1. PRESCRIPTION DRUG ABUSE/MISUSE IN OKLAHOMA Avy Redus, MS Project Coordinator AvyD@health.ok.gov Claire Nguyen, MS Injury Epidemiologist ClaireN@health.ok.gov Oklahoma State Department of Health Injury Prevention Service 405-271-3430 http://poison.health.ok.gov

2. BACKGROUND Poisoning  Ingestion, inhalation, absorption, or contact with a substance resulting in a toxic effect or bodily harm. Unintentional  Individual did not intend harm to themselves or someone else  May intentionally take a drug, but did not intend to harm themselves

3. METHODS Office of the Chief Medical Examiner  Centralized system  IPS receives ME reports for all non-natural deaths  Narrative  Autopsy  Toxicology  Manner of death

5. SCOPE OF THE PROBLEM

6. Source: Centers for Disease Control and Prevention, 2013 *Deaths are those for which poisoning by drugs (illicit, prescription, and over-the-counter) was the underlying cause. Unintentional drug overdose death rates in the U.S. have more than tripled since 1990.

7. MAGNITUDE OF THE PROBLEM, U.S. 15,000 deaths annually In 2010, 1 in 20 used pain killers for nonmedical purposes Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month. Source: Centers for Disease Control and Prevention, 2012

8. UNINTENTIONAL POISONING DEATH RATES, OKLAHOMA AND THE UNITED STATES, 1999-2010 Source: WISQARS, Centers for Disease Control and Prevention

9. UNINTENTIONAL POISONING AND MOTOR VEHICLE CRASH DEATH RATES, OKLAHOMA, 1999-2010 Source: WISQARS, Centers for Disease Control and Prevention

10. MORTALITY RATES BY AGE GROUP* AND GENDER, UNINTENTIONAL POISONING, OKLAHOMA, 2007-2012 *Decedents under age 15 and over age 74 were excluded due to small number of cases (<1% of all UP deaths) Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

11. DEATHS INVOLVING PRESCRIPTION DRUGS, ILLICIT DRUGS, OR ALCOHOL BY YEAR OF DEATH, UNINTENTIONAL POISONING, OKLAHOMA, 2007-2012 Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports)

12. SUBSTANCES INVOLVED IN UNINTENTIONAL POISONING DEATHS, OKLAHOMA, 2007-2012

13. MEDICATIONS Medication TypeNumberRate Prescription medication307513.7 Narcotic analgesic267712.0 Anti-anxiety10074.5 Muscle relaxant3051.4 Antidepressant2521.1 Tri-cyclic antidepressant1860.8 Non-narcotic analgesic1860.8 Antipsychotic470.2 Respiratory520.2 Hypnotic/sedative390.2 Antiemetic310.1 CNS stimulant250.1 Other**600.3 Over the counter1430.6  Most common medications (number of deaths);  Oxycodone (791)  Hydrocodone (787)  Alprazolam (733)  Methadone (628)  Morphine (463)

14. Unintentional Poisoning Death Rates by County of Residence 1, Oklahoma, 2007-2012 Cimarron Texas Beaver Harper Ellis Beckham Woodward WoodsAlfalfa Major Dewey Custer Washita Kiowa Blaine Caddo Grant Garfield Kingfisher Kay Noble Logan Canadian Oklahoma Cleveland Grady Osage McClain Jackson Tillman Comanche Cotton Stephens Murray Bryan Pushmataha Choctaw Muskogee Ottawa Washington Nowata Craig Mayes Harmon Top 5 counties 21.1 – 34.2 17.9 – 21.0 12.6 – 17.8 7.6 – 12.5 <5 deaths Roger Mills Greer Tulsa Okmulgee Creek Okfuskee Payne Lincoln Wagoner Cherokee Adair Rogers Delaware Carter Johnston Jefferson Garvin Love Marshall Le Flore Atoka Hughes McIntosh Latimer Haskell Sequoyah Seminole Potta- watomie Rates per 100,000 population State rate 2 : 17.5 1 County of residence was unknown for 31 persons. Source: OSDH, Injury Prevention Service, Unintentional Poisonings Database (Abstracted from Medical Examiner reports) Pawnee Coal Pontotoc McCurtain Pittsburg

15. CONSEQUENCES ASSOCIATED WITH PRESCRIPTION DRUG ABUSE/MISUSE

16. LEGAL CONSEQUENCES

17. HEALTH CONSEQUENCES

18. SOCIAL CONSEQUENCES

19. FINANCIAL CONSEQUENCES

20. WHY HAS PRESCRIPTION DRUG ABUSE/MISUSE BECOME SO PREVALENT?

21. WHAT CAN YOU DO?

22. SAFE USE Never take prescription medication that is not prescribed to you Never take your prescription medication more often or in higher doses than prescribed Never drink alcoholic beverages while taking prescription medications Never share your prescription medications with anyone Taking prescription pain medications with other depressants such as sleep aids, anti-anxiety medications, or cold medicine can be dangerous Tell your healthcare provider about ALL medicines and supplements you take

23. SAFE STORAGE Keep your prescription drugs in a secure location to make sure kids, family, and guests don’t have access to your medications Know where your prescription medications are at all times Keep prescription pills in the original bottle with the label attached, and the child resistant cap secured Keep track of how many prescription pills are in your bottle so you are immediately aware if any are missing

24. SAFE DISPOSAL Please take your medications to a permanent collection site (drop box) or a special community take-back event Call your city or county law enforcement professionals Do not flush prescription drugs down the toilet unless information on your prescription label or FDA specifically instructs you to do so. Follow FDA guidelines when throwing the drugs in household trash

25. WHAT CAN COMMUNITIES DO? Engage in community take-back events Get involved Town hall meetings Community coalitions Community-based prevention education Support groups Promote safe use, storage, and disposal Promote the use of the PMP Naloxone

26. WHAT CAN BUSINESSES DO? Active promotion of a referral to treatment hotline (211) Provide educational information of prescription drug abuse/misuse Explanation of substance abuse services in new employee orientation Onsite support services (employee benefits, employee assistance program, counselor, clinician, etc.)

27. WHAT CAN BUSINESSES DO? Adopt workplace prescription drug policies Prohibited behavior Major medical insurance Pharmacy benefit program EAP Crisis intervention Assessment, referral Short-term and follow-up counseling Treatment monitoring

28. WHAT SHOULD PARENTS DO? Educate yourself Defining Risks Signs and Symptoms Prevention Communicate the risks of prescription drug abuse/misuse to your kids Children who know the risks of drugs at home are up to 50% less likely to use drugs than those who do not get the education Safeguard your medicine cabinet Keep prescription medicine in a secure location; lock them up Count and monitor the number of pills you have Ask your friends and family members to do the same Get help 211 1-855-DRUGFREE (1-855-378-4373)

29. SIGNS AND SYMPTOMS OF A DRUG OVERDOSE EMERGENCY Won’t awaken when aroused Bluish purple skin tones for lighter skinned people and grayish or ashen tones for darker skinned people Slow, shallow, erratic, or absent breathing Snore-like gurgling or choking sounds Elevated body temperature Vomiting Irrational behavior or confusion Signs and symptoms of drug overdose may differ depending upon the type of drug consumed. Emergency: If you suspect someone is experiencing a drug overdose, you must react to this true medical emergency by calling “911” without delay.

30. CONTACT INFORMATION Call 211 for treatment referrals Call OBNDD directly to report diversion 1-800-522-8031 http://www.ok.gov/obndd/

31. People

32. CASE STUDIES A male in his 40s with a history of knee pain due to years of working laying carpet. He had recently been released from rehab for his prescription pain medication addiction, but was prescribed more pain medications for his knee and back pain. He was home with his wife and not feeling well. His wife was doing laundry and could hear him snoring loudly. She noticed he was no longer snoring, went to check on him, and found him unresponsive. His death was pronounced by EMS. His toxicology report included five different prescriptions medications, two of which were opioids.

33. CASE STUDIES An older adult female had recently been to the doctor and prescribed two new medications, fentanyl patches and oxycodone for pain. She was also previously prescribed hydrocodone. She fell asleep on the couch and her husband carried her to the bedroom and put her to bed. She slept most of the day, and her husband woke late that evening and noticed she would not move when he asked her. He called 911 and she was pronounced by EMS.

34. CASE STUDIES A female in her 30s suffered from arthritis and bipolar disorder. She went to rehab approximately a year before her death after overmedicating several times. Her husband worked out of town, but said she was in great spirits when he came home for the weekend. She complained of some pain from her arthritis, and told her husband she knows her body and doses herself. He woke in the middle of the night to her snoring, and several hours later became concerned when she did not get up to check on their crying baby. She was unresponsive with blue face, lips, and tongue. Her toxicology report included an antidepressant, opioid, and muscle relaxant.

35. CASE STUDIES A male in his 30s with a history of a work-related back injury 5-10 years previous. He had multiple surgeries on his back and neck since the injury. He was home alone and found unresponsive by family on their arrival to the home. He did not have a known history of substance abuse or mental health problems. He had a prescription for both of the drugs involved in his death.

36. CASE STUDIES A young adult male veteran had recurring pain from an injury sustained during a tour in Iraq. He suffered from depression and had a history of overmedicating. He was found unresponsive in the middle of the night and pronounced on arrival by a first responder. His death involved multiple prescription drugs, including prescription painkillers and antidepressants. He had a known prescription for almost all of the drugs.

37. ADDRESSING THE PROBLEM

38. STATE PLAN Community/Public Education Provider/Prescriber Education Disposal/Storage for the Public Disposal/Storage for Providers Tracking and Monitoring Regulatory/Enforcement Treatment/Interventions

39. LEGISLATION HB 1781 Share PMP data HB 1782 Expand use of naloxone HB 1783 Limit hydrocodone refills HB 1491 Notify providers of possible doctor shoppers

40. CASE STUDY

41. PROJECT LAZARUS

42. Town hall meetings Task forces/coalitions Tool kit for primary care prescribers Pain management guidelines Sample patient-prescriber agreement Patient education materials Screening, brief intervention, and referral to treatment information Support group for pain patients COMMUNITY ORGANIZATION

43. Schools Colleges Civic organizations Churches Red Ribbon campaign Media Billboards COMMUNITY-BASED PREVENTION EDUCATION

44. One-on-one prescriber education on pain management Continuing medical education Promotion of prescription monitoring program PRESCRIBER EDUCATION

45. Enhanced hospital policy Limit on amount dispensed Required check of PMP Take-back events by law enforcement Fixed disposal sites Drug detox and treatment programs REDUCE EXCESS SUPPLY AND INCREASE TREATMENT

46. More than half of deaths occurred at home Emergency medical care not called or not able to reach victim in time to reverse the overdose Bystanders did not recognize as lethal overdose Concern for liability Free naloxone for high risk patients NALOXONE PROGRAM

47. Source: Wilkes Co. Health Department; NC SCHS; CDC Wonder Results: Opioid Prescribing The overdose death rate dropped 71% in two years after the start of Project Lazarus and the Chronic Pain Initiative.

48. High prescription opioid unintentional poisoning rates Some degree of community awareness Coalition building capacity Motivated community organizer Support from the medical establishment Strong data utilization practices KEY COMPONENTS

49. State plan action items Assist with local plans Link with DMH contacts Presentations Train-the-trainer Regional provider training Educational materials Provide local data Death, hospital discharge, PMP Technical assistance OSDH SUPPORT

50. Avy Redus, MS Oklahoma State Department of Health Project Coordinator 405-271-3430 AvyD@health.ok.gov Claire Nguyen, MS Oklahoma State Department of Health Injury Epidemiologist (405) 271-3430 ClaireN@health.ok.gov http://poison.health.ok.gov