deemed an inappropriate interference with the practice of medicine and unwarranted. Threats to pursue action against drug store chains, DEA and federal and state regulators to stop the interference Threats to go to Congress for legislation to eliminate any form of pharmacist prescription verification requirement
Wholesalers Setting Thresholds The DEA is putting pressure on the wholesalers to limit the supply of certain controlled substances Each wholesaler is using their own unpublished algorithm to set these thresholds Can sometimes result in legitimate pain patients not being able to fill their scripts
Big Pharma is Getting Sued
A Call-to-Action
What Can You Do? Meet with local law enforcement/sheriff s Offices to get drop boxes in place Get trained on the Rx360 curriculums to educate the public, and specifically parents and youth Contact your public health department and your RHBA to create a collaboration Approach your local media partners to ask about in-kind radio, television and print spots for public awareness messaging Promote PDMP sign up, clinical guidelines and proper storage and disposal Ready your coalition: The Triple P Approach
Be Prepared Get the right people at the table - you need a champion in each sector Arm yourself with data Get a dissemination plan with designated worker bees
Arm Yourself With Data
Use Data to Make Your Case The Problem Arizona ranks 6 th highest in the country for Rx drug misuse among individuals 12+ years Who It s Affecting 13% of adults and 6% of youth reported misusing Rx drugs in the past 30 days, with Rx pain relievers accounting for the majority of misuse What It s Costing Arizona currently ranks 12 th highest in the nation for drug-related deaths; deaths related to Rx drugs now surpass deaths for heroin and cocaine combined Contributing Factors Enough Rx Pain Relievers were prescribed in 2013 to medicate every Arizona adult around-the-clock for more than two weeks - as high as four weeks in some counties Only 29% of AZ prescribers are using the Prescription Drug Monitoring Program (PDMP) as low as 13% of prescribers in some counties The majority of youth (78.9%) reported obtaining them from friends, family and right out of the home
Be Persistent
Be Patient
Frustration is Part of the Process
But The Payoff Is Worth It!
Final Tip: Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has. --Margaret Mead
Contacts For additional information, please visit our website http://www.azcjc.gov/acjc.web/rx/default.aspx or contact: Karen Ziegler (initiative co-chair): kziegler@azcjc.gov Sheila Sjolander (initiative co-chair): Sheila.Sjolander@azdhs.gov Tammy Paz-Combs (ASAP contact): tcombs@az.gov Jeanne Blackburn (state-level strategies): Jblackburn@az.gov Phil Stevenson (evaluation): pstevenson@azcjc.gov Shana Malone (county-level strategies): smalone@azcjc.gov Dean Wright (PDMP specifics): DWright@azphamcy.gov Shelly Mowrey (prevention): shellymowreymail@gmail.com Tomi St. Mars (prescriber education): Tomi.St.Mars@azdhs.gov