Presentation on theme: "Office of the Governor And the Oscar for Best Actor Goes to…Hydrocodone? Prescription Drug Abuse in Modern American Film: Lessons for Treatment, Prevention,"— Presentation transcript:
Office of the Governor And the Oscar for Best Actor Goes to…Hydrocodone? Prescription Drug Abuse in Modern American Film: Lessons for Treatment, Prevention, and Public Health Robert Valuck, PhD, RPh Professor of Pharmacy, Epidemiology, and Family Medicine Coordinating Center Director, Colorado Consortium for Prescription Drug Abuse Prevention May 18, 2014
Office of the Governor Objectives Using a sample (real, but identity protected) patient and clips from modern American films as examples… – Describe the scope of the prescription drug abuse problem in the United States and Colorado – Discuss some of the factors contributing to the growth in prescription drug abuse – Highlight policy initiatives and programs at the federal and state levels (including Colorado) to address the problem – Offer examples of actions that physicians can take to promote safe use, safe storage, and safe disposal of prescription drugs
Office of the Governor Prologue So, what’s the big deal?
Office of the Governor Drug Overdose Mortality In 2010, 38,329 people died from a drug overdose in the U.S. – One every 14 minutes – Nearly 60% of those deaths involved prescription drugs – Painkillers (opioids) were involved in 75% of those deaths In Colorado, drug overdose deaths range from 250-500/year Since 2003, more overdose deaths have involved opioids than heroin and cocaine combined Rates of misuse and overdose death are highest among men, persons aged 20-64, non-Hispanic whites, and poor and rural Two main at-risk populations: long term medical users (>10 million) and nonmedical users in past month (>6 million) CDC/MMWR Jan 13, 2012; 61(01):10-13. Colorado Rx Abuse Task Force data SAMSHA/NSDUH 2009 survey.
Office of the Governor Drug Overdose Mortality in the U.S. (2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..
Office of the Governor Drug Overdose Mortality Trends (1979-2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..
Office of the Governor Drug Overdose Death Rates in the US NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data
Office of the Governor 8 Opioid and Benzodiazepine Trends Different than Heroin and Cocaine in the US (1999-2010) CDC/NCHS National Vital Statistics System, CDC Wonder. Updated 2010..
Office of the Governor 9 Prescription Drugs: primary driver of Overdose Deaths in US (2010) Jones et al. JAMA 2013; and CDC/NCHS 2010.
Office of the Governor 10 Opioids more likely to be involved in single drug class deaths (US, 2010) Jones et al. JAMA 2013
Office of the Governor 11 Deaths are the Tip of the Iceberg… For every opioid overdose death in 2011 SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007. http://www.insurancefraud.org/downloads/drugDiversion.pdf
Office of the Governor Cost of Prescription Drug Abuse on the U.S. Economy (2006) Hansen et al. Clin J Pain 2011; 27(3): 194-202.
Office of the Governor How did we get into this mess? An enormous amount of opioids moves through U.S. channels – 1997: 96mg “morphine equivalents” dispensed per person (in the U.S.) – 2007: 700mg per person (in the US) – an increase of >600% – That 700mg per person is enough for every person in the U.S. to take a typical 5mg dose of Vicodin every 4 hours for 3 weeks – While accounting for about 5 percent of the world’s population, the U.S. now consumes 99 percent of the world’s Vicodin and 84 percent of its Oxycontin Causes of the increase? There are many, including… – Increased recognition of pain, undertreatment of pain – Pain as the “fifth vital sign”, JCAHO quality measure, etc. – Drug company advertising and promotion – Practitioners are not well trained in opioid pharmacology, addiction – Drugs are very powerful, highly addictive if not used properly – Scamming, doctor/pharmacy shopping, black market for opioids CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey. CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey.
Office of the Governor Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11) #37 in U.S.
Office of the Governor Sales of Opioid Pain Relievers and Nonmedical Opioid Use (2010-11) #2 in U.S. (Oregon = 6.4)
Office of the Governor Scene #1 Nonmedical Use: The Beginnings
Office of the Governor A Typical Patient: Aaron Aaron is a 22 year old male, who started using prescription opioids when he was in high school He was a typical high school student, from an upper middle class family, played sports, was looked up to by siblings and friends Aaron started experimenting with prescription drugs at a “pharming” party, where students raid their (parents’) medicine cabinets, bring any Rx drugs they can find to the party, dump them all into a bowl, stir them around, and “pick one or two and chase them with a beer” This led to further nonmedical use: trying one or two of his parents’ Vicodin, then one or two more; getting more from friends; and gradually falling into the spiral of increased use, leading to tolerance, leading to increased use, leading to dependence, and ultimately addiction
Office of the Governor Other Paths to Nonmedical Use From 1967…Valley of the Dolls http://youtu.be/t054GSzRywg
Office of the Governor Other Paths to Nonmedical Use From 2014…in your own home https://www.youtube.com/watch?v=0bZOgj5HEAE
Office of the Governor Sources of Opioids among Nonmedical Users CDC/MMWR Jan 13, 2012; 61(01):10-13. SAMHSA/NSDUH 2009 survey.
Office of the Governor Scene #2 Getting Worse: Scamming and Stealing
Office of the Governor Aaron: Spiraling Downward As his addiction became stronger, Aaron started to scam doctors for opioid medications (later described it as easy: “Google ‘how to get opioids from a doctor’ and you’ll get lots of ideas”) He estimated that he visited between 40 and 50 doctors over an 18 month period, and went to about an equal number of pharmacies, to “spread myself around and stay beneath the radar” Most of the doctors gave him at least an initial Rx for Vicodin (his drug of choice due to the ability to request and get refills from doctors, their weekend colleagues covering for them, etc.) He finally started running into difficulty when the Vicodin “didn’t do it for me”, and he progressed to OxyContin (oxycodone)
Office of the Governor 23 Majority of opioids consumed by small percentage of patients (Arkansas Medicaid, 2005) Edlund et al. J Pain Symp Manage 2010;40:279-289
Office of the Governor 24 Top 8.1% of providers prescribe 79% of CII-CIV drugs (Oregon PDMP, 2011-12) Oregon PDMP Report 2012: http://www.orpdmp.com/orpdmpfiles/PDF_Files/ Reports/Statewide_10.01.11_to_03.31.12.pdf http://www.orpdmp.com/orpdmpfiles/PDF_Files/ Reports/Statewide_10.01.11_to_03.31.12.pdf
Office of the Governor 25 Top 20% of prescribers account for 63% of Overdose Deaths (Ontario Public Drug Program, 2006) Dhalla et al. Can Fam Physician 2011;57:e92-e96.
Office of the Governor 26 Overdose risk highest among small percentage of patients at high dosage (Group Health, 1997-2005) Dunn et al, Ann Int Med 2010;152:85-92.
Office of the Governor 27 More patients on opioids = more doctor shoppers Cepeda et al. J Opioid Manag. 2013. 100% of patients are doctor shoppers
Office of the Governor Stealing Can Turn to Robbery…and Worse From 1989…Drugstore Cowboy http://youtu.be/puXEHhZgXaY
Office of the Governor Scene #3 Rock Bottom: Heroin and Overdose
Office of the Governor Aaron: Spiraling Downward AD eventually started using OxyContin at very high doses, mixed it with Xanax and often alcohol, and overdosed at age 21 AD had a difficult stay in the ICU, and while there had two myocardial infarctions, seizures, a staph infection and pneumonia, and underwent extreme withdrawal symptoms Doctors were preparing AD’s parents for his death, which appeared imminent and very likely Surprisingly, AD regained consciousness, and eventually recovered well enough to be discharged home with his parents The disposition of AD’s case will be shown at the end of the talk; his is certainly not the only example of the downward spiral…
Office of the Governor 31 Frequent Nonmedical Users of Opioids more likely to Engage in Risky Use Behaviors (US, 2008-2010) Characteristic 1-29 Days of PYNMU of Opioid Pain Relievers 30-99 Days of PYNMU of Opioid Pain Relievers 100-365 Days of PYNMU of Opioid Pain Relievers aOR (95% CI) Past Year Heroin Usereferent2.8 (1.7-4.5)6.4 (3.7-11.1) Ever Inject Heroinreferent1.6 (0.9-2.9)4.3 (2.5-7.3) Ever Inject Opioid Pain Relieversreferent3.8 (1.9-7.8)13.3 (7.7-23.0) Past Year Heroin Abuse or Dependence referent3.2 (1.7-6.1)7.8 (4.7-12.8) Past Year Opioid Pain Reliever Abuse or Dependence referent2.9 (2.3-3.8)8.9 (7.1-11.3) Heroin Fairly or Very Easy to Obtainreferent1.4 (1.1-1.7)2.1 (1.8-2.6) Abbreviations: PYNMU, past year nonmedical use; aOR, adjusted Odds Ratio; 95% CI, 95% Confidence Interval 1 Odds ratio adjusted for sex, age, race/ethnicity, total family income, and county type Jones, CM. Drug Alcohol Depend 2013.
Office of the Governor 32 Majority of Heroin users in past year reported Nonmedical use of Opioids before heroin initiation (US, 2002-2004 and 2008-2010) Jones, C.M. Drug Alcohol Depend 2013.
Office of the Governor The Heroin Lifestyle From 1996…Trainspotting http://www.youtube.com/watc h?v=Naf_WiEb9Qs&list=PLBA06 889EA057B4C0&feature=share
Office of the Governor Scene #4 The Way Out: Treatment and Recovery
Office of the Governor 35 Rates of opioid overdose deaths, sales and treatment admissions increased in parallel (US, 1999-2010) CDC/National Vital Statistics System DEA ARCOS System SAMHSA’s TEDS System
Office of the Governor Substance Abuse Treatment Gap (2011) SAMHSA/NSDUH 2011 survey
Office of the Governor Physicians Authorized to Treat Addiction (Buprenorphine/Methadone) SAMHSA. National Expenditures for MH Services and Substance Abuse Treatment, 1986-2009. Pub SMA-13-4740.
Office of the Governor Scene #5 The Way Forward: Coordinated Responses
Office of the Governor Federal Initiatives (alphabet soup warning) FDA: REMS programs, stricter regulation on DTC advertising, support of rescheduling certain drugs (hydrocodone) to C-II CDC: Increased surveillance, grant funding, elevate topic in national discussion DEA: Takeback events (2X/year), new rules on returning unused controlled substances (pending), rescheduling ONDCP: Federal strategic plan, elevate topic in national discussion DOJ: Promote PDMP programs, interstate data sharing CMS: Pharmacy/provider restrictions, quantity restrictions NIH: Research funding (basic science, clinical science, policy, collaborative mechanisms/center grants)
Office of the Governor Other States and Policy Examples Tougher Pill Mill Laws, Doctor Shopping Laws Physical Exam Requirements Tamper Resistant Form Requirements Prescription Limits Patient ID Requirements Immunity from Prosecution Naloxone Laws Prospective Reports from PDMP programs (and other enhancements)
Office of the Governor 42 Pill Mill Laws CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 43 Doctor Shopping Laws CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 44 Physical Exam Requirements CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 45 Tamper Resistant Forms CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 46 Prescription Limits CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 47 Patient ID Requirements CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 48 Immunity from Prosecution CDC PHLP 2013 Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Office of the Governor 49 PDMP Proactive Reporting Brandeis TTAC Best Practices Report 2013. Trust for America’s Health Report 2013..
Recommendations to Reduce Prescription Drug Misuse and Abuse in Colorado Colorado Consortium for Prescription Drug Abuse Prevention The Colorado Consortium for Prescription Drug Abuse Prevention, housed at the CU School of Pharmacy, will serve as the operational lead for the CO Plan to Reduce Rx Abuse with participation from the Governor’s Policy Office, a variety of state agencies, and community partners. The Consortium will help to facilitate and implement Workgroup Recommendations mentioned below. Provider & Prescriber Education Change state board policies (or rules) for all DORA-licensed prescribers to include pain management guidelines. Enlist and support DORA to provide education about the existence and utilization of PDMP as part of the licensing processes for prescribers and pharmacists. PDMP Form taskforce with representation from various agencies to examine the use of PDMP as a public health tool. Improve usability and appropriate accessibility of the PDMP system through the use of information technology and increased stakeholder access. Disposal Expand take-back program in law enforcement agencies – develop permanent drop-off sites with Law Enforcement. Expand take-back program to pharmacies (pending DEA approval). Establish Colorado guidelines on flushing. Public Awareness Develop (or utilize existing) social marketing campaign that targets the General Public and overcomes existing obstacles and misperceptions. Develop (or utilize existing) social marketing campaign that targets Youth and Young Adults (12-25 year olds) and overcomes existing obstacles and misperceptions. Data & Analysis Map out all sources of data related to prescription drug use, misuse and overdose in the state in order to monitor trends, educate the public and inform decision making by multiple stakeholders. Identify other efforts that successfully use crosswalks between diverse data sources and successfully standardize their data collection tools across agencies.
Office of the Governor Prescriber and Provider Education Workgroup Agency Co-Chair: Cathy Traugott, HCPF Univ Co-Chair: Lee Newman, MD PDMP Workgroup Agency Co-Chair: Chris Gassen, DORA Univ Co-Chair: Jason Hoppe, DO Safe Disposal Workgroup Agency Co-Chair: Shannon Breitzman, CDPHE Univ Co-Chair: Sunny Linnebur, PharmD Public Awareness Workgroup Agency Co-Chair: Stan Paprocki, OBH Univ Co-Chair: Carol Runyan, PhD Treatment Workgroup Agency Co-Chair: Denise Vincioni, OBH Univ Co-Chair: Paula Riggs, MD Data/Analysis Workgroup Agency Co-Chair: Barbara Gabella, CDPHE Univ Co-Chair: Ingrid Binswanger, MD Coordinating Center CU School of Pharmacy +Coordinating Committee Governor Policy Lead CO Attorney General Substance Abuse Trend & Response Task Force CO Legislature Colorado Consortium for Prescription Drug Abuse Prevention A coordinated, statewide, interuniversity/interagency network LEGEND = New = Existing Subcommittee
Office of the Governor Epilogue Making an Impact: One Patient at a Time
Office of the Governor Aaron: Where is he now? http://www.riseaboveco.org/rx/rx4.html
Office of the Governor What can I do for my patients?
Office of the Governor Six Things You Can Do 1.Take C.E. courses, get all the additional training you can 2.Find and follow guidelines for safe opioid prescribing 3.Be willing to prescribe less (smaller quantities, other alternatives), and see patients more often 4.Check the PDMP more often (more on this shortly) 5.Educate patients on the importance of safe storage and disposal of unused medications 6.Talk with your colleagues, family, friends and neighbors about this…tell them stories about affected patients
HB14-1283 (PDMP Enhancement Bill) Passed this Spring, will be signed into law on Weds 5/21/14 Several key provisions: – Mandatory registration for PDMP account (not mandatory use) – Delegated access (up to three delegates per provider) – Unsolicited reports of potential doctor/pharmacy shoppers – CDPHE access to system for public health surveillance – Advisory Board (consortium PDMP work group) to guide implementation and future directions Not requiring legislation: daily reporting of dispensing data (Rx’s filled) by pharmacies, system/interface enhancements, batch querying and reporting, fewer clicks and fewer attestations (monthly or quarterly)