And the Oscar for Best Actor Goes to…Hydrocodone?
Prescription Drug Abuse in Modern American Film:
Lessons for Treatment, Prevention, and Public Health
Robert Valuck, PhD, RPh
Professor of Pharmacy, Epidemiology, and Family Medicine
Coordinating Center Director, Colorado Consortium for
Prescription Drug Abuse Prevention
May 18, 2014
Office of the
Governor
Objectives
• Using a sample (real, but identity protected) patient and
clips from modern American films as examples…
– Describe the scope of the prescription drug abuse problem
in the United States and Colorado
– Discuss some of the factors contributing to the growth in
prescription drug abuse
– Highlight policy initiatives and programs at the federal and state
levels (including Colorado) to address the problem
– Offer examples of actions that physicians can take to promote
safe use, safe storage, and safe disposal of prescription drugs
Office of the
Governor
Prologue
So, what’s the big deal?
Office of the
Governor
Drug Overdose Mortality
• In 2010, 38,329 people died from a drug overdose in the U.S.
– One every 14 minutes
– Nearly 60% of those deaths involved prescription drugs
– Painkillers (opioids) were involved in 75% of those deaths
• In Colorado, drug overdose deaths range from 250-500/year
• Since 2003, more overdose deaths have involved opioids
than heroin and cocaine combined
• Rates of misuse and overdose death are highest among men,
persons aged 20-64, non-Hispanic whites, and poor and rural
• Two main at-risk populations: long term medical users (>10
million) and nonmedical users in past month (>6 million)
CDC/MMWR Jan 13, 2012; 61(01):10-13.
Colorado Rx Abuse Task Force data
SAMSHA/NSDUH 2009 survey
.
Office of the
Governor
Drug Overdose Mortality in the U.S. (2010)
CDC/NCHS National Vital Statistics System,
CDC Wonder. Updated 2010..
Office of the
Governor
Drug Overdose Mortality Trends (1979-2010)
CDC/NCHS National Vital Statistics System,
CDC Wonder. Updated 2010..
Office of the
Governor
Drug Overdose Death Rates in the US
Motor Vehicle Traffic
Drug Poisoning (Overdose)
25
Deaths per 100,000 population
20
15
10
5
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Year
Office of the
Governor
NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data
Opioid and Benzodiazepine Trends Different than
Heroin and Cocaine in the US (1999-2010)
Opioids
Heroin
Cocaine
Benzodiazepines
18,000
16,000
Number of Deaths
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
CDC/NCHS National Vital Statistics System,
CDC Wonder. Updated 2010..
Office of the
Governor
8
Prescription Drugs: primary driver of
Overdose Deaths in US (2010)
18,000
16,000
Number of Deaths
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Drug or Drug Class
Jones et al. JAMA 2013; and CDC/NCHS 2010.
Office of the
Governor
9
Opioids more likely to be involved in
single drug class deaths (US, 2010)
35
30
29.4
25
Percent
20
15
10.5
9.1
10
8.3
6.4
6.2
3.7
5
0
Opioid Analgesics
(n=16651)
Antiepileptic and
Antiparkinsonism
Drugs (n=1717)
Benzodiazepines
(n=6497)
Barbiturates (n=296)
Antidepressants
(n=3889)
Antipsychotic and
Neuroleptic Drugs
(n=1351)
Other Psychotropic
Drugs (n=24)
Psychotherapeutic Pharmaceuticals
Jones et al. JAMA 2013
Office of the
Governor
10
Deaths are the Tip of the Iceberg…
For every opioid overdose death in 2011
SAMHSA NSDUH, DAWN, TEDS data sets
Coalition Against Insurance Fraud. Prescription for Peril.
http://www.insurancefraud.org/downloads/drugDiversion.pdf 2007
.
Office of the
Governor
11
Cost of Prescription Drug Abuse on the
U.S. Economy (2006)
Hansen et al. Clin J Pain 2011; 27(3): 194-202.
Office of the
Governor
How did we get into this mess?
• An enormous amount of opioids moves through U.S. channels
– 1997: 96mg “morphine equivalents” dispensed per person (in the U.S.)
– 2007: 700mg per person (in the US) – an increase of >600%
– That 700mg per person is enough for every person in the U.S. to take
a typical 5mg dose of Vicodin every 4 hours for 3 weeks
– While accounting for about 5 percent of the world’s population, the U.S. now
consumes 99 percent of the world’s Vicodin and 84 percent of its Oxycontin
• Causes of the increase? There are many, including…
–
–
–
–
–
–
Increased recognition of pain, undertreatment of pain
Pain as the “fifth vital sign”, JCAHO quality measure, etc.
Drug company advertising and promotion
Practitioners are not well trained in opioid pharmacology, addiction
Drugs are very powerful, highly addictive if not used properly
Scamming, doctor/pharmacy shopping, black market for opioids
CDC/MMWR Jan 13, 2012; 61(01):10-13.
SAMHSA/NSDUH
2009
CDC/MMWR Jan
13,survey
2012; 61(01):10-13.
. SAMHSA/NSDUH 2009 survey
.
Office of the
Governor
Sales of Opioid Pain Relievers and
Nonmedical Opioid Use (2010-11)
#37 in U.S.
Office of the
Governor
Sales of Opioid Pain Relievers and
Nonmedical Opioid Use (2010-11)
#2 in U.S.
(Oregon = 6.4)
Office of the
Governor
Scene #1
Nonmedical Use: The Beginnings
Office of the
Governor
A Typical Patient: Aaron
• Aaron is a 22 year old male, who started using prescription opioids
when he was in high school
• He was a typical high school student, from an upper middle class family,
played sports, was looked up to by siblings and friends
• Aaron started experimenting with prescription drugs at a “pharming”
party, where students raid their (parents’) medicine cabinets, bring any
Rx drugs they can find to the party, dump them all into a bowl, stir them
around, and “pick one or two and chase them with a beer”
• This led to further nonmedical use: trying one or two of his parents’
Vicodin, then one or two more; getting more from friends; and gradually
falling into the spiral of increased use, leading to tolerance, leading to
increased use, leading to dependence, and ultimately addiction
Office of the
Governor
Other Paths to Nonmedical Use
From 1967…Valley of the Dolls
http://youtu.be/t054GSzRywg
Office of the
Governor
Other Paths to Nonmedical Use
From 2014…in your own home
https://www.youtube.com/watch?v=0bZOgj5HEAE
Office of the
Governor
Sources of Opioids among Nonmedical Users
CDC/MMWR Jan 13, 2012; 61(01):10-13.
SAMHSA/NSDUH 2009 survey
.
Office of the
Governor
Scene #2
Getting Worse: Scamming and Stealing
Office of the
Governor
Aaron: Spiraling Downward
• As his addiction became stronger, Aaron started to scam doctors for opioid
medications (later described it as easy: “Google ‘how to get opioids from
a doctor’ and you’ll get lots of ideas”)
• He estimated that he visited between 40 and 50 doctors over an 18 month
period, and went to about an equal number of pharmacies, to “spread
myself around and stay beneath the radar”
• Most of the doctors gave him at least an initial Rx for Vicodin (his drug of
choice due to the ability to request and get refills from doctors, their
weekend colleagues covering for them, etc.)
• He finally started running into difficulty when the Vicodin “didn’t do it for
me”, and he progressed to OxyContin (oxycodone)
Office of the
Governor
Majority of opioids consumed by
small percentage of patients
(Arkansas Medicaid, 2005)
70
62.9
Percent of total opioids consumed
60
50
40
30
20
16.4
8.9
10
0.1
0.3
0.6
1
1.6
2.9
<17
17-22
23-27
28-31
32-38
39-45
5
0
46-56
57-75
76-99
100+
Deciles of Daily Dosage in Morphine Equivalents
Edlund et al. J Pain Symp Manage 2010;40:279-289
Office of the
Governor
23
Top 8.1% of providers prescribe 79% of CII-CIV drugs
(Oregon PDMP, 2011-12)
Remaining 45,330
Providers
21%
Top 2,000
Providers
2,001-4,000
Providers
19%
60%
Oregon PDMP Report 2012:
http://www.orpdmp.com/orpdmpfiles/PDF_Files/
Reports/Statewide_10.01.11_to_03.31.12.pdf
Office of the
Governor
24
Top 20% of prescribers account for
63% of Overdose Deaths
(Ontario Public Drug Program, 2006)
Pct of total patients
70
Pct of total deaths
62.7
60
Percent
50
40
30
20
17.3
21.9
20.4
18.9
18.6
21.4
12.7
10
4.0
2.0
0
1
2
3
4
5
Quintiles of Prescribers from lowest to highest prescribing rate
Dhalla et al. Can Fam Physician 2011;57:e92-e96.
Office of the
Governor
25
Overdose risk highest among small percentage
of patients at high dosage
(Group Health, 1997-2005)
8.87
100
9
90
8
80
7
70
6
60
5
50
3.73
4
40
3
30
2
1
1.44
% Patient Years
Risk (Odds Ratio)
10
20
1
10
0
0
1-19
20-49
50-99
100+
Opioid dosage (MME/d)
Dunn et al, Ann Int Med 2010;152:85-92.
Office of the
Governor
26
More patients on opioids = more doctor shoppers
Odds ratio of having doctor shoppers as patients
700
620.1
600
500
400
300
200
100
0
100% of
patients
are doctor
shoppers
171.1
60.1
1.0
4.1
7.1
14.5
1-17
18-35
36-65
66-149
29.8
0.0
150-227
228-457
458-915
916-1831
1,832-2936
Number of patients on opioid analgesics per prescriber
Cepeda et al. J Opioid Manag. 2013.
Office of the
Governor
27
Stealing Can Turn to Robbery…and Worse
From 1989…Drugstore Cowboy
http://youtu.be/puXEHhZgXaY
Office of the
Governor
Scene #3
Rock Bottom: Heroin and Overdose
Office of the
Governor
Aaron: Spiraling Downward
• AD eventually started using OxyContin at very high doses, mixed it with
Xanax and often alcohol, and overdosed at age 21
• AD had a difficult stay in the ICU, and while there had two myocardial
infarctions, seizures, a staph infection and pneumonia, and underwent
extreme withdrawal symptoms
• Doctors were preparing AD’s parents for his death, which appeared
imminent and very likely
• Surprisingly, AD regained consciousness, and eventually recovered well
enough to be discharged home with his parents
• The disposition of AD’s case will be shown at the end of the talk; his is
certainly not the only example of the downward spiral…
Office of the
Governor
Frequent Nonmedical Users of Opioids more likely to
Engage in Risky Use Behaviors (US, 2008-2010)
1-29 Days of PYNMU of
Opioid Pain Relievers
30-99 Days of PYNMU of
Opioid Pain Relievers
100-365 Days of PYNMU of
Opioid Pain Relievers
aOR (95% CI)
aOR (95% CI)
aOR (95% CI)
Past Year Heroin Use
referent
2.8 (1.7-4.5)
6.4 (3.7-11.1)
Ever Inject Heroin
referent
1.6 (0.9-2.9)
4.3 (2.5-7.3)
Ever Inject Opioid Pain Relievers
referent
3.8 (1.9-7.8)
13.3 (7.7-23.0)
Past Year Heroin Abuse or
Dependence
referent
3.2 (1.7-6.1)
7.8 (4.7-12.8)
Past Year Opioid Pain Reliever
Abuse or Dependence
referent
2.9 (2.3-3.8)
8.9 (7.1-11.3)
Heroin Fairly or Very Easy to Obtain
referent
1.4 (1.1-1.7)
2.1 (1.8-2.6)
Characteristic
Abbreviations: PYNMU, past year nonmedical use; aOR, adjusted Odds Ratio; 95% CI, 95% Confidence Interval
1Odds
ratio adjusted for sex, age, race/ethnicity, total family income, and county type
Jones, CM. Drug Alcohol Depend 2013.
Office of the
Governor
31
Majority of Heroin users in past year reported
Nonmedical use of Opioids before heroin initiation
(US, 2002-2004 and 2008-2010)
Age first use OPR same as heroin
Age first use heroin before OPR
Age first use OPR before heroin
100
90
80
Percent
70
65.1
69.1
60
64.1
74.7
66.8
76.4
77.4
82.6
50
40
30
20
2.1
18.4
32.8
10
15.2
12.4
10.1
2008-2010
2002-2004
6.7
16.4
25.4
9.7
6.2
16.9
10.5
11.2
2002-2004
2008-2010
16.8
12.9
2002-2004
2008-2010
0
2002-2004
1-29 Days PYNMU
2008-2010
30-99 Days PYNMU
100-365 Days PYNMU
Any PYNMU
Frequency of Past Year Nonmedical Use
Jones, C.M. Drug Alcohol Depend 2013.
Office of the
Governor
32
The Heroin Lifestyle
From 1996…Trainspotting
http://www.youtube.com/watc
h?v=Naf_WiEb9Qs&list=PLBA06
889EA057B4C0&feature=share
Office of the
Governor
Scene #4
The Way Out: Treatment and Recovery
Office of the
Governor
Rates of opioid overdose deaths, sales and treatment
admissions increased in parallel (US, 1999-2010)
Opioid Sales KG/10,000
Opioid Deaths/100,000
Opioid Treatment Admissions/10,000
8
7
6
Rate
5
4
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
CDC/National Vital Statistics System
DEA ARCOS System
SAMHSA’s TEDS System
Office of the
Governor
35
Substance Abuse Treatment Gap (2011)
SAMHSA/NSDUH 2011 survey
Office of the
Governor
Physicians Authorized to Treat Addiction
(Buprenorphine/Methadone)
SAMHSA. National Expenditures for MH Services and
Substance Abuse Treatment, 1986-2009. Pub SMA-13-4740.
Office of the
Governor
Scene #5
The Way Forward: Coordinated Responses
Office of the
Governor
Office of the
Governor
39
Federal Initiatives (alphabet soup warning)
• FDA: REMS programs, stricter regulation on DTC advertising,
support of rescheduling certain drugs (hydrocodone) to C-II
• CDC: Increased surveillance, grant funding, elevate topic in
national discussion
• DEA: Takeback events (2X/year), new rules on returning unused
controlled substances (pending), rescheduling
• ONDCP: Federal strategic plan, elevate topic in national discussion
• DOJ: Promote PDMP programs, interstate data sharing
• CMS: Pharmacy/provider restrictions, quantity restrictions
• NIH: Research funding (basic science, clinical science, policy,
collaborative mechanisms/center grants)
Office of the
Governor
Other States and Policy Examples
•
•
•
•
•
•
•
•
Tougher Pill Mill Laws, Doctor Shopping Laws
Physical Exam Requirements
Tamper Resistant Form Requirements
Prescription Limits
Patient ID Requirements
Immunity from Prosecution
Naloxone Laws
Prospective Reports from PDMP programs
(and other enhancements)
Office of the
Governor
Pill Mill Laws
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
42
Doctor Shopping Laws
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
43
Physical Exam Requirements
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
44
Tamper Resistant Forms
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
45
Prescription Limits
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
46
Patient ID Requirements
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
47
Immunity from Prosecution
CDC PHLP 2013
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
48
PDMP Proactive Reporting
Brandeis TTAC Best Practices Report 2013.
Trust for America’s Health Report 2013.
.
Office of the
Governor
49
Here in Colorado…
Office of the
Governor
In 2010…
Office of the
Governor
Office of the
Governor
Office of the
Governor
Recommendations to Reduce Prescription Drug
Misuse and Abuse in Colorado
Colorado
Consortium for
Prescription Drug
Abuse Prevention
Provider &
Prescriber
Education
• The Colorado Consortium for Prescription Drug Abuse Prevention, housed at the CU School of Pharmacy,
will serve as the operational lead for the CO Plan to Reduce Rx Abuse with participation from the
Governor’s Policy Office, a variety of state agencies, and community partners. The Consortium will help
to facilitate and implement Workgroup Recommendations mentioned below.
• Change state board policies (or rules) for all DORA-licensed prescribers to include pain management
guidelines.
• Enlist and support DORA to provide education about the existence and utilization of PDMP as part of the
licensing processes for prescribers and pharmacists.
• Form taskforce with representation from various agencies to examine the use of PDMP as a public health tool.
PDMP
• Improve usability and appropriate accessibility of the PDMP system through the use of information technology
and increased stakeholder access.
• Expand take-back program in law enforcement agencies – develop permanent drop-off sites with
Law Enforcement.
Disposal
• Expand take-back program to pharmacies (pending DEA approval).
• Establish Colorado guidelines on flushing.
• Develop (or utilize existing) social marketing campaign that targets the General Public and overcomes existing
obstacles and misperceptions.
Public Awareness
Data &
Analysis
• Develop (or utilize existing) social marketing campaign that targets Youth and Young Adults (12-25 year olds)
and overcomes existing obstacles and misperceptions.
• Map out all sources of data related to prescription drug use, misuse and overdose in the state in order to
monitor trends, educate the public and inform decision making by multiple stakeholders.
• Identify other efforts that successfully use crosswalks between diverse data sources and successfully
standardize their data collection tools across agencies.
Office of the
Governor
Colorado Consortium for Prescription Drug Abuse Prevention
A coordinated, statewide, interuniversity/interagency network
PDMP
Workgroup
Treatment
Workgroup
Agency Co-Chair:
Prescriber
and Provider
Education
Workgroup
Chris Gassen, DORA
Univ Co-Chair:
Jason Hoppe, DO
Agency Co-Chair:
Governor
Denise Vincioni, OBH
Univ Co-Chair:
Paula Riggs, MD
Policy
Lead
Agency Co-Chair:
Cathy Traugott, HCPF
Univ Co-Chair:
Lee Newman, MD
Coordinating Center
CU School of Pharmacy
CO Attorney
General
Subcommittee
+Coordinating Committee
Substance Abuse
Trend & Response
Task Force
Safe Disposal
Workgroup
Agency Co-Chair:
Shannon Breitzman,
CDPHE
Univ Co-Chair:
Sunny Linnebur,
PharmD
Public
Awareness
Workgroup
Data/Analysis
Workgroup
CO
Legislature
Agency Co-Chair:
Barbara Gabella,
CDPHE
Agency Co-Chair:
Stan Paprocki, OBH
LEGEND
Univ Co-Chair:
= New
Ingrid Binswanger, MD
Univ Co-Chair:
Carol Runyan, PhD
Office of the
Governor
= Existing
Epilogue
Making an Impact: One Patient at a Time
Office of the
Governor
Aaron: Where is he now?
http://www.riseaboveco.org/rx/rx4.html
Office of the
Governor
What can I do for my patients?
Office of the
Governor
Six Things You Can Do
1. Take C.E. courses, get all the additional training you can
2. Find and follow guidelines for safe opioid prescribing
3. Be willing to prescribe less (smaller quantities, other
alternatives), and see patients more often
4. Check the PDMP more often (more on this shortly)
5. Educate patients on the importance of safe storage
and disposal of unused medications
6. Talk with your colleagues, family, friends and neighbors
about this…tell them stories about affected patients
Office of the
Governor
Office of the
Governor
HB14-1283 (PDMP Enhancement Bill)
• Passed this Spring, will be signed into law on Weds 5/21/14
• Several key provisions:
–
–
–
–
–
Mandatory registration for PDMP account (not mandatory use)
Delegated access (up to three delegates per provider)
Unsolicited reports of potential doctor/pharmacy shoppers
CDPHE access to system for public health surveillance
Advisory Board (consortium PDMP work group) to guide
implementation and future directions
Not requiring legislation: daily reporting of dispensing data (Rx’s filled)
by pharmacies, system/interface enhancements, batch querying and
reporting, fewer clicks and fewer attestations (monthly or quarterly)
Office of the
Governor
Questions?
Office of the
Governor