Prescription Drug Overdose
Prevention
FY 2014 Background Document
Preventing Prescription Drug Overdoses Saves Lives
Drug overdose death rates in the United States have more than
tripled since 1990. Three quarters of drug overdose deaths involve
prescription drugs in the US today. Nearly three out of four
prescription drug overdoses are caused by prescription painkillers.
The public health consequences of prescription-drug use have led the
Centers for Disease Control and Prevention (CDC) to classify
prescription drug overdose as an epidemic. CDC’s National Center for
Injury Prevention and Control (Injury Center) provides leadership in
conducting surveillance, identifying and evaluating prevention
strategies and work with clinical providers to reduce prescription
drug overdoses in the United States. Prescription drug overdoses can
be prevented and lives can be saved.
Public Health Problem
Prescription painkillers work by binding to receptors in the brain to decrease the perception of pain. These
powerful drugs can create a feeling of euphoria, cause physical dependence, and can lead to addiction in some
people. They can also cause sedation and slow down breathing. A person who is abusing prescription painkillers
might take larger doses or inject the drug to achieve a euphoric effect. Used in this way, prescription painkillers
can cause breathing to slow down so much that it stops, resulting in a fatal overdose. Drug overdoses are now
the leading cause of injury death in the United States.
 Over 38,329 people died from drug overdoses in the United States in 2010, and more than
16,650 of these deaths involved an opioid pain reliever.
 More than 125,000 people in the United States have died from overdoses involving opioid pain
relievers in the last decade.
 Opioid pain relievers are now involved in more overdose deaths than cocaine and heroin
combined.
This unprecedented rise in overdose parallels dramatic increases in the prescribing of opioid pain relievers (drugs
derived from the opium poppy or semi-synthetic or synthetic versions of it like oxycodone, hydrocodone,
methadone, or fentanyl).
 Millions of Americans now use opioids for chronic pain, and millions more use opioids
nonmedically (for reasons not associated with pain).
 Enough opioid pain relievers were prescribed in 2010 to medicate every American adult aroundthe-clock for one month.
 Although most of these pills were prescribed for a medical purpose, many ended up in the hands
of people who misused or abused them.
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Additionally, prescription drug abuse can lead to other public health problems including unintentional injuries,
such as falls and fractures among the elderly or motor vehicle crashes. and intentional injuries including drugrelated self harm and drug-crime-related interpersonal violence; infections from intravenous use including HIV
and Hepatitis C, and; reproductive health problems including birth defects related to opioid exposure during
pregnancy, newborn withdrawal syndrome and infertility from chronic heavy use. In addition to the negative
health and social consequences, this epidemic exacts a significant economic toll on the United States, with
nonmedical use of opioids costing more than $72 billion annually.
Promising Strategies
Several promising strategies have been identified to address this problem, but additional research is needed to
understand the impact of these interventions on prescription drug overdose deaths. States play a central role in
protecting the public health and regulating health care and the practice of the health professions. As such, states
are a powerful ally in reversing the prescription drug overdose epidemic. Promising strategies include:
Prescription Drug Monitoring Programs (PDMPs)
PDMPs are state-run electronic databases used to track the prescribing and dispensing of controlled
prescription drugs to patients. Forty-three states have operational PDMPs. They are designed to
monitor this information for suspected abuse or diversion—the channeling of the drug into an illegal
use—and can give a prescriber or pharmacist critical information regarding a patient’s controlled
substance prescription history. CDC’s Injury Center recommends PDMPs focus on:
 Patients at highest risk in terms of prescription painkiller dosage, numbers of controlled
substance prescriptions, and numbers of prescribers; and
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 Prescribers who clearly deviate from accepted medical practice in terms of prescription
painkiller dosage, numbers of prescriptions for controlled substances, and proportion of
doctor shoppers among their patients.
CDC’s Injury Center also recommends PDMPs link to electronic health records systems so PDMP
information is better integrated into health care providers’ day-to-day practices.
Patient Review and Restriction Programs (PRRs)
State benefits programs and workers’ compensation programs can monitor prescription claims and
PDMP data for inappropriate use of controlled drugs. For patients whose use of multiple providers and
multiple controlled drugs cannot be justified on medical grounds, reimbursement of claims for these
drugs are limited to a single designated physician and a single designated pharmacy. These PRR
programs can improve the coordination of care and use of medical services.
Preventing Prescription Drug Abuse and Diversion
States can enact and enforce laws to prevent doctor shopping, the operation of rogue pain clinics or
“pill mills,” and other laws to reduce opioid painkiller diversion and abuse while safeguarding
legitimate access to pain management services. These laws should also be rigorously evaluated for
their effectiveness.
Reassess the Prescription of Methadone for Pain
Methadone prescribed for pain is disproportionately involved in this epidemic, contributing to nearly
one (1) in three (3) opioid pain reliever overdose deaths in 2009. Methadone persists in the body long
after its painkilling effect wears off, so it can accumulate over time if taken too frequently and lead to
a greater risk for overdose. Policies and practices promoting the use of methadone for pain such as
naming methadone as a preferred drug on insurance formularies should be evaluated critically.
Unique Role of the CDC Injury Center and Federal Partnerships
The CDC Injury Center’s primary focus for reversing the prescription drug overdose epidemic is to conduct
surveillance on prescription drug abuse and overdose trends, evaluate and identify effective interventions for
reducing overdoses, and improve clinical practice to reduce prescription drug diversion and abuse.
CDC’s Injury Center works closely with federal partners such as the White House Office of National Drug Control
Policy (ONDCP), Substance Abuse and Mental Health Services Administration (SAMHSA), Food and Drug
Administration (FDA), National Institute on Drug Abuse (NIDA) and the Department of Justice (DOJ) to address the
problem of prescription drug overdose through surveillance, research, and policy-related activities. As an
example, CDC’s Injury Center is a key player in the ONDCP National Drug Control Strategy and collaborates with
DOJ’s Bureau of Justice Assistance to better understand how PDMPs can be effectively used to curb abuse and
overdose deaths.
Prescription Drug Overdose Prevention in Action
Understanding the Epidemic
The greatest challenges facing states and other policy makers in mitigating drug overdose deaths have been a lack
of knowledge regarding the scope and nature of this public health problem as well as identification and
implementation of effective intervention strategies. CDC’s Injury Center leads the way in enhancing data sources
for surveillance and evaluation purposes to sharpen the understanding of this epidemic.
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Research
CDC’s Injury Center research was instrumental in connecting the increased prescribing of opioid pain
relievers with the rise in overdose deaths. Research done by the CDC Injury Center in this area has
been presented to Congress, NIDA, FDA, the Safe States Alliance, the Association of State and
Territorial Health Officials (ASTHO), and the Council of State and Territorial Epidemiologists (CSTE) and
is widely cited in the press.
Data and Trend Analysis
CDC’s Injury Center is conducting a number of studies to better understand the nature of this public
health problem. Additional analyses are also underway identifying trends in prescribing rates and daily
dosage; studying state variations in drug distributions to physicians who are both prescribers and
dispensers (such physicians have been associated with ‘pill mills’); and using insurance claims data to
identify patterns of inappropriate prescribing and use of opioid pain relievers.
Improving Surveillance
CDC’s Injury Center is also working to improve surveillance of prescription drug misuse and abuse. It is
working to better characterize drug use using survey data, working to expand the use of prescription
drug monitoring programs as a surveillance and evaluation tool, and exploring publicly available data
sources that can inform surveillance activities. The CDC Injury Center is also partnering with FDA and
DOJ’s Bureau of Justice Assistance to develop the Prescription Behavior Surveillance System, a
surveillance and evaluation tool incorporating PDMP data from multiple states. This system will
leverage PDMP data to track drug use and misuse more accurately and rapidly and provide a means of
measuring and evaluating the impact of national and selected state interventions.
Identifying and Evaluating Policy Solutions
Effective policies and practices are needed to reduce prescription drug overdoses while ensuring legitimate
patients have access to appropriate treatment. The CDC Injury Center works to identify, evaluate, and
recommend promising local, state, and federal policies to reduce prescription drug abuse and overdose.
PRR Evaluation
CDC’s Injury Center is evaluating PRR programs used by Medicaid and private insurers. Past evaluations
indicate such programs reduce costs by improving the coordination of care and reducing inappropriate
utilization of medical and pharmacy services. For example, total savings of the Washington state PRR
through 2012 are estimated at $120 million, with the calculated return on investment of at least $12
for every $1 invested in the program. Other states have also reported substantial savings with their
PRR program. Evaluation is needed to examine PRRs’ impact on patient drug use and abuse.
Proactive PDMP Evaluation
CDC’s Injury Center is funding a randomized controlled trial in Nevada, which will test whether a
PDMP’s proactive reporting to health care providers of patients going to multiple providers and
pharmacies to obtain controlled prescription drugs affects their subsequent use of such drugs.
State Law Inventory
CDC’s Injury Center and Public Health Law Program maintain an environmental scan of state laws
related to prescription drugs. State laws regarding prescription drugs differ considerably, and the CDC
Injury Center created this inventory of laws to better understand how states are approaching the
epidemic and to inform evaluation efforts.
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Improving Clinical Practice
CDC’s Injury Center is working to evaluate the impact of programs and regulations on clinical practice and to help
develop and evaluate guidelines designed to improve the prescribing of controlled substances. This includes
efforts to integrate PDMP data into clinical work flow.
Emergency Department Guidelines
The CDC Injury Center has worked with the American College of Emergency Physicians (ACEP) to
develop a clinical policy for prescribing opioid pain relievers in emergency departments (EDs). These
guidelines are aimed at helping prevent the overprescribing of opioids while ensuring legitimate
patients still receive effective pain treatment. The goal is to have these guidelines serve as the basis for
standards of care for opioid prescribing in EDs.
Assessment of State Prescriber Guidelines
CDC’s Injury Center will assist in the evaluation of the impact of statewide guidelines for use of opioids
for chronic non-cancer pain such as those implemented in Utah and Washington State.
“Consistent Care” Evaluation
CDC’s Injury Center is funding two research teams in Washington and North Carolina to conduct
randomized trials of “Consistent Care” programs in emergency departments. Such programs develop
care plans for patients frequently visiting EDs with complaints of pain to ensure opioids are being used
appropriately.
Successes
The CDC Injury Center’s work has yielded important advances in the understanding of this epidemic including:
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Developing clinical policy for the prescribing of opioid pain relievers in emergency departments
in collaboration with the American College of Emergency Physicians (ACEP).
Funding the National Governor’s Association (NGA) to support a year-long prescription drug
abuse initiative co-chaired by the governors of Alabama and Colorado to develop and implement
comprehensive and coordinated strategies to address prescription drug overdose in seven (7)
states.
Supporting the Association of State and Territorial Health Officials (ASTHO) through an initiative
for state planning teams, including the state health official, from six states (Kentucky, Ohio,
Oklahoma, South Carolina, Tennessee, and West Virginia) to develop state action plans. CDC’s
Injury Center is also providing technical assistance to states to evaluate interventions and
conduct evaluations of their state action plans and state policies implemented to address
prescription drug misuse and drug diversion.
Publishing two (2) major Vital Signs reports and a Policy Impact report defining the opioid pain
reliever epidemic. These reports were widely distributed and significantly enhanced public
understanding of the problem. The Vital Signs reports are regularly cited and used in public
health literature, and major partners including SAMHSA and the National Governors Association
(NGA), have cited the Policy Impact report.
Tracking prescription drug abuse and overdose trends using a variety of data sources (e.g.,
PDMPs, medical examiner data, drug distribution reports from DEA and IMS Health, medical
claims data) to significantly improve scientific understanding of the scope of the epidemic, risk
groups, and geographic distribution of overdoses. CDC Injury Center surveillance has been
instrumental in understanding the connection between opioid sales in a state and the respective
state’s rate of overdose death.
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Developing and publishing an inventory of state prescription drug laws providing a broad
understanding of different state legal and regulatory efforts to reverse the epidemic.
Future Goals
If the painkiller overdose death rate had remained level since 1999, rather than rising so sharply, more than
60,000 people would still be alive today. If overdose death rates remain at this historic high, thousands more will
die unnecessarily, and health and economic consequences will continue to rise. The CDC Injury Center will
continue to work to expand the capacity to evaluate and identify evidence-based interventions for reducing
prescription drug overdose deaths, which remains a major need for states working to reverse this epidemic.
Short-Term Next Steps
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Work with other Health and Human Services (HHS) agencies to facilitate real-time access to
PDMPs by leveraging health information technology. Led by the Office of National Coordinator for
Health and Information Technology, CDC’s Injury Center has a lead role in the design, evaluation,
and policy implications of the pilot projects.
Conduct analyses of prescription and medical claims and other data to identify and quantify
indicators of inappropriate prescribing and use of opioid pain relievers and other controlled
prescription drugs. These findings are critical to the field and will help inform and tailor
intervention strategies.
Work with state Medicaid patient review and restriction (PRR) program directors and other
stakeholders to identify and disseminate best practices for these programs.
Long-Term Goals
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Work with insurers and pharmacy benefit managers on claims review programs, formulary
development, PRR programs, and other tools to reduce inappropriate use of controlled drugs.
Evaluate the impact of selected state laws and regulations designed to prevent drug diversion
through field investigations and other study designs and disseminate findings.
Provide guidance to states on implementing a comprehensive suite of evidence-based
interventions aimed to preventing prescription drug overdoses.
Realize a reduction in drug overdose deaths as a result of evidence-based intervention
implementation in 25 states.
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