IPOP Opioid Overdose Training Academy The Basics of Opioid Overdose: A Public Health Perspective Joann Yoon Kang, JD Policy and Partnerships Team Lead Division of Unintentional Injury Prevention October 17, 2016

CDC PRIORITIES: Unintentional Injury Prevention Motor Vehicle Safety Prescription Drug Overdose Older Adult Falls Traumatic Brain Injury

& Disseminate Effective interventions Public Health Model Assess the Problem Identify the Causes Develop & Evaluate Programs & Policies Implement & Disseminate Effective interventions

Changing Landscape of Prescription Drug Overdoses – Rise of an Epidemic

Unintentional drug poisoning mortality by drug, United States, 1979-1998 Slide developed by Dr. Lenard Paulozzi Source: CDC WONDER

States Waving Red Flags, 1999-2004 Maine medical examiner report (2002) finds “a rising problem with prescription drug abuse.” North Carolina epi aid (2002) finds that “prescription narcotics” accounted for 90% of the increase in drug deaths, 1997-2001 11-state MMWR (2004) uses new ICD10 coding, finds rx opioid deaths outnumber heroin deaths during 1999-2000. Slide developed by Dr. Lenard Paulozzi Sources: CDC Epidemiological Assistance to North Carolina, 2002 (K. Sanford, M. Ballesteros, D. Budnitz, G. Agyekum) MMWR, 2004, vol 53, no 11 (M. Davies, V. Coronado)

CDC Involvement Begins, 2004 Tools then available to study the issue Mortality data from National Vital Statistics System Drug sales data from DEA Datasets from the Drug Abuse Warning Network of SAMHSA Slide developed by Dr. Lenard Paulozzi

First DUIP Publication on Rise of Opioid Overdose “Increasing deaths from opioid analgesics in the United States” Published in Pharmacoepidemiology and Drug Safety in 2006 Paulozzi, Budnitz, and Xi First use national data coded to ICD-10 Distinguishes heroin from opioid analgesics for first time Slide developed by Dr. Lenard Paulozzi

Confirmation Study using a different source, DAWN medical examiner data, confirmed deaths were attributed to specific opioids (2006) Epi Aid to West Virginia confirmed that opioid analgesics were causing deaths in the absence of alcohol or illicit drugs (2008) Slide developed by Dr. Lenard Paulozzi Sources: AJPH 2005; 96:1755-57 (L. Paulozzi) CDC Epidemiological Assistance to West Virginia, 2008 (A. Hall, J. Logan, R. Toblin, et al.)

Changing Landscape of Prescription Drug Overdoses – Current Burden

Sharp Increase in Opioid Prescriptions Increase in Deaths

Role of Prescribing Opioids and Overdose Deaths

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).

Rise in Rx overdose deaths since 2000 and recent increase in heroin & fentanyl deaths Heroin SOURCE: National Vital Statistics System Mortality File.

Overview of CDC’s Response

HHS Secretary’s Opioid Initiative Focus on three priority areas that tackle the opioid crisis and significantly impact those struggling with substance use disorders to help save lives Providing training and educational resources to assist health professionals in making informed prescribing decisions 1 2 Increasing use of Naloxone 3 Expanding the use of Medication-Assisted Treatment

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

Improving Data Quality and Tracking Trends: Recommendations from Ohio EpiAid Use multiple data sources for comprehensive analysis Vital Statistics Coroner/Medical Examiner Reports and Toxicology Utilized unintentional drug overdose module in the National Violent Death and Reporting System (NVDRS) Prescription drug monitoring programs Emergency Dept. chief complaint and triage notes Emergency Medical Services Naloxone administration data DEA data on heroin and fentanyl drug seizures

Law enforcement seizures (dark blue) and fentanyl-involved overdoses (light blue), Ohio, Jan 2013- June 2015

Improving Tracking and Monitoring CDC is working to maximize capabilities and use of Prescription Drug Monitoring Programs (PDMPs): Statewide databases that track controlled prescription drugs Contain critical clinical data that helps: Identify patients at risk for opioid-related overdoses Inform providers of other medications the patient is receiving that may interact with those prescribed Identify patients struggling with substance-use disorder

Strengthening States’ Efforts

CDC’s Overdose Prevention in States Effort Prevention for States Program 29 States 4 Key Strategies: Enhancing and maximizing PDMPs Community, insurer, and health systems interventions Policy evaluation Rapid response projects Data-Driven Prevention Initiative 14 States Two levels of funding: Planning and Data Prevention in Action

CDC’s Overdose Prevention in States Effort Enhanced State Surveillance of Opioid-Involved Morbidity and Mortality Support to enhance states’ data capacity 12 states funded to: Monitor illicit opioid use risk factors Improve the timeliness and quality of opioid overdose data Improved quality and timeliness of surveillance data will support and inform prevention and response efforts

Pillar 3: Providing Resources to Healthcare Providers Primary care Patients > 18 Years with chronic pain Outpatient settings Outside of active cancer, palliative, and end of life care

THE EVIDENCE Opioids treat pain effectively long-term. There is no unsafe opioid dose. Addiction risk is low. Lack of evidence that opioids control pain effectively long term. Risk of serious harm increases with opioid dose. Up to a quarter of patients receiving opioids long-term in a primary care setting struggles with addiction. First, do no harm. Opioids are not first-line or routine therapy for chronic pain. When opioids are used, prescribe the lowest effective dosage. Exercise caution when prescribing opioids and monitor all patients closely.

CDC Guideline Implementation Translation and Communication Clinical Training Health System Implementation Insurer/Pharmacy Benefit Manager Implementation

Educational Resources Patient materials Graphics and messages Fact sheets Posters Podcasts Infographics

Training Resources: Webinars COCA webinar series Overview Nonopioid Treatments for Chronic Pain Assessing Benefits and Harms of Opioid Therapy Dosing and Titration of Opioids Additional webinars coming soon!

Health Systems Quality Improvement (QI) Initiative Clinical Decision Supports Create sharable EHR code/artifacts Clinical sites to implement guideline & track outcomes Coordinated Care Plan Create the Chronic Pain Care Involving Opioids: A Coordinated Care Plan for Safer Practice State-led efforts through CDC-funded states EHR and PDMP (prescription drug monitoring program) integration

Insurer Interventions Coverage for non-pharmacologic therapies Improve ease of prescribing non-opioid pain medications Reimbursement for patient counseling, care coordination, & checking PDMP Promote more judicious use of high dosages of opioids outside of palliative care, active cancer or end-of-life care, using mechanisms such as drug utilization review Remove barriers to evidence-based treatment of opioid use disorder, such as eliminate lifetime limits on buprenorphine

Collaboration with Partners Federal Agencies Law Enforcement and DEA Medical and Pharmacy Associations Academic Institutions Insurers and health systems Partner organizations States and local health departments

1600 Clifton Road NE, Atlanta, GA 30333 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 Special thanks to Kristen Sanderson, MPH for her assistance with this presentation. Please note that 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.