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Preven&ng Prescrip&on Drug Abuse
R. Gil Kerlikowske, Director
White House Office of Na;onal Drug Control Policy
April 10-‐12, 2012 Walt Disney World Swan Resort
Na;onal Drug Control Strategy
• Science-‐based, public health approach to drug policy • Coordinated federal effort on 115 ac&on items
– Special emphasis on ac&ve duty, veterans, and military families; women and girls; individuals in the criminal jus&ce system; and college students
• Signature ini&a&ves – Prescrip&on Drug Abuse – Preven&on – Drugged Driving
Pain Reliever Prescrip;ons: 2000-‐2009
ER – Extended Release, LA – Long-‐Ac&ng, IR – Immediate Release Source: SDI, Vector One: Na;onal. Extracted June 2010.
Prevalence of Past Year Drug Use Among 12th graders 2011 Monitoring the Future Study
* Nonmedical use
Drug Prev. Drug Prev. Alcohol 63.5 OxyContin* 4.9 Marijuana/Hashish 36.4 Sedatives* 4.3 Synthetic Marijuana 11.4 Hall other than LSD 4.3 Amphetamines* 8.2 Inhalants 3.2 Vicodin* 8.1 Cocaine (any form) 2.9 Adderall* 6.5 LSD 2.7 Salvia 5.9 Ritalin* 2.6 Tranquilizers* 5.6 Ketamine 1.7 Cough Medicine* 5.3 Provigil 1.5 MDMA (Ecstasy) 5.3 GHB 1.4 Hallucinogens 5.2 Methamphetamine 1.4
Categories not mutually exclusive
Prescrip;ons Dispensed for select opioids in U.S. Outpa;ent Retail Pharmacies, 2000-‐2009
0
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
120,000,000
140,000,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Hydrocodone Oxyocodne methadone buprenorphine tramadol
Num
ber of Prescrip;
ons
Source: SDI, Vector One: Na;onal. Extracted June 2010.
Heroin Cocaine
27,658 uninten&onal drug overdose deaths
Uninten&onal Drug Overdose Deaths United States, 1970–2007
Na;onal Vital Sta;s;cs System, hZp://wonder.cdc.gov
Year
Emergency Department Visits
Persons Classified with Substance Abuse/Dependence on Psychotherapeu;cs
0
500
1,000
1,500
2,000
2,500
2002 2003 2004 2005 2006 2007 2008 2009 2010*
Results from the 2010 Na2onal Survey on Drug Use and Health (NSDUH): Na2onal Findings, SAMHSA (2011). hXp://www.oas.samhsa.gov/nsduhLatest.htm.
*Number in 2010 is sta;s;cally significantly higher than in 2005.
Drug-‐Induced Deaths vs. Other Injury Deaths, 1999–2009
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Injury by firearms 28,874 28,663 29,573 30,242 30,136 29,569 30,694 30,896 31,224 31,593 31,347
Drug-‐induced 19,128 19,720 21,705 26,040 28,723 30,711 33,541 38,396 38,371 38,649 39,147
Homicide 16,889 16,765 20,308 17,638 17,732 17,357 18,124 18,573 18,361 17,826 16,799
Suicide 29,199 29,350 30,622 31,655 31,484 32,439 32,637 33,300 34,598 36,035 36,909
Motor vehicle accidents 42,401 43,356 43,788 45,380 44,757 44,933 45,343 45,316 43,495 39,790 36,216
0 5,000
10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
NU
MB
ER O
F D
EATH
S
Causes of death aZributable to drugs include accidental or inten;onal poisonings by drugs and deaths from medical condi;ons resul;ng from chronic drug use. Drug-‐induced causes exclude accidents, homicides, and other causes indirectly related to drug use. Not all injury cause categories are mutually exclusive.
Source: Na;onal Center for Health Sta;s;cs, Centers for Disease Control and Preven;on. Na;onal Vital Sta;s;cs Reports Deaths: Final Data for the years 1999 to 2009 (January 2012).
Source of Prescrip;on Pain Relievers
Source: SAMHSA, Center for Behavioral Health Sta&s&cs and Quality, Na&onal Survey on Drug Use and Health, 2008-‐2009
Prescrip;on Drug Abuse Preven;on Plan
• Coordinated effort across the Federal government
• 4 focus areas – Educa;on – Prescrip;on Drug Monitoring Programs
– Proper Medica;on Disposal
– Enforcement
Educa;on • Educa;on Goals for healthcare providers
– Knowledge on appropriate prescribing – Effec;vely iden;fying those at risk for abuse – PDMP use in everyday clinical prac;ce – Screening, interven;on, and referral for those misusing or abusing
prescrip;on drugs • Main Ac;ons
– Legisla;on requiring mandatory educa;on for all clinicians who prescribe controlled substances
– Increase substance abuse educa;on in health profession schools, residency programs, and con;nuing educa;on
– Work with the American College of Emergency Physicians to develop evidence-‐based clinical guidelines that establish best prac;ces for opioid prescribing in the Emergency Department
– Expedi;ng research on the development of abuse deterrent formula;ons
Top 10 prescribing special&es immediate-‐release opioids, 2009
General Prac&&oners/Family Medicine; 26.7%
Internal Medicine; 15.4%
Den&sts; 7.7%
Nurse Prac&&oners; 3.5%
Physicians Assistants; 4.0%
Emergency Medicine; 4.7%
Other; 20.2%
Physical Med & Rehab; 2.7%
Anesthesiologists; 3.2%
Orthopedist; 7.4% Unspec.; 4.5%
SDI, Vector One: National, 2009. Extracted June 2010. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM217510.pdf
General Prac&&oners/
Family Medicine; 27.0%
Internal Medicine; 16.8%
Nurse Prac&&oners; 5.7%
Physicians Assistants; 4.3%
Hematology; 1.7%
Orthopedist; 1.9%
Neurologist; 2.8%
Unspec.; 4.9%
Physical Med & Rehab; 9.3%
Anesthesiologists; 13.8%
Other; 11.8%
Top 10 prescribing special&es extended-‐release/long ac&ng opioids, 2009
SDI, Vector One: National. Years 2009. Extracted June 2010. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/AnestheticAndLifeSupportDrugsAdvisoryCommittee/UCM217510.pdf
Educa;on Gaps • Physicians
– 2000 survey: 56 % of residency programs required substance use disorder training, median number of curricular hours ranged from 3 to 12 hours1
– 2008 follow-‐up: “Although the educa;on of physicians on substance use disorders has gained increased aZen;on, and progress has been made to improve medical school, residency, and postresidency substance abuse educa;on since 2000, these efforts have not been uniformly applied.”2
• Pharmacists3 – 67.5% report receiving two hours or less of addic;on or substance
abuse educa;on in pharmacy school – 29.2% reported receiving no addic;on educa;on – Pharmacists with greater amounts of addic;on-‐specific educa;on:
• Higher likelihood of correctly answering ques;ons rela;ng to the science of addic;on and substance abuse counseling
• Counseled pa;ents more frequently and felt more confident about counseling
1. Isaacson JH, Fleming M, Kraus M, Kahn R, Mundt M. A Na;onal Survey of Training in Substance Use Disorders in Residency Programs. J Stud Alcohol. 61(6):912-‐915. 2000. 2. Polydorou S, Gunderson EW, Levin FR. Training Physicians to Treat Substance Use Disorders. Curr Psychiatry Rep. 10(5):399-‐404. 2008. 3. Lafferty L. Hunter TS, Marsh WA. Knowledge, aktudes and prac;ces of pharmacists concerning prescrip;on drug abuse. J Psychoac:ve Drugs. 2006 Sep:38(3):229-‐232.
Proper Medica;on Disposal
• Goals: – Easily accessible, environmentally friendly method of drug disposal that reduces the amount of prescrip;on drugs available for diversion and abuse
• Main Ac;ons – Publish and implement regula;ons allowing pa;ents and caregivers to easily dispose of controlled substance medica;ons
– Next DEA Take Back Day April 28 – Once regula;ons are in place, partner with stakeholders to promote proper medica;on disposal programs
Enforcement
• Goals: – Assist states in addressing “pill mills” and doctor shopping
• Main Ac;ons – Provide technical assistance to states on model regula;ons/laws for pain clinics
– Encourage High-‐Intensity Drug Trafficking Areas (HIDTAs) to work on prescrip;on drug abuse issues
– Support prescrip;on drug abuse-‐related training programs for law enforcement
hZp://www.whitehouse.gov/ondcp