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Educa&on and Advocacy Track: Overview of State Strategies to
Stop the Epidemic Presenters:
Sherry L. Green Joanna Katzman, MD, MSPH
Jennifer Weiss, MBA, BSIT
Moderator: Karen H. Perry,
Disclosures
• Sherry L. Greenhas disclosed no relevant, real or apparent personal or professional financial rela&onships.
• Joanna Katzman has disclosed no relevant, real or apparent personal or professional financial rela&onships.
• Jennifer Weiss has disclosed no relevant, real or apparent personal or professional financial rela&onships.
Learning Objec&ves
1. Outline implementa&on strategies to reduce prescrip&on drug abuse based on the successes New Mexico has had specifically with prescribers, medical facili&es, legislatures, educators, and other key stakeholders.
2. Build a statewide coali&on comprised of an academic medical center, state agencies, community coali&ons, legislatures, and key community stakeholders in an effort to reduce overdose death rates.
3. Iden&fy resources to advocate for change, with specific focus on state strategies.
2014 NATIONAL PRESCRIPTION DRUG ABUSE SUMMIT
EDUCATION & ADVOCACY TRACK: OVERVIEW OF STATE STRATEGIES TO
STOP THE EPIDEMIC APRIL 22, 2014 3:15 P.M. – 4:30 P.M.
SNAPSHOT OF SELECTED STATE PRESCRIPTION DRUG LAWS & POLICIES
SHERRY L. GREEN, CEO NATIONAL ALLIANCE FOR MODEL
STATE DRUG LAWS (NAMSDL)
NAMSDL
● 501(c)(3) non-profit corporation
● Successor to the President’s Commission of Model State Drug Laws
● 20 years
● Congress funds NAMSDL’s services
● Provides legislative and policy services on over 40 types of drug and alcohol laws to stakeholders at the local, state, and federal levels
TYPES OF LAWS & POLICIES USED TO ADDRESS PRESCRIPTION DRUG
PROBLEMS
● State prescription drug monitoring programs (PMPS)
● Regulation of pain clinics/pain management
● Prescribing & dispensing guidelines/practices
● Proper disposal of unused medications
● Education for the public and health care providers
● Treatment & prevention
● Good Samaritan & naloxone access
● Identification of person picking up prescription
● Lock-in programs
● Doctor shopping
SNAPSHOT OF FOUR TYPES
● State PMPs
● Regulation of pain clinics/pain management
● Prescribing & dispensing guidelines/practices
● Good Samaritan & naloxone access
MORE RESEARCH NEEDED
● National Governors Association Reducing Prescription Drug Abuse: Lessons Learned from an NGA Policy Academy, February 2014
● More research needed to determine:
Effective interventions to reduce abuse
Effective approaches to change prescribing
Effective public messaging to change consumer behavior
STATE PRESCRIPTION DRUG MONITORING PROGRAMS (PMPS)
Law and Policy
● Statewide electronic databases that collect prescription controlled substance data
● 49 states and D.C. have laws
● 48 PMP programs operational
● Increase usefulness of PMPs as health care tools
Allow delegates/authorized agents for prescribers and dispensers
Expand healthcare professionals who can use PMP data
Medical examiners/coroners
Increase frequency of dispenser reporting
Oklahoma – real-time reporting
Most states – 7 days/weekly
Provide interstate data sharing
Permit proactive alerts
Mandate registration for prescribers/ dispensers
No clear consensus about usefulness
Mandate use by prescribers/dispensers
No clear consensus about usefulness
Research – surveys, studies, assessments
● State practitioners surveys in OH, KY, OK, and OR suggest that PMPs can enhance patient care and patient safety by:
Helping practitioners become more informed prescribers, and
Helping practitioners determine if a patient may have an abuse or addiction problem
Example: Use of OHIO OARRS data by ER physicians (2009)
41% changed patient prescription plan
61% of patients received fewer or no opioids
39% of patients received more pain medication than planned
Baehren, DF, Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A statewide prescription monitoring program affects emergency department prescribing behaviors. Annuals of Emergency Medicine, 2010 Jul; 45(1):19-23
● 2014 evaluation of impact of state PMPs on opioid dispensing
Implementation of state PMPs through 2008 had no measurable overall impact on prescription opioids dispensed
Result likely related to unexamined factors: interstate sharing, frequency of reporting, education about PMP, restrictions on access, integration into health care systems
J Brady, H Wunsch, C DiMaggio, B Lang, J Giglio, G Li. Prescription Drug Monitoring and Dispensing of Prescription Opioids. Public Health Reports, March-April 2014; vol. 129: 139-147.
● 2012 analysis of Poison Control Center data
In states with PMPs, rate of increase in opioid misuse/abuse less than in states with no PMP
Independent of # of patients filling prescriptions
Reifler L., Droz D, Bailey J, Schnoll S, Fant R, Dart R et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Medicine 2012; 3(3):434-42.
REGULATION OF PAIN CLINICS/PAIN MANAGEMENT
Law and Policy
● 9 states with pain clinic regulation acts
● Definition of “pain clinic”
publicly or privately owned facility
majority of patients in a specific time frame, usually a month, are prescribed or dispensed certain substances, e.g., opioids
● Ownership eligibility
Example: Must be physician with unrestricted license
● Certification and training requirements for owners and practitioners at clinic
● Prescribing and dispensing restrictions
● Requirement to access state PMP
● Owners/medical directors have to be on site % of operating hours
● Indiana
State medical licensing board required to issue rules for prescribing of controlled substances
December 2013 – emergency rules for use of opioids for chronic pain patients receiving certain dosage amounts
Requirements:
Discuss risks/benefits with patient
Schedule periodic visits
Check PMP at beginning of treatment and annually
● Alabama
All physicians providing pain management services must register with the medical board
Registrants must access state PMP
Research – surveys, studies, assessments
● Florida – University of Central Florida, Criminal Justice Assistant Professor Jacinta Gau
“Pill mill” legislation implemented as designed
Impact of legislation
● Kentucky – University of Kentucky, College of Pharmacy, Institute for Pharmaceutical Outcomes and Policy
Unintended consequences of pain clinic and other laws
Recommendations for improvements
PRESCRIBING & DISPENSING GUIDELINES/ PRACTICES
Law and Policy
● Seven commonly recommended prescribing practices for non-cancer or chronic pain
Required or recommended education on selected topics
Comprehensive patient exam – physical and substance abuse screening
Treatment plan
Informed consent
Periodic review
Use of state PMP
Recommended steps for high risk patients
Referral to addiction or pain management specialists
Patient agreements – urine drug testing and lock-in program
Limitations on number of days’ supply or refills of Schedule II or Schedule III prescriptions
Maintenance of complete and accurate medical records
Research – surveys, studies, assessments
● Washington state evidence-based prescribing guidelines
23% reduction in drug overdose death rate since 2008
National Safety Council, Prescription Nation: Addressing America’s Prescription Drug Abuse Epidemic, 2013.
● Federation of State Medical Boards (FSMB), Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain, July 2013.
GOOD SAMARITAN & NALOXONE ACCESS
Law and Policy
● Good Samaritan – 14 states + D.C.
● Naloxone access – 18 states + D.C.
Removes civil and criminal liability for prescribers and lay administration
Allows third party prescription
● The Network for Public Health Law, Legal Intervention to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws, March 2014.
Research - surveys, studies, assessments
● National Association of State Alcohol and Drug Abuse Directors (NASADAD), Overview of State Legislation to Increase Access to Treatment for Opioid Overdose, December 2013.
Trained bystanders can safely and effectively administer injections like naloxone
Peers able to administer second dose when needed and prevent victims from additional opioid use
No evidence that people will increase drug use by removing threat of overdose
SARAH KELSEY ACTING CEO
NAMSDL 1598 Gray Fox Trail
Charlottesville, VA 22901 Phone: 703-836-6100, ext. 119
Email: [email protected] WEBSITE: www.namsdl.org
Overview of State Strategies: The Crisis of Unintended Opiate Overdose Deaths in New Mexico
Joanna Katzman, MD, MSPH Associate Professor, Neurosurgery, University of New Mexico
Director, University of New Mexico Pain Center Project ECHO® Pain
Jennifer Weiss, MBA, BSIT Execu&ve Director, Healing Addic&on In Our Community
Known as the Land of Enchantment. Popula&on: 2,085,500. Biggest City is Albuquerque. Popula&on: 552,800. We are NEW Mexico, not Mexico. Yes, we have running water. We are home to the largest interna&onal hot air balloon fiesta. You will be asked “red, green or Christmas” at every Mexican food restaurant you venture into.
Facts About New Mexico
Healing Addic&on in Our Community
501c3 Non-‐Profit
Dedicated to educa&on and awareness regarding substance abuse issues.
40+ volunteer member base comprised of parents and people in recovery.
Speaking engagements (over 5,000 people), advocacy, grade school and college educa&on programs, legisla&ve support, provide assistance finding treatment resources.
Opening NM’s 1st Adolescent Transi&onal Living Center.
Rest in Peace!
Grieve not, nor speak of me with tears, but laugh and talk of me as if I were beside you there.!
Drug Overdose Death Rates Leading States, U.S., 2009
Sources: CDC Vital Signs Rates are age-adjusted to the 2000 US Standard Population.
0.0
5.0
10.0
15.0
20.0
25.0
30.0 1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012*
Deaths pe
r 100,000 pe
rson
s
Year
Drug Overdose Death Rates New Mexico and United States, 1990-‐2012
New Mexico
United States
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Union Cibola Curry
United States Luna
McKinley Roosevelt
Lea Los Alamos
San Juan Dona Ana Sandoval Chaves Otero
Lincoln Socorro Colfax
New Mexico Valencia
Guadalupe Eddy
Santa Fe Torrance Bernalillo Hidalgo Grant Taos
San Miguel Quay
Catron Sierra Mora
Rio Arriba
Age-‐adjusted Rated per 100,000 persons
Drug Overdose Death Rates by County New Mexico, 2008-‐2012* and U.S., 2010
Senate Bill 159 Added new sec&on to the New Mexico Drug, Devise and Cosme&c Act in
regard to prescrip&on opioids which:
Required a discussion with pa&ent and provide educa&onal pamphlet on opiate addic&on/risk.
Required that prac&&oners receive wrilen consent from pa&ents receiving opiates for the first &me indica&ng that they understand the risk.
Limited those with cancer pain, chronic pain, or those in hospice care to a 30 day supply per Schedule II opioid prescrip&on.
Limited those with acute pain or cough to a 7 day supply per Schedule II opioid prescrip&on.
Forbade refills for prescrip&on opioids.
Mandated use of a Prescrip&on Drug Monitoring Report.
Senate Bill 215 – Passed Senate and House in 2012
Amended the pain Relief Act in the following ways:
Provided specific defini&ons of “chronic” and “acute” pain.
Called on licensing boards to adopt rules, standards, and procedures for the applica&on of the Pain Relief Act.
Required provider con&nuing educa&on (CEUs) for the treatment of non-‐cancer pain management.
Established the Prescrip&on Drug Misuse and Overdose Preven&on and Pain Management Advisory Council alached to DOH.
Mandatory use of the Prescrip&on Drug Monitoring Program (PDMP) by all prescribers.
In 2012…. NM now requires all clinical licensing boards to mandate CME specific to pain and addic&on.
NM Medical Board and other clinical licensing boards require use of Prescrip&on Monitoring Program (PMP) at least on ini&al use of chronic opioids and every 6 months.
NM Board of Pharmacy upgrades PMP to share data with other states regionally.
NM Governor developed the Prescrip&on Drug Misuse and Overdose Preven&on and Pain Management Advisory Council.
Rules and Values: A Coordinated Regulatory and Educational Approach to the Public Health Crises of Chronic Pain and Addiction
• UNM Health Sciences Center • Joanna G. Katzman, MD, MSPH
• Cynthia M. A. Geppert, MD, PhD, MPH
• George D. Comerci, MD, FACP
• Sanjeev Arora, MD, FACP
• Summers Kalishman, PhD
• Lisa Marr, MD
• Chris Camarata, MD
• Daniel Duhigg, DO, MBA
• Jennifer Dillow, MD
• Eugene Koshkin, MD
• Denise E. Taylor, MD
• Healing Addic[on In Our Community • Jennifer Weiss, MBA, BSIT
• Project ECHO® Ins[tute • Sanjeev Arora, MD, FACP
• Joanna G. Katzman, MD, MSPH
• George D. Comerci, MD, FACP
• Daniel Duhigg, DO, MBA
• NM Department of Health • Michael Landen, MD, MPH
• NM Board of Pharmacy • Larry Loring, RPH
• NM Medical Board • Steven M. Jenkusky, MD, MA, FAPA
• Presbyterian Health Care Services • Steven M. Jenkusky, MD, MA, FAPA
• NM Veterans’ Affairs Health Care System • Cynthia M. A. Geppert, MD, PhD, MPH
University of New Mexico Pain Center and Project ECHO Pain Clinical Centers of Excellence -‐ American Pain Society
UNM Pain Center-‐ the only interdisciplinary Pain Center with integrated addic&on services in New Mexico
Project ECHO Pain-‐ began in 2009, par&cipants include primary care clinicians from New Mexico and throughout the United States
ECHO Pain Program replicated by University of Washington (TelePain), UC Davis, Community Health Centers (CHC), the VA (SCAN-‐ECHO), the DoD (Army Pain ECHO), the Indian Health Service (ECHO Pain and Addic&on), and Canada (ECHO Ontario Pain and Addic&on)
University of New Mexico
Family Medicine Internal Medicine Pediatrics Psychiatry Emergency/Urgent Care
Series1 356 150 79 76 72
356
150
79 76 72
0
50
100
150
200
250
300
350
400
Total = 733
Table 1: Most represented UNM Pain Center Course par[cipants by MD and DO specialty
NP PA DDS CNM
Series1 214 113 18 12
214
113
18 12
0
50
100
150
200
250
Total = 357
Table 1: Most represented UNM Pain Center Course par[cipants by profession for non-‐physician clinicians
0
200,000,000
400,000,000
600,000,000
800,000,000
1,000,000,000
1,200,000,000
2008 Jan-‐Jun
2008 Jul-‐Dec
2009 Jan-‐Jun
2009 Jul-‐Dec
2010 Jan-‐Jun
2010 Jul-‐Dec
2011 Jan-‐Jun
2011 Jul-‐Dec
2012 Jan-‐Jun
2012 Jul-‐Dec
2013 Jan-‐Jun
Total MME of Opioids Dispensed
Total MME of Opioids Dispensed
0
200
400
600
800
1,000
1,200
1,400
2008 Jan-‐Jun
2008 Jul-‐Dec
2009 Jan-‐Jun
2009 Jul-‐Dec
2010 Jan-‐Jun
2010 Jul-‐Dec
2011 Jan-‐Jun
2011 Jul-‐Dec
2012 Jan-‐Jun
2012 Jul-‐Dec
2013 Jan-‐Jun
Opioid MME per prescrip[on
Opioid MME per prescrip&on
0.0
5.0
10.0
15.0
20.0
25.0
30.0 1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012*
Deaths pe
r 100,000 pe
rson
s
Year
Drug Overdose Death Rates New Mexico and United States, 1990-‐2012
New Mexico
United States
Drug Overdose Death Rates Leading States, U.S., 2010
Sources: CDC Wonder Rates are age-adjusted to the 2000 US Standard Population.
The NM Board of Pharmacy has noted a 7% decline in the quan&ty of Schedule II and Schedule III controlled substances dispensed in the first 6 months of 2013.
Opiate prescrip&ons and benzodiazepines decreased more than 7% sugges&ng safer controlled substance prescribing.
New Mexico had 35 fewer overdose deaths in 2012 compared to 2011.
Down from 521 deaths to 486.
In Summary:
Mandatory PDMP usage
Doctor Shopping laws Support for Substance Abuse treatment services through Medicaid expansion
Prescriber educa&on required Good Samaritan Laws
Rescue Drug Laws ID requirement for controlled substances
Lock-‐in programs for Medicaid pa&ents
New Mexico Scored 10 out of 10 on New Policy Report
Card of Promising Strategies to Help Curb Prescrip&on Drug Abuse
Lessons Learned: Iden&fy ALL of your stakeholders and bring them on board
early in the process.
Iden&fy possible unintended consequences and acknowledge them and alempt to address them.
Don’t make assump&ons. Address all issues associated with whatever change you are proposing and work with people to find out pros and cons from all perspec&ves.
Funding…. Ensure you have a plan to address funding issues and incorporate this plan within your strategy.
Next Steps Increase prescriber knowledge for beler pain management prescribing prac&ces.
Increase and improve the use of the PDMP. Establish evidence-‐based drug preven&on programs in the middle and high schools.
Expand and improve access to evidence-‐based drug addic&on treatment.
Increase Medically Assisted Treatment and the number of Bupenorphine prescribers.
Increased Naloxone distribu&on statewide in communi&es, pharmacies (April 2014) and first responders.
www.healingaddic&onnm.org healingaddic&[email protected] P.O. Box 56632 Albuquerque, NM 87187 @HAC_Heal
hlp://hospitals.unm.edu/pain/ hlp://echo.unm.edu