1. 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

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

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

4. Changing Landscape of Prescription Drug Overdoses – Rise of an Epidemic

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

6. 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,
11-state MMWR (2004) uses new ICD10 coding, finds rx opioid deaths outnumber heroin deaths during
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)

7. 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

8. 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

9. 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: (L. Paulozzi)
CDC Epidemiological Assistance to West Virginia, 2008 (A. Hall, J. Logan, R. Toblin, et al.)

10. Changing Landscape of Prescription Drug Overdoses – Current Burden

13. Sharp Increase in Opioid Prescriptions Increase in Deaths

14. Role of Prescribing Opioids and Overdose Deaths

15. 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).

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

17. Overview of CDC’s Response

18. 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

19. 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

20. 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

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

22. 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

23. Strengthening States’ Efforts

24. 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

25. 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

26. 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

27. 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.

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

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

30. 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!

31. 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

32. 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

33. 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

34. 1600 Clifton Road NE, Atlanta, GA 30333
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Web:
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.