Prescription Drug Abuse and Overdose in the United States · 2017-01-10 · Motor vehicle traffic,...
Transcript of Prescription Drug Abuse and Overdose in the United States · 2017-01-10 · Motor vehicle traffic,...
Prescript ion Drug Abuse and Overdose in the United States
National Center for Injury Prevention and Control Division of Unintentional Injury Prevention
Christopher M. Jones, PharmD, MPH LCDR, US Public Health Service
Division of Unintent ional Injury Prevention National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
Overview
Abuse and overdose trends Drivers of the epidemic Prescribing and use patterns contribut ing to risk CDC’s public health response
Motor vehicle traffic, poisoning, and drug poisoning (overdose) death rates
United States, 1980-2010
NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Dea
ths p
er 1
00,0
00 p
opul
atio
n
Year
Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose)
Drug overdose deaths by intent, US, 1999-2010
National Vital Statistics System. 1999-2010.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f Dea
ths
Year
Unintentional Suicide Undetermined
Number of drug overdose deaths involving opioid pain relievers and other drugs
US, 1999-2010
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f dea
ths
Any opioid analgesic
Specified drug(s) other than opioid analgesic
Only non-specified drug(s)
CDC/NCHS, National Vital Statistics System
0
5,000
10,000
15,000
20,000
25,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f Dea
ths
Rx with Opioids Rx without Opioids
CDC/NCHS, National Vital Statistics System
Prescript ion drug overdose deaths with and without opioids, US, 1999-2010
Drug overdose deaths by major drug type, US, 1999-2010
CDC/NCHS National Vital Statistics System, CDC Wonder. Updated with 2010 mortality.
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f Dea
ths
Year
Opioids Heroin Cocaine Benzodiazepines
Emergency department visits related to drug misuse or abuse, US, 2004-2010
SAMHSA. Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related ED Visits, (2011).
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
2004 2005 2006 2007 2008 2009 2010
Num
ber o
f ED
Vis
its
Year
Illicit Drugs Pharmaceuticals Opioid Pain Relievers Benzodiazepines
Primary substance of abuse at t reatment admission, US, 2000-2010
0
2
4
6
8
10
12
14
16
18
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Adm
issi
ons p
er 1
0,00
0 Po
pula
tion
Year
Alcohol only Alcohol w/secondary drug Heroin Other opiates Cocaine Marijuana/hashish St imulants Other drugs
SAMHSA Treatment Episode Data Set, 2000-2010.
Opioid pain reliever overdose death rates by age group, US, 2010
CDC National Vital Statistics 2010.
0
2
4
6
8
10
12
< 1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Rate
per
100
,000
Age Group (years)
Opioid prescript ions per person by age group, U.S., 2009
Volkow et al. JAMA 2011;305:1299-1301
0.0 0.3
0.7
1.1
1.9
0.0
0.5
1.0
1.5
2.0
2.5
0-9 10-29 30-39 40-59 60+
Pres
crip
tion
s pe
r pe
rson
Age group (years)
Opioid pain reliever overdose death rates by sex and race, US, 2010
CDC National Vital Stastistics System 2012
0
1
2
3
4
5
6
7
8
9
American Indian or Alaska Native Asian or Pacific Islander Black or African American White
Age
-Adj
uste
d Ra
te p
er 1
00,0
00 p
opul
atio
n
Race
Female Male
Opioid pain reliever overdose death rates by urbanizat ion, US, whites, 2010
CDC National Vital Statistics System 2012
0
1
2
3
4
5
6
7
8
9
Large Central Metro Large Fringe Metro Medium Metro Small Metro Micropolitan (non-metro) NonCore (non-metro)
Age
-Adj
uste
d ra
te p
er 1
00,0
00 p
opul
atio
n
Urbanizat ion category
High risk populat ions
Men Whites, American Indians/Alaska Nat ives Middle-aged persons People taking high daily doses of opioids People who “doctor shop” People using mult iple abuseable substances Low-income people and those living in rural areas People with substance abuse or other mental health
issues
Overview
Abuse and overdose trends Drivers of the epidemic Prescribing and use patterns contribut ing to risk CDC’s public health response
Opioid prescript ions dispensed by retail pharmacies, U.S., 1991-2011
76 78 80 86 91 96 100
109 120
131 139 144
151 158
169 180
192 201 202
210 219
0
50
100
150
200
250
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Num
ber o
f Pre
scri
ptio
ns (i
n m
illio
ns)
Year
IMS Vector One. From “Prescription Drug Abuse : It’s Not what the doctor ordered” Nora Volkow National Prescription Drug Abuse Summit April 2012. Available at: http://www.slideshare.net/OPUNITE/nora-volkow-final-edits
Rates of opioid overdose deaths, sales and treatment admissions, US, 1999-2010
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rate
Year
Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000
Drug overdose death rate 2008 and opioid pain reliever sales rate 2010
National Vital Statistics System, 2008; Automated Reports Consolidated Orders System (2010)
Kg of opioid pain relievers used per 10,000
Age-adjusted rate per 100,000
Overview
Abuse and overdose trends Drivers of the epidemic Prescribing and use patterns contribut ing to risk CDC’s public health response
Percent of total opioids consumed by pat ient consumption level, Arkansas Medicaid, 2005
0.1 0.3 0.6 1 1.6 2.9 5 8.9
16.4
62.9
0
10
20
30
40
50
60
70
<17 17-22 23-27 28-31 32-38 39-45 46-56 57-75 76-99 100+
Perc
ent o
f tot
al o
pioi
ds co
nsum
ed
Deciles of Daily Dosage in Morphine Equivalents
Source: Edlund et al. J Pain Symp Manage 2010;40:279289
Overdose risk highest among small percentage of pat ients at high dosage, Group Health, 1997-2005
1 1.44
3.73
8.87
0 10 20 30 40 50 60 70 80 90 100
0 1 2 3 4 5 6 7 8 9
10
1-19 20-49 50-99 100+
% P
atie
nt Y
ears
Risk
(Odd
s Rat
io)
Opioid dosage (MME/d)
Dunn et al, Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92.
Most opioids consumed by small percentage of pat ients at high dosage levels,
New Mexico, 2007-2008
89.8
4.3 2.6 3.5
48.4
11.0 13.8
26.8 32.2
4.4 5.5
57.8
0 10 20 30 40 50 60 70 80 90
100
<20 >20-40 >40-100 >100
Perc
ent
Average Opioid Dosage over six months (MME/day)
Pct of Controls Pct of Deaths Pct of MME
Unpubliished data from New Mexico case-control study.
Oregon PDMP report top 8.1% of providers prescribe 79% of CII-CIV drugs
Oregon PDMP Report 2012: http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf
60% 19%
21% Top 2,000 Providers
2,001-4,000 Providers
Remaining 45,330 Providers
Top 10% of prescribers account for 76% of total Rxs CA Workers Compensation, 2005-2009
0.4 0.4 0.4 0.6 0.9 1.4 2.4 4.9 12
76.4
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 10
Perc
ent o
f tot
al p
resc
ript
ions
wri
tten
Deciles of prescribers from lowest to highest volume Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011
Top 20% of prescribers account for 72% of Rxs, Public Drug Program, Ontario, Canada, 2006
Dhalla, IA et al. Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician 2011;57:e92-6
1.1 3.4 7.4
16.3
71.7
0
100
200
300
400
500
600
700
800
900
1000
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5
Rx p
er 1
,000
peo
ple
Perc
ent o
f opi
oid
pres
crip
tions
Quint iles of prescribers from lowest to highest prescribing rate
Top 20% of prescribers account for 63% of overdose deaths
Ontario Public Drug Program, 2006
17.3 18.9 20.4 21.9 21.4
2.0 4.0
12.7 18.6
62.7
0
10
20
30
40
50
60
70
1 2 3 4 5
Perc
ent
Quint iles of Prescribers from lowest to highest prescribing rate
Pct of total patients Pct of total deaths
Adapted from data from Dhalla et al. Can Fam Physician 2011;57:e92-e96
Overview
Abuse and overdose trends Drivers of the epidemic Prescribing and use patterns contribut ing to risk CDC’s public health response
CDC Goal
Reduce abuse and overdose of opioids and other controlled prescript ion drugs while ensuring pat ients with pain are safely and effect ively treated.
CDC in Context of Nat ional Response
Blueprint for Federal government
Focus Areas I. Education II. Monitoring III. Disposal IV. Enforcement
CDC Role - Fits within our mission and complement other Federal agencies
CDC Strategic Focus Areas
Enhance Surveillance Inform Policy Improve Clinical Practice
Intervent ion Points
Pill Mills
Problem Prescribing
General Prescribing
EDs & Hospitals
Pharmacies
Insurer & Pharmacy Benefit Managers (PBMs)
General Pat ients & The Public
People at High Risk of Overdose
Public Health Policy Options
Prescript ion Drug Monitoring Programs (PDMPs)
Patient Review & Restrict ion Programs
Laws/Regulat ions/Policies Insurers & Pharmacy Benefit
Managers (PBM) Mechanisms Clinical Guidelines Substance Abuse Treatment
Prescript ion Drug Monitoring Programs (PDMPs)
Maximize Prescript ion Drug Monitoring Programs (PDMPs)
Focus PDMPs On patients at highest risk of abuse and overdose On prescribers who clearly deviate from accepted medical practice
Implement PDMP Best Pract ices Allow access to prescribers and dispensers Allow access to regulatory boards, state Medicaid and public
health agencies, Medical Examiners, and law enforcement (under appropriate circumstances)
Provide real-time data and access Share data with other states (interoperability) Integrate with other health information technology to improve
use among health care providers Have ability to send unsolicited reports
Patient Review and Restrict ion Programs (aka “Lock-In” Programs)
Applies to pat ients with inappropriate use of controlled substances
1 prescriber and 1 pharmacy for controlled substances
Improve coordinat ion of care and ensure appropriate access for pat ients at high risk for overdose
Evaluat ions show cost savings as well as reduct ions in ED visits and numbers of providers and pharmacies
Laws/Regulat ion/Policies
Some states have enacted laws and policies aimed at reducing diversion, abuse, and overdose
Policies can strengthen health care provider accountability
Safeguard access to treatment when implementing policies
Rigorous evaluat ions to determine effect iveness and ident ify model aspects
Insurer/Pharmacy Benefit Manager (PBM) Mechanisms
Reimbursement strategies Formulary development Quantity limits Step therapies/Prior Authorizat ion Real-t ime claims analysis Retrospect ive claims review programs
Clinical Guidelines
Improve prescribing and treatment Basis for standard of accepted medical pract ice for
purposes of licensure board act ions Several consensus guidelines available
Clinical Guidelines
Common themes among current consensus guidelines Screen and monitor patients for substance abuse and mental
health problems Prescribe opioids only when other treatments have not been
effective for pain Prescribe only quantity needed based on expected length of pain Use patient-provider agreements combined with urine drug tests
for long-term users Teach patients how to safely use, store and dispose of medications Avoid co-prescribing opioids and benzodiazepines (if possible) Use PDMPs to identify patients improperly using opioids and other
controlled prescription drugs
Improve Access to Substance Abuse Treatment
Access to substance abuse treatment is crit ical Effect ive, accessible treatment programs can reduce
abuse and overdose among people struggling with dependence and addict ion
States should expect increased demand, including access to medicat ion assisted therapies
Intervention Points Key Strategy
Pill Mills PDMPs, Laws/Regulations/Policies
Problem Prescribing PDMPs, Laws/Regulations/Policies, Insurers/PBMs, Clinical Guidelines
General Prescribing PDMPs, Laws/Regulations/Policies, Insurers/PBMs, Clinical Guidelines
EDs & Hospitals PDMPs, Laws/Regulations/Policies, Insurers/PBMs, Clinical Guidelines
Pharmacies PDMPs, Patient Review & Restriction Programs, Laws/Regulations/Policies, Insurers/PBMs, Clinical Guidelines
Insurers & Pharmacy Benefit Managers
PDMPs, Patient Review & Restriction Programs, Laws/Regulations/Policies, Insurers/PBMs
People at High Risk of Overdose
PDMPs, Patient Review & Restriction Programs, Laws/Regulations/Policies, Insurers/PBMs, Clinical Guidelines, increase access to substance abuse treatment
General Pat ients & The Public
PDMPs, Insurers/PBMs, Clinical Guidelines
SAME Strategy = Mult iple Intervent ion Points
Addit ional Information
http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm?s_cid=mm6126a5_w
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
Conclusions
Drug overdose deaths are exact ing a significant toll on individuals and communit ies across the US
Data can improve understanding of the problem and help drive decision making
Promising intervent ions exist and need to be fully implemented and robust ly evaluated
Collaborat ion between mult iple sectors is essent ial
Christopher M. Jones, PharmD, MPH [email protected]
Thank You
The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.