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Centers for Disease Control and Prevention
From Sounding the Alarm to Turning the Tide:Action to Combat the Opioid Epidemic
Tom Frieden, MD, MPHDirector, Centers for Disease Control and Prevention
National Rx Drug Abuse & Heroin SummitMarch 30, 2016
500,000drug overdose deaths since 1999
4x as many Rx opioid deaths in 2013 as in 1999
1999 DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
2002 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
2005 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
2008 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
2011 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
2014 RAPID INCREASE IN DRUG OVERDOSE DEATH RATES
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System
The amount of opioids prescribed has
But the pain that Americans report remains
Any one of these could potentially ruin – or end – a patient’s life
Prescriptions for opioids were written by health care providers in 2013
OPIOID PRESCRIBING RATES ARE 3X HIGHER IN SOME STATES THAN OTHERS
Source: MMWR Vital Signs, July 2014. Source: IMS, National Prescription Audit (NPATM), 2012.
SHARP INCREASES IN HEROIN AND OPIOID DEATH RATES IN RECENT YEARS
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
prescription opioid (natural or semi-synthetic opioid or methadone)
illicit opioid (heroin)
unknown whether pre-scription or illicit opioid (synthetic opioid)
any opioid (prescription or illicit)
Deat
hs p
er 1
00,0
0 po
pula
tion
Source: CDC/NCHS, National Vital Statistics System, Mortality.
THE OPIOID EPIDEMIC INVOLVES INTERSECTION AND OVERLAP OF BOTH PRESCRIPTION AND ILLICIT OPIATES
3 out of 4 people reporting Rx opioid and heroin use in past year
took Rx opioids first
7 out of 10 people who used heroin in the past year also misused opioids in the
past year
SCOTT COUNTY, INDIANA: SENTINEL EVENT
Epicenter of 2015 injection drug-associated HIV outbreak (Opana)
80% co-infected with HCV
VULNERABILITY TO HIV/HCV INFECTIONS AMONG PERSONS WHO INJECT DRUGS
26 states with 1 or more vulnerable counties
Ranked indexTop 220 counties
TWO GROUPS, TWO DIFFERENT SETS OF NEEDSAddicted/Dependent
Need accessto services
At risk for addiction/dependence
Protect fromdangerous drugs
POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC
Rigorous, real-time monitoring with adaptive response
Improve prescribing for pain Improve management of addiction Prescription drug monitoring programs, science-
based guidelines, pain clinic laws, prescribing defaults in EHRs, prior authorization for risky prescriptions, patient review and restriction programs, naloxone prescriptions, etc.
Involve payors including Medicaid/Medicare, health systems, pharmacy benefit plans; clinicians; patients
Increase access to medication-assisted treatment and improve quality and accountability for treatment outcomes
Link people to treatment and support them through recovery and living with addiction
Increase access to naloxone for emergency reversals
Partner with law enforcement Community awareness and support Enforce laws, policies and regulations to reduce
diversion, abuse & overdose Reduce availability of illicit drugs Criminal justice system as entry point for addiction
treatment
Increase awareness of risks and benefits of opioids Promote economic development to reduce
initiation/continuation of drug use
POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC
Rigorous, real-time monitoring with adaptive response
Reduce Supply
Improve management of addiction Increase access to medication-assisted treatment
and improve quality and accountability for treatment outcomes
Link people to treatment and support them through recovery and living with addiction
Increase access to naloxone for emergency reversals
Community awareness and support Increase awareness of risks and benefits of opioids Promote economic development to reduce
initiation/continuation of drug use
POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC
Rigorous, real-time monitoring with adaptive response
Improve prescribing for pain
Reduce Demand
Prescription drug monitoring programs, science-based guidelines, pain clinic laws, prescribing defaults in EHRs, prior authorization for risky prescriptions, patient review and restriction programs, naloxone prescriptions, etc.
Involve payors including Medicaid/Medicare, health systems, pharmacy benefit plans; clinicians; patients
Partner with law enforcement Enforce laws, policies and regulations to reduce
diversion, abuse & overdose Reduce availability of illicit drugs Criminal justice system as entry point for addiction
treatment
REDUCE SUPPLY: IMPROVE PRESCRIBING FOR PAIN
1. Non-opioid therapy preferred for chronic pain outside of active cancer, palliative, and end-of-life care
2. When opioids are used, start low and go slow
3. Clinicians should always exercise caution when prescribing opioids and monitor all patients closely
PRESCRIPTION OPIOIDS FOR CHRONIC PAINClear risks and uncertain benefits
Nearly all prescription opiates are no less addictive than heroin
ADDICTION
We know of no other medication routinely used for a nonfatal condition that kills patients so frequently
DEATH
Initiation of treatment with opioids is a momentous decision and should be undertaken only with full understanding by both the physician and the patient of the substantial risks involved
MOMENTOUS DECISION
Frieden TR, Houry D. Reducing the Risks of Relief – The CDC Opioid-Prescribing Guideline. N Engl J Med. 2016 Mar 15. [Epub ahead of print].
REDUCE SUPPLY: LAW ENFORCEMENT, OHIOFentanyl seizures closely mirror fentanyl-related deaths
ADDICTION MANAGEMENT AND TREATMENTMost people with addiction are not receiving medication-assisted treatment
No more than 1 mil-
lion
At Least 1.5 million
Receiving MATNot Receiving MAT
Volkow et al. NEJM 2014;370:2063-2066.
COMMUNITY AWARENESS AND SUPPORT Engaged and empowered
communities support patients and families
We can work together to both prevent addiction and support recovery
The structure of our communities structures our lives in many more ways than we recognize
WE ALL HAVE A ROLE TO PLAYPatientsAsk your doctor if an opioid is needed, and if so for how long and what’s the goal
DoctorsConsider other treatments first; start low & go slow; follow up
Health systemsUse guideline to implement own guidance
InsurersStructure evidence-based programs and evaluate strategies to improve patient safety
State governmentsImprove prescribing; maximize PDMPs
Federal governmentContinue to refine based on data; expand access to care including methadone, buprenorphine, naltrexone, naloxone
Public health, law enforcement, industry & communities working together cut crash deaths in halfWE CAN DO THE SAME FOR OVERDOSES
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
0
5
10
15
20
25 Motor Vehicle Crash Overdose
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ation
Data: NCHS.
POSSIBLE TECHNICAL PACKAGE TO STOP THE OPIOID OVERDOSE EPIDEMIC
Use data to improve performance
Improve prescribing for pain Improve management of addiction
Partner with law enforcement Community awareness and support
DRUG POISONING DEATH RATES HAVE INCREASED IN ALMOST EVERY STATE
West
Virginia
New Hampshire
OhioUtah
Delaware
Tennessee
Massach
usetts
Missouri
Arizona
Connecticu
t
Louisia
naAlaska
Alabama
United States
Distric
t of C
olumbia
Vermont
Idaho
Florid
a
Oregon
Montana
Kansas
Mississ
ippi
Californ
iaTexa
sIowa
Nebraska05
10152025303540
20102014
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te(p
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00 p
op.,
age
adju
sted
)
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov