1. Trends in Drug Use and Policy Challenges for Prevention and Treatment

2. Prescription Drug Abuse:  Prescription drug abuse is the nation’s fastest- growing drug problem. Prescription opioid availability rose dramatically through the 1990s, with large increases in diversion and abuse that continued through 2012.  From 1999 to 2013, the drug poisoning death rate more than doubled from 6.1 to 13.8 per 100,000 population, and the rate for drug poisoning deaths involving opioid analgesics nearly quadrupled from 1.4 to 5.1 per 100,000.

3.  In 2010, 12 million people in the U.S. used prescription painkillers, including oxycodone and morphine, for nonmedical reasons.  In 2009, nearly half a million emergency department visits were due to people misusing or abusing prescriptions painkillers.  In that same year, health insurers spent $24 billion on treatment for substance use disorders, of which Medicaid accounted for 21% of all spending.

4.  According to the CDC, 22,767 Americans die each year involving prescription drug overdose, that’s 62 deaths every day.  According to the CDC, health care providers wrote 259 million prescriptions for opioid painkillers in 2012, enough for every American adult to have a bottle of pills.  Although the U.S. comprises less than 5% of the world’s population, Americans consume 80% of the global opioid painkillers, and 99% of the global supply of hydrocodone.

5.  Vicodin and other drugs containing the narcotic hydrocodone are now the most commonly prescribed medications in the U.S.  It is estimated that up to 25% of people who use prescription pain pills over the long term become addicted to these medications.  70% of people who abuse prescription painkillers obtain the drugs from a family member or friend.  Rates of emergency room visits and SUD treatment admissions related to prescription opioids have also increased markedly.

6.  Every day, 2,500 American youth abuse a prescription pain reliever for the first time.  Nearly 1 in 20 high school seniors has taken Vicodin, 1 in 30 has abused OxyContin.  The number of opioids prescribed to adolescents and youth adults nearly doubled between 1994- 2007.

14. Heroin Abuse:  Overdose deaths linked to heroin jumped 39% in 2013 from the year before.  4 out of 5 heroin users started abusing prescription drugs first.  The “whack-a-mole” theory: successful reductions in prescription opioid abuse since 2012, combined with the availability of high-purity, low-cost heroin, have led to the unintended consequence of increasing heroin abuse and the rise in fatal heroin overdoses.

15.  The simultaneous use of both heroin and prescription painkillers has increased, especially among young, white men.  While heroin users have more criminal justice involvement than prescription drug abusers, those who use both report more mental health problems and higher rates of emergency room visits than those using one drug or the other.

16. Each year since 2010, roughly 600,000 people in the U.S. used heroin. According to the CDC, there are more than 100 overdose deaths a day in the U.S., and about 8,200 deaths annually from heroin overdoses. Nationwide, drug overdose deaths now claim more lives than car accidents.

17. PREVENTION  Refocus the education of health care providers and prescribers, as it relates to pain and addiction, in order to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse. On average, U.S. medical schools provide approximately 7 hours of education on pain, compared to 75 hours for veterinarians. A survey from 2000 found that less than 20% of primary care physicians considered themselves very prepared to identify alcohol or drug dependence in their patients, compared to 80% feeling comfortable diagnosing hypertension and diabetes.

18.  Target education to raise public awareness of the fact that, while prescription drugs may be safe and effective when used properly, they can also be harmful and addictive.  ONDCP and HHS should work with pharmacies manufacturers to develop effective educational materials for patients that address the appropriate use of prescription drugs, the risks and signs of addiction and abuse, seeking treatment for addiction, and the need for safe disposal of unused medications.

19.  Reduce inappropriate access to opioids through prescription drug monitoring programs. Last session California passed legislation to provide funding for the CURES system (Controlled Substance Utilization Review and Evaluation System), which provides information that can be used to support the legitimate medical use of controlled substances, prevent “doctor shopping” or diversion, and help identify patients who may have an addiction problem.

20.  The FY 2015 Federal budget provides $20 million to prevent prescription drug abuse through the Centers for Disease Control and Prevention. CDC has selected 16 states, including California, to receive awards between $750,000 and $1 million each year over the next 4 years. The President’s 2016 budget proposal includes a request to expand the program to all states.

21.  Support the development and use of abuse- deterrent medications. A Washington University study found that the abuse- deterrent formulation of extended-release oxycodone curtailed its abuse by 35-40%. The White House has issued a policy that supports the development and adoption of these new medications. A bill currently pending in the California Legislature (AB 623) would prohibit health plans from requiring step therapy where a patient must fail first on an opioid medication before having access to a medication with abuse-deterrent formula.

22.  Increase access to the opioid overdose antidote Naloxone (Narcan). As of November 2014, twelve states have enacted legislation or regulations to explicitly allow for the dispensing of naloxone under standing orders from a physician. Last year the California Legislature passed legislation (AB 1535) that allows pharmacists to furnish naloxone, without a prescription, to third parties in accordance with standardized procedures and protocols of the State Board of Pharmacy and Medical Board. The new law includes provisions to ensure training of pharmacists and education for the persons to whom the drug is furnished.

23. California also passed legislation last year (SB 1438) that requires the Emergency Medical Services Authority to establish training for all prehospital emergency care personnel regarding the use of naloxone to assist persons experiencing an overdose.  The Clinton Foundation recently negotiated a lower price for a device (Evzio) that delivers a single dose of naloxone, which will be available to institutions that can distribute this overdose antidote more widely.  The World Health Organization has said that increasing the availability of naloxone could prevent more than 20,000 deaths in the U.S. annually.

24.  Improve access to opioid dependence treatment, including medication-assisted treatment. Currently only 15% of FQHCs provide medically- assisted therapy for opioid abuse.  Increase the capacity and willingness of health providers to serve more patients with addiction. HRSA should encourage health clinics to report measures of how many patients are screened for opioid addiction and are provided clinical services for treatment.

25.  Medication-assisted therapy, in combination with counseling and behavioral therapies, can provide a whole patient approach to the treatment of opioid addiction. Federal law prohibits physicians from treating more than 100 patients with buprenorphine at a given time. (HHS is currently considering a revision to this regulation.) Allied professionals, such as nurse practitioners and physician’s assistants, are currently ineligible to prescribe buprenorphine for addiction treatment, which can severely limit access to this treatment in rural areas.

26.  The good news: The White House Budget request includes $12 million for discretionary grants to states for the purpose of expanding treatment services to those with heroin or opioid dependence, including MAT.  The challenge: in spite of the effectiveness of MAT, these medications are still way underutilized. Of the 2.5 million Americans who were dependent on opioids in 2012, fewer than 1 million received medication-assisted treatment.

27. What are the barriers contributing to low utilization of MATs?  Not enough trained prescribers.  Negative attitudes and misunderstandings about addiction medications held by the public, providers and patients.  Policy and regulatory barriers, including utilization management techniques such as limits on dosages, annual or lifetime medication limits, minimal counseling coverage, and “fail first” criteria.

28.  Emphasizing the treatment of SUD using a team- based approach that focuses on treatment adherence, coordinated access to recovery, overall health, counseling and case management would provide a more holistic approach to health care for individuals with opioid dependence that mirrors the high quality care provided for other chronic health conditions.

29.  To ensure that treatment is coordinated with other needed physical and behavioral health services, pursue new mechanisms, such as Medicaid Health Homes, that promote integrated care for individuals with opioid dependency. There is a proposal in California to leverage the requirements of Narcotic Treatment Programs to encompass key health home components. Given the responsibility of these programs to provide daily doses of methadone to patients, they have a “captive audience” that is enviable in Medicaid health homes.

30.  Encourage information sharing among providers who treat opioid dependent patients. Federal confidentiality requirements (42CFR) are often cited as a barrier to effective integration of care and sharing of vital information between the SUD treatment provider and other medical professionals. Opioid dependency health home programs should ensure that team members understand privacy laws, and encourage the use of 42CFR-compliant release forms.

31.  Reduce health insurance coverage barriers to treatment in all treatment settings. Despite federal parity laws, private insurers still implement benefits management, pre-approval and re-approval approaches that interfere with patients gaining timely access to treatment (i.e. “fail first” requirements). In cases where a patient is on long-term medication assisted treatment, a provider may be required to “re- authorize” continued treatment every 6 months, a burden that is not required for medication management of other chronic diseases.

32.  State Medicaid plans should be required to give all individuals with diagnosed opioid dependency the choice and opportunity to receive care in the setting of the patient’s choice.  In California, counties and providers are working to change state law that currently prohibits Medi-Cal reimbursement for more than one Medi-Cal service in the same day. This law restricts access to needed care for many individuals, especially in rural areas, who may need MAT for opioid dependency as well as treatment for other co- occurring health problems.

33. Bills in the 114 th Congress:  Stop Overdose Stat Act of 2015 (H.R. 2850) Supports prevention programs to reduce drug overdose deaths, create a task force to recommend a national public health campaign to Congress, and authorize funding to research and test new treatment and prevention methods. Status: House Energy & Commerce Committee  The Opioid Addiction Treatment Modernization Act (H.R. 2872) Helps increase patient awareness and access to all treatment options for opioid addiction. Status: House Energy & Commerce and Judiciary Committees

34.  The Heroin & Prescription Opioid Abuse Prevention, Education and Enforcement Act of 2015 (S. 1134) Aims to improve healthcare providers’ and public health officials’ ability to prevent prescription drug abuse; support law enforcement efforts to remove heroin from the streets; give more first responders access to naloxone, and increase awareness among health care providers, patients, and the public about prescription opioid abuse and heroin. Status: Senate Judiciary Committee  The Safer Prescribing of Controlled Substances Act of 2015 (S. 1392) Establishes additional safeguards to educate providers who prescribe opioid to treat addiction. Status: Senate Health Committee

35.  The Treatment and Recovery Act (S. 1410) Expands existing funding to combat the nation’s addiction crisis, increases funding for the SAPT Block Grant, and creates news programming aimed at increasing access to and strengthening SUD services for adolescents and perinatal. Status: Senate Health Committee  Increasing the Safety of Prescription Drug Use Act (S. 636) Increases patients’ access to prevention services and treatment; strengthens prescription drug monitoring programs and training for medical professionals; and authorizes new grant programs to increase patient assessment and referral to treatment. Status: Senate Health Committee

36.  The Opioid Overdose Reduction Act of 2015 (S. 707) Offers legal protections to first responders, family members, and volunteers who are education to administer opioid overdose prevention drugs. Status: Senate Judiciary Committee  Comprehensive Addiction and Recovery Act (CARA) (S. 524, H.R. 953) Invests funding in prevention, evidence-based treatment, and recovery supports to help individuals struggling with addiction to heroin or narcotic painkillers. Status: Senate Judiciary Committee; House Judiciary; House Education & Workforce Committees

37.  Prescription Electronic Reporting Reauthorization Act of 2015 (S. 480) Reauthorizes through FY 2020 the controlled substance monitoring program; allows grants to be used to maintain and operate existing state controlled substance monitoring programs; requires a state receiving a grant to facilitate prescriber and dispenser use of monitoring system. Status: Senate Health Committee  Protecting Our Infants Act (S. 799) Requires the Agency for Healthcare Research and Quality to report on prenatal opioid abuse and neonatal abstinence syndrome (symptoms of withdrawal in a newborn). The report must include an evaluation of treatment for pregnant women with opioid use disorders. Status: Senate Health Committee

38. 2014 National Survey on Drug Use & Health: Upward trends in marijuana use are largely responsible for an overall increase in illicit drug use. Marijuana and prescription drugs used non-medically continue to be the two most prominent illicit drugs. Current marijuana use overall was 8.4% in 2014, higher than rates in any year in the 2002-2013 period. The rate of marijuana use among adolescents 12 to 17 was 7.4% in 2014, an increase of.3% from 2013 (7.1%), but a decrease from the 7.9% rate in 2011. The rate of marijuana use among adults 18-25 was 19.6% in 2014, and the rate among adults 26 or older was 6.6%. Both rates were higher than any year since 2002.

39. New California Medical Marijuana Regulatory Bills: (AB 266, AB 243, SB 643 awaiting Governor’s action)  Provide a statewide licensing and regulatory framework for the medical marijuana industry.  Classify medical marijuana as an agricultural product, requiring cultivators to abide by the same environmental regulations as farmers.  Provide for local control protections, explicit county taxation authority, and employer protections for workplace use of medical marijuana..  Local jurisdictions have until March 1, 2016 to adopt their own regulations and licensure scheme for the industry. Should the county not adopt local rules, the state’s regulations would take effect for that jurisdiction.

40.  To oversee this multiagency licensing and regulatory framework, the legislation establishes a new Bureau of Medical Marijuana Regulation, with the appropriate acronym: BUMMR.