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The Prescription Drug Overdose Epidemic: Prevention and Mitigation A National Overview Len Paulozzi, MD, MPH March 13, 2014 National Center for Injury Prevention and Control Centers for Disease Control and Prevention National Center for

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Len Paulozzi, MD, MPH

March 13, 2014 National Center for Injury Prevention and Control Centers for Disease Control and Prevention

The Prescription Drug Overdose Epidemic:

Prevention and Mitigation A National Overview

National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

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5 10 15 20 25 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Deaths per 100,000 population Year

Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose)

Drug overdoses have surpassed motor vehicle crashes as the leading cause of injury death

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Death Rates for Drug Overdose by State, 2010

3.4 - 10.9* 10.9* - 13.9 14.0 - 28.9

Age-adjusted rate per 100,000 population

10.0 9.6 7.8 8.6 10.6 6.3 3.4 6.7 7.3 13.9 11.8 11.4 9.6 14.4 13.2 15.0 23.8 11.8 10.9 11.4 19.4 10.7 6.8 12.7 23.6 10.9 12.9 16.9 14.6 16.1 12.9 16.9 15.3 28.9 13.1

17.5

10.4 16.4 17.0 20.7 11.6 NH 11.8 VT 9.7 MA 11.0 RI 15.5 CT 10.1 NJ 9.8 DE 16.6 MD 11.0 DC 12.9 12.5 Footnote: *10.9 is in two ranges due to rounding. HI is 10.88 while WI is 10.94

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4 Middle-aged adults are at greatest risk for drug

verdose in the US

5 10 15 20 25 30 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Deaths per 100,000 population

15-24 25-34 35-44 45-54 55-64 65 & over Death rates by age

CDC/NCHS, National Vital Statistics System

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Opioid overdoses have driven the surge in

verdose deaths

National Vital Statistics System, 1999-2010

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

4,030 opioid deaths in 1999 16,651 opioid deaths in 2010

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6 Opioid deaths, sales, and treatment admissions have increased in lockstep

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

1 2 3 4 5 6 7 8 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Opioid Sales (kg per 10k) Opioid Deaths (per 100k) Opioid Treatment Admissions (per 10k)

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

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Opioid analgesic prescribing rates, United States, 2011

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Opioid analgesics users in the past month

National Survey on Drug Use and Health, 2012. http://www.oas.samhsa.gov

Medical users

9.0 million

Nonmedical users 4.9 million

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Overdose deaths are the tip of the iceberg

SAMHSA NSDUH, DAWN, TEDS data sets Coalition Against Insurance Fraud. Prescription for Peril. http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007.

emergency department visits

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Economic costs are high

 $72.5 billion in healthcare

costs1

 Opioid abusers generate, on

average, annual direct health care costs 8.7 times higher than nonabusers2

1. Coalition Against Insurance Fraud. Prescription for peril: how insurance fraud finances theft and abuse of addictive prescription drugs. Washington, DC: Coalition Against Insurance Fraud; 2007 2. White AG, Birnbaum, HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J Manag Care

Pharm. 11(6):469-479. 2005

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Risk Factors

 Demographics

Men
35-54 year olds
Whites
American Indians/Alaska

Natives

Socioeconomics and Geography

Medicaid
Rural

Clinical Characteristics

Chronic pain
Substance abuse
Mental health
Nonmedical use
Multiple prescriptions
Multiple prescribers
High daily dosage

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CDC’s public health response: focus areas

Enhance Surveillance Inform Policy Improve Clinical Practice Empower States

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CDC’s approach to prescription drug overdose prevention

 Data driven and evidence-based  Complements other agencies  Focuses on empowering states to

address 3 key drivers of the epidemic

The link between increased, often

inappropriate, prescribing of opioids and increased overdose deaths

The small percentage of providers responsible

for most of the inappropriate prescribing

The small percentage of high-risk patients

engaging in abuse and diversion going undetected by providers

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Pivot to Prevention

 Prescription Drug Monitoring

Programs (PDMPs)

 Patient Review & Restriction

Programs

 Laws/Regulations/Policies  Insurers & Pharmacy Benefit

Managers (PBM)

 Clinical Guidelines

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Prescription Drug Monitoring Programs (PDMPs)

Source: Alliance of States with Prescription Monitoring Programs

Status of PDMPS – September 2013

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Patient Review and Restriction Programs (aka “Lock-In” Programs)

 APPLICATION: Patients with

inappropriate use of controlled substances

 STRATEGY: 1 prescriber and 1

pharmacy for controlled substances

 OUTCOME: Improve coordination of

care and ensure appropriate access for patients at high risk for overdose

 IMPACT: Cost savings as well as

reductions in ED visits and numbers of providers and pharmacies

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Laws/Regulation/Policies

 STATE RESPONSE: Some states

have enacted laws & policies aimed at reducing diversion, abuse &

verdose

 KEY AIM: Strengthen health care

provider accountability

 PATIENT PROTECTION: Safeguard

access to treatment when implementing policies

 GAP: Rigorous evaluations to

determine effectiveness and identify model components

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Insurer/Pharmacy Benefit Manager (PBM) Mechanisms

 Reimbursement

incentives/disincentives

 Formulary development  Quantity limits  Step therapies/Prior

Authorization

 Real-time claims analysis  Retrospective claims review

programs

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Clinical Guidelines

 Improve prescribing and

treatment

 Basis for standard of

accepted medical practice for purposes of licensure board actions

 Several consensus

guidelines available

 Common themes among

guidelines

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Conclusions

 BURDEN: Overdose deaths from

prescription drugs have reached epidemic levels in the United States

 KEY DRIVERS: Defining the drivers

f the epidemic are critical to effective

solutions

 SCOPE OF SOLUTION: Multifaceted

approach is needed. Recent successes promising

 KNOWN EFFECTIVENESS:

Interventions must be evaluated to determine effectiveness and need for state-specific adaptation

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National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

Thank You

Len Paulozzi lbp4@cdc.gov

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.