Rita Noonan, PhD

National Center for Injury

Prevention and Control

Centers for Disease Control and Prevention

The Prescription Drug

Overdose Epidemic

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention

Dramatic increase in overdose deaths related to opioid pain relievers since 1999

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 2011

opioid pain relievers

heroin

cocaine

CDC, National Center for Health Statistics, National Vital Statistics System

Opioid pain reliever-related overdose deaths increasing

at a faster rate than deaths from any major cause

-34%

-23%

-23%

-22%

-16%

-14%

-3%

0%

2%

4%

7%

11%

13%

20%

31%

36%

40%

47%

68%

276%

-50% 0% 50% 100% 150% 200% 250% 300%

Aortic Aneurysm

Influenza & Pneumonia

Cerebro-vascular

Motor vehicle traffic

Heart disease

Perinatal Period

Homicide

Diabetes Mellitus

Pneumonitis

Malignant Neoplasms

HIV

Septicemia

Chronic Lower Respiratory disease

Liver Disease

Suicide

Nephritis

Parkinson's Disease

Hypertension

Alzheimer's

Rx opioid overdose

% change in number of deaths, United States, 2000-2010

WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System

Middle-aged adults are at greatest risk for drug overdose in the United States

0

5

10

15

20

25

30

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010De

ath

s p

er

10

0,0

00

po

pu

lati

on

CDC/NCHS, National Vital Statistics System

Death rates by age

45-54

35-44

25-34

55-64

15-24

65 +

Males, American Indians/Alaska Natives, and Whites at

highest risk for opioid overdose deaths

5.3

0.4

1.9

4.6

8.7

0.8

2.3

7.1

0

1

2

3

4

5

6

7

8

9

10

American Indian or Alaska Native

Asian or Pacific Islander

Black or African American

White

Ra

te p

er

10

0,0

00

Females Males

National Vital Statistics System; crude rates, 2009

Opioid pain reliever prescribing

rates vary by state

CDC Vital Signs, July 2014. Rates per 100 people in 2012

Opioid prescribing rates correlate with

drug overdose death rates

Kg of opioid pain

relievers used per

10,000

Age-adjusted rate

per 100,000

Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System

Opioid prescribing rates correlate with

opioid overdose death rates

*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and mortality update. Epi Data Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf

Rates of unintentional opioid pain reliever

overdose deaths by NYC neighborhood

Rates of hydrocodone and/or

oxycodone filled by NYC neighborhood

Opioid -related overdose death rates and treatment

admissions increased over time along with opioid sales

United States, 1999-2011. National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS. Treatment admission rates are per 10,000 people ages 12+.

Half of United States opioids market is

treatment for chronic, non-cancer pain

Primary care providers prescribe the most opioids

IMS Health, National Prescription Audit, United States, 2012

Pain specialists prescribe opioids most frequently

Doctors most common source of opioids

for most frequent nonmedical users

Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. JAMA Internal Medicine. 2014

JAMA 2011;305:1315-1321

Patients receiving high doses of opioid pain relievers

account for disproportionate share of overdoses

Perc

en

t

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);10-13.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

patients receiving opioid pain relievers patients overdosing with opioid pain relievers

one doctor, high dose

one doctor, lower dose

multiple doctors,

high doses

multiple doctors,

high doses

one doctor, high dose

one doctor, lower dose

Patients with depression 3x more likely to be prescribed long-term opioid therapy

0

5

10

15

20

25

Braden JB et al. Trends in long-term opioid therapy for noncancer pain among persons with a history of depression. General

Hospital Psychiatry. 31 (2009); 564-570.

Patients with depression

Patients without depression

Rate

of

lon

g-t

erm

in

cid

en

t o

pio

id u

se p

er

10

00

no

ncan

cer

pati

en

ts,

20

05

Opioid pain reliever overdose deaths: summary of epidemiology

• Increasing at a faster rate than deaths from any

major cause in the United States

• Correlation between opioid prescribing rates

and drug overdose death rates

• Patients receiving opioids from multiple

prescribers and at high doses at highest risk

Prevention Policies & Interventions

Overdose deaths continue to climb

National Vital Statistics System

“It is one of the happy incidents

of the federal system that a

single courageous state may, if

its citizens choose, serve as a

laboratory; and try novel

social and economic

experiments without risk to the

rest of the country.”

–Justice Louis Brandeis

Opioid prescribing is the key driver

0

1

2

3

4

5

6

7

8

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS

Sales (kg per 10k)

Deaths (per 100k)

For every Rx opioid overdose death in 2011,

there were...

SAMHSA NSDUH, DAWN, TEDS data sets.

0 100 200 300 400 500 600 700

12 treatment admissions for opioids

25 emergency department visits for opioids

105 people who abused or were dependent on opioids

659 nonmedical opioid users

Risk

Policy & the Continuum of Risk

Risk

Prescription Drug Monitoring Programs & Prescribing Rules

What Are Prescription Drug Monitoring Programs?

Source: PDMP Center of Excellence at Brandeis University.

Prescription Drug Monitoring Programs (PDMPs)

Source: PDMP Training and Technical Assistance Center. http://www.pdmpassist.org/pdf/pmpprogramstatus2013_a.pdf

Status of PDMPS – September 2013

PDMP Promising Practices

Epidemiological analysis

Unsolicited reporting

Criteria for questionable

activity

Integrating with EHRs and

HIEs

Increasing utilization

Interstate data-sharing

Interagency collaboration

Improving data quality

Conducting evaluation

Source: ASTHO, Brandeis PDMP Center of Excellence:

Prescription Drug Monitoring Programs: Tools for Education, Epidemiological Surveillance, Prevention, and Early

Intervention

Source: Arizona Prescription Monitoring Program, Arizona State Board of Pharmacy

Example of Innovation:PDMP Report Cards to Outliers

Prescribing Rules

Washington State Rules

Washington Agency Medical Directors’

Opioid Dosing Guidelines

Pain Management Rules

ED prescribing guidelines

Other measures

Good Samaritan Law

PDMP

Medicaid Narcotic Review Program

Expanded Patient Review and

Coordination program

Insurer/Pharmacy Benefit Manager (PBM) Mechanisms

Reimbursement

incentives/disincentives

Quantity limits

Step therapies/Prior

Authorization

Real-time claims analysis

Retrospective claims review

programs

Pain Clinic Laws

The Problem of “Pill Mills”

“You just walk in, they ask you what hurts, they take

your blood pressure, they weigh you, and they say

actually – literally sometimes, ‘What do you want?’…

‘How many do you take a day?’ You could be

ridiculous and say 40. I mean, I could get 200 of

each, Roxi's and Oxy's at the same time, which

makes no sense, and Xanny bars (Xanax) at the

same time. They just ask you what you want.”

—White female, 41

Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681–702.

Anatomy of a Pain Clinic Law

Louisiana

Statute passed in ‘05; rules in Jan. ‘08

Passes a pain management clinic law

Brings heightened scrutiny to pain

clinics

Requirements:

Pain specialist physician ownership

Licensure from Department of Health and Hospitals

Inspections

50% on-site requirement

Urine drug screen for each patient

30-day supply limit

Florida and the Epidemic

2003-2009 (CDC MMWR)

84% increase in prescription

drug overdoses

264% increase in oxycodone

overdoses

In 2009, 8 people died of

overdoses every day

MMWR. Drug overdose deaths — Florida, 2003–2009. 869-72. 60(26). July 8 2011.

2010:

90 of the top 100 oxycodone purchasing physicians in US were

in Florida

900+ pain clinics

Florida’s Policy Response

Jan. 2010: State legislature required pain clinics register with the state

Feb. 2010: DEA and various Florida law enforcement agencies began to work

together in Operation Pill Nation

Late 2010: Pain clinic regulations further expanded

Feb. 2011: Law enforcement conducted statewide raids

July 2011: State legislature prohibited physician dispensing of schedule II or

III; activated regional strike forces to address the emergency.

Sept. 2011: Mandatory dispenser reporting to the newly established PDMP

2012: State legislature expanded regulation of wholesale drug distributors

Florida opioid overdoses fell sharply between 2010 and 2012

Johnson H; Paulozzi L; Porucznik C. Mack K. Herter B. Decline in Drug Overdose Deaths After State Policy Changes —Florida,

2010–2012. MMWR. 63(26). 569-74. July 2014.

0

2

4

6

8

10

12

14

16

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Oxycodone overdoses

Opioid pain reliever overdoses

Benzodiazepine overdoses

Naloxone & Good Samaritan Laws

Naloxone Access

Source: Public Health Law Research - phlr.org

Naloxone Access Laws

April 2014

Good Samaritan Laws

PHLR, Law Atlas. April 2014.

Good Samaritan Laws

April 2014

Laws that explicitly limit criminal liability in some way for an

overdose bystander who summons help in good faith.

Three Pillars of CDC’s PDO 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

Example Program:Boost for State Prevention

Advance and evaluate comprehensive

state-level interventions for preventing

prescription drug overdose in 3 areas:

• Enhancing and maximizing PDMPs

• Improving and evaluating public insurer mechanisms

• Evaluating state-level laws, policies, and regulations

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.

National Center for Injury Prevention and Control

Division of Unintentional Injury Prevention