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 cjones@cdc.gov

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.