A Multifaceted Approach to
Addressing Prescription Drugs in
Your Community
Jason B. Fields MD
Medical Services Manager, DACCO
Florida’s Prescription Drug Diversion
and Abuse Roundup
2012 to 2015
Pam Bondi, Attorney General
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
Contributors to the Crisis
• Florida had weak regulatory oversight of pain
management practices,
• Limited oversight of physician dispensing
habits
• No statewide Prescription Drug Monitoring
Program (PDMP).
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
The Crisis
• “Most serious public health and safety threat to
our state”
• Prescription drug abuse kills more than seven
Floridians every day
• Florida’s communities suffer from prescription drug
addiction due to increasing health care costs and
a growing proportion of prescription drug diversion
fueled crime.
• There are reporting increases in the number of
infants suffering from Neonatal Withdrawal
Syndrome due to their mother’s abuse of opioid
painkillers.
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
Goals of the Roadmap
• This action has led to a dramatic decrease in the
number of Florida physicians dispensing the most
powerful pain-killing narcotics from their offices.
• Law enforcement and health regulators are now
actively collaborating in regional strike forces to
inspect, investigate, and prosecute those who seek to
flood our communities with diverted pharmaceuticals.
• At the end of 2011, Florida successfully launched its
PDMP, which is a crucial component in our efforts to
combat prescription drug abuse.
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
HB 7095 (June 1st, 2011)
• This significant piece of legislation banned dispensing
of Schedule II and Schedule III controlled substances by
physicians
• Created a standard of care for all physicians prescribing
controlled substances to treat chronic pain
• Required physicians to either electronically prescribe
controlled substances or use counterfeit-proof
prescriptions
• Added several critical criminal violations to support
enforcement
• Improved reporting to the state’s PDMP from 15 days
to 7 days.
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
PDMP
• HIPAA compliant Prescription Drug Monitoring
Program (PDMP) in accordance to F.S. 893.055.
• Has contributed to the steep decline in the number
of Florida doctors dispensing the most oxycodone in
a given year.
• Florida went from 90 of the top 100 prescribers to, as
of last count, only 13 of the top 100 now residing in
Florida.
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
PDMP
• The PDMP became operational on September 1,
2011, when it began receiving controlled substance
dispensing data from pharmacies and dispensing
practitioners
• Health care practitioners began accessing the data
reported to the PDMP on October 17, 2011, and Law
Enforcement Agencies began requesting PDMP
reports during the course of active investigations on
November 14, 2011
PDMP
• Information collected in the database is available to
registered health care
practitioners to help guide their decisions in
prescribing and dispensing certain highly abused
prescription drugs
• It may also assist health care practitioners in
identifying patients who are “doctor shopping” or
trying to obtain multiple prescriptions for the
same controlled substance from multiple health care
practitioners, which is a felony in the State of
Florida.
The Crisis
• Florida has became the epicenter of
pharmaceutical drug diversion
• Prescription drug overdoses kill on average
seven Floridians every single day – a tragic
number five times greater than deaths caused
by all illicit drugs combined.
• For every 1 overdose death there are 9
treatment admissions, 35 emergency room
visits for misuse or abuse, 161 people with
abuse and/or dependence issues and a
staggering 461 nonmedical users of
prescription drugs.
Florida’s Prescription Drug Diversion and Abuse Roadmap, 2012 – 2015, April 2nd, 2012
Substance Use in Adolescents
• There are multiple genetic and environmental risk
factors that make adolescents vulnerable to the
initiation of substance use.
• Unfortunately, earlier use of tobacco, alcohol,
and drugs is more likely to result in substance use
disorders in adulthood.
• The substance use in the teenage years which
begins as minimal or experimental use with
minimal consequences can progress in a subset of
individuals to more serious substance use
disorders like substance abuse or dependence.
Substance Use in Adolescents
• Substance abuse is regular use that has a
negative impact on daily functioning or that is
associated with recurrent significant problems.
• Substance dependence is associated with loss of
control over the use of a drug with more serious
consequences.
• There is abundant evidence that the earlier the
initiation of use of substances like tobacco,
alcohol, or marijuana, the more likely that
individual will have significant addiction issues.
MTF
• Monitoring the Future (MTF) is a long-term
study of American adolescents, college
students, and adults through age 50.
• It has been conducted annually by the
University of Michigan’s Institute for Social
Research since its inception in 1975 and is
supported under a series of investigatorinitiated, competing research grants from the
National Institute on Drug Abuse.
Narcotics Other than Heroin
• The use of narcotic drugs other than heroin (most of which
are prescription analgesics) increased sharply in recent
years, as have emergency room admissions involving these
drugs, making this class of drugs of particular concern.
• Use in 12th grade—the only grade for which use is
reported—showed some no significant decline in 2012. The
two major components of this class are Vicodin and
OxyContin, and both showed no significant declines in all
three grades.
• However, for the three grades combined, the declines for
both Vicodin and OxyContin were significant in 2012, as a
result of the greater precision gained with the larger
combined sample.
Oxycontin
• OxyContin use increased some in all grades
from 2002 (when it was first measured)
through 2011,
• In 2012 the prevalence rate dropped in all
three grades; though no single grade change
was significant, the change for the three
grades combined was.
• Annual prevalence in 2012 was 1.6%, 3.0%,
and 4.3% in grades 8, 10, and 12, respectively.
Vicodin
• Use of Vicodin remained fairly steady at
somewhat higher levels since 2002, until
among 10th and 12th graders its use declined
after 2009.
• Use among 8th graders also declined in 2011.
• In 2012 annual prevalence rates were 1.3%,
4.4%, and 7.5% in grades 8, 10, and 12; and
the decline in 2012 was significant for the
three grades combined.
Marijuana Use
Past Year Use and Perception of
Risk of Using Regularly
NSDUH: Past Year Non-Medical Use
• Misuse of prescription drugs is second only to
marijuana as the Nation’s most prevalent illicit
drug problem and is a public health concern, with
approximately 22 million persons initiating
nonmedical pain reliever use since 2002.
• Combined 2010 and 2011 data indicate that the
rate of past year nonmedical use of prescription
pain relievers among those aged 12 or older was
4.6 percent nationally and ranged from 3.6
percent in Iowa to 6.4 percent in Oregon
NSDUH: Past Year Non-Medical Use
• The national rate for the total population
declined between 2009-2010 and 2010-2011
(from 4.9 to 4.6 percent).8 This rate also
decreased nationally among persons aged 12
to 17 (from 6.4 to 6.1 percent)
• Among those 18 to 25 (from 11.5 to 10.4
percent); however, the rate remained
unchanged for persons aged 26 or older.
Myth: Having an Rx prescription gives
a patient license to adjust the dosage, and it
is safe to continue taking the medicine after
it is no longer needed. Likewise, if the
medication is prescribed, it can be shared
with family and friends.
Fact: Taking prescription drugs that are
not prescribed—or taking them in any way
other than directed by a doctor—is considered
misuse or abuse and can lead to dangerous
outcomes. Additionally, using another person’s
medication is against the law. Sharing your
prescription medicines with another person is
also illegal and could lead to devastating
results.
Myth: Because Rx drugs are legal,
misuse and abuse of these drugs is less
risky than using illegal drugs.
Fact: Rx medications provide many
benefits when used correctly under a
prescriber’s care. But when misused or
abused, they can be just as dangerous as
illicit drugs, especially when taken with
alcohol or other drugs.
Myth: Prescription medications are not
drugs of typical abuse among teens and
young adults.
Fact: Even though the percentages of
teens abusing these drugs is relatively low,
compared to marijuana, current trends reveal
troubling signs that abuse of these medications
is acceptable behavior. What makes it more
complicated is that parents, other adult
caregivers and those prescribing the
medications to teens seem to be unaware of
the problem.
Myth: Rx medications are more
difficult to obtain than illegal drugs.
Fact: Those who abuse Rx
medications report that these drugs can be
easily obtained from family members and
friends. Additional sources include family
medicine cabinets and other frequented
locations such as kitchen cabinets, night
stands and purses.
Myth: Parents believe that because
Rx medications are prescribed by healthcare
professionals, teens and young adults will
not abuse them.
Fact: Many parents are not even
aware that commonly prescribed
medications are being abused to get high. In
fact, some do not consider the possibility
that their unused medicines could get into
the wrong hands, and many do not know
how to properly dispose of old medicines.
NSDUH: Source Where Pain
Relievers Were Obtained for Most
Recent Nonmedical Use among
Past Year Users Aged 12 or Older:
2010-2011
Developmental Vulnerability
• There is a 2 to 8 fold increase in substance use
problems if use of tobacco, alcohol, and THC
begins < 15
• There is a 1 in 4 chance of coming into harm if
using starts < 15
• A narrow window of approximately 2 years for
onset of onset of first use makes such a
significant difference
New Users in the Past Year of Specific Illicit Drugs
among Persons Aged 12 or Older, 2010
Number of New Users (Thousands)
2,500
2,000
2,426 2,417
Note: The specific drug refers to the drug
that was used for the first time in the past
year, regardless of whether it was the first
drug ever used or not.
2,004
1,500
1,238
937
1,000
973
624
637
500
377
252
140
45
0
Mari- Psycho- Pain
juana thera- Reliepeutics* vers*
Tran- Ecstasy Inhaquililants
zers*
Stimu- Cocaine
lants*
LSD
Seda- Heroin
tives*
PCP
*Includes pain relievers, tranquilizers, stimulants, and sedatives
Source: SAMHSA, 2009 National Survey on Drug Use and Health (September 2010).
Drug-Induced Deaths vs. Other
Injury Deaths, 1999–2009*
*Data for 2008 and 2009 are provisional and subject to change.
Causes of death attributable to drugs include accidental or intentional poisonings by drugs and deaths from medical conditions resulting 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.
9/2011
Source: National Center for Health Statistics, Centers for Disease Control and Prevention. National Vital Statistics Reports
Deaths: Final Data for the years 1999 to 2007 (2001 to 2009); Deaths: Preliminary Data for the years 2008 and 2009
(2010 and 2011).
Unintentional Drug Overdose Deaths
United States, 1970–2007
10
Death rate per 100,000
9
27,658 unintentional drug overdose deaths
8
7
6
5
4
3
2
Cocaine
Heroin
1
0
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Year
National Vital Statistics System, http://wonder.cdc.gov
The Prescription Drug Abuse
Problem
• 478 million prescriptions for controlledsubstances dispensed in U.S. in 2010
• 7 million Americans reported current nonmedical use of prescription drugs in 2010
• 1 in 4 people using drugs for first time in 2010
began by using a prescription drug non-medically
• 6 of top 10 abused substances among high school
seniors are prescription drugs
• 28,000 unintentional overdose deaths in 2007 –
driven by prescription opioids
Commonly Abused Prescription Drugs
Prescriptions Dispensed for select opioids in U.S.
Outpatient Retail Pharmacies, 2000-2009
140,000,000
Number of Prescriptions
120,000,000
100,000,000
80,000,000
60,000,000
40,000,000
20,000,000
0
2000
2001
Hydrocodone
2002
Oxyocodne
Source: SDI, Vector One: National. Extracted June 2010.
2003
2004
methadone
2005
2006
2007
buprenorphine
2008
tramadol
2009
SAMHSA
2007
Treatment Admissions Involving
Opioid Analgesics1
Number of admissions (x 1000)
140
120
OxyContin introduced
100
80
60
40
1
Includes admissions where primary, secondary, or tertiary
substance was reported as Other opiates/synthetics. Excludes
admissions for non-prescription use of methadone.
20
0
1992
1994
1996
1998
2000
2002
2004
2006
56
Unintentional Drug Overdose Deaths
United States, 1970–2007
10
Death rate per 100,000
9
27,658 unintentional drug overdose deaths
8
7
6
5
4
3
2
Cocaine
Heroin
1
0
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Year
National Vital Statistics System, http://wonder.cdc.gov
8 Signs in Teens
• Change in sleep habits
• Change in energy level
• Change in personal hygiene
• Change in mood/ personality
• Sudden change in grades
• Change of friends
• Loss of Appetite
• Constricted eye pupils (“pin-point pupils” for
suspected opiate use)
Prescription Drug Abuse Prevention
Plan
• Coordinated effort
across the Federal
government
• 4 focus areas
– Education
– Prescription Drug
Monitoring Programs
– Proper Medication
Disposal
– Enforcement
Resources
• 2012 Monitoring the Future Survey
• 2011 NSUDH
• 2012 Medical Examiners Commission Interim
Drug Report
• CADCA
• Preventrxabuse.org