epidemiologic basis for pain clinic laws

Noah Aleshire

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Epidemiologic Basis for

Pain Clinic Laws

National Center for Injury Prevention and ControlDivision of Unintentional Injury Prevention

, JD

Outline of Presentation

Pill Mills and Pain Clinics

Key Facts About the Epidemic

Florida’s Experience

Pill MillA doctor, clinic, or pharmacy that is prescribing or dispensing controlled

prescription drugs inappropriately

Pain ClinicA privately-owned facility providing pain management services to patients, often including the prescription of controlled substances

What’s “inappropriate” prescribing?

http://current.com/groups/vanguard-the-oxycontin-express/

http://current.com/groups/vanguard-the-oxycontin-express/

#1

a small number of opioid prescribers

vast majority of opioid prescribing

Just 3% of California workers compensation opioid prescribers…

Swedlow et al. Prescribing patterns of schedule II opioids in California Workers’ Compensation, CWCI Institute, 2011

55% of all CSII opioid Rx

3% of prescribers


62% of all morphine

equivalents3% of prescribers


65% of all associated payments3% of prescribers


1% of prescribers


33% of all CSII opioid Rx

41% of all morphine

equivalents 42% of all associated payments

Oregon PDMP Report 2012: http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf

Oregon PDMP report top 8.1% of providers prescribe 79% of CII-CIV drugs

60%19%

21%Top 2,000 Providers

2,001-4,000 Providers

Remaining 45,330 Providers

http://www.orpdmp.com/orpdmpfiles/PDF_Files/Reports/Statewide_10.01.11_to_03.31.12.pdf

Top 20% of prescribers account for 63% of overdose deaths

Ontario Public Drug Program, 2006

1 2 3 4 50

10

20

30

40

50

60

70

17.3 18.9 20.4 21.9 21.4

2.0 4.0

12.718.6

62.7Pct of total patients Pct of total deaths

Quintiles of Prescribers from lowest to highest prescribing rate

Perc

ent

Adapted from data from Dhalla et al. Can Fam Physician 2011;57:e92-e96

Percent of CS II-V prescriptions prescribed by prescriber decile by year, KY, 2009

Blumenschein, K, et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All Schedule Prescription Electronic Reporting Program (KASPER) Institute for Pharmaceutical Outcomes and Policy , Univ of Kentucky, 2010

20090

102030405060708090

100

8.4

17.9

64.3

Top decile9th 8th 7th 6th 5th 4th 3rd 2nd Lowest decile

Perc

ent o

f pre

scri

ptio

ns

CS II-V controlled substance prescriptions

per hour by prescriber rank by year, KY

Year Median80th %ile

90th %ile

Highest Prescriber

2005 0.07 0.43 0.94 13.04

2006 0.07 0.43 0.96 14.85

2007 0.07 0.44 1.01 15.30

2008 0.06 0.40 0.95 17.32

2009 0.07 0.43 1.03 20.60Calculated from Blumenschein et al. Independent Evaluation of the Impact and Effectiveness of the Kentucky All

Schedule Prescription Electronic Reporting Program . Institute for Pharmaceutical Outcomes and Policy , Univ of Kentucky, 2010

Pill Mills = High Volume Prescribers

“You just walk in, they ask you what hurts, they take your blood pressure, they weigh you, and they say actually – literally sometimes, ‘What do you want?’ … ‘How many do you take a day?’ You could be ridiculous and say 40. I mean, I could get 200 of each, Roxi's and Oxy's at the same time, which makes no sense, and Xanny bars (Xanax) at the same time. They just ask you what you want.” --White female, 41, street based/illicit drug user

Rigg KK, March SJ, Inciardi JA. Prescription drug abuse and diversion: role of the pain clinic. J Drug Issues. 2010 ; 40(3): 681–702.

#2

taking high doses of opioids

higher risk of overdose

Most opioids consumed by small percentage of patients at high dosage levels, NM, 2007-

2008

<20 >20-40 >40-100 >1000

10

20

30

40

50

60

70

80

90

10089.8

4.3 2.6 3.5

48.4

11.0 13.8

26.832.2

4.4 5.5

57.8

Pct of Controls Pct of Deaths Pct of MME

Average Opioid Dosage over six months (MME/day)

Perc

ent

Unpubliished data from New Mexico case-control study.

Average MME per Rx (Ca. Workers Comp. Study)


4287

1517

Top percentile

51st-60th percentile

Dunn et al, Opioid prescriptions for chronic pain and overdose. Ann Int Med 2010;152:85-92.

Overdose risk highest among small percentage of patients at high dosage, Group

Health, 1997-2005

1-19 20-49 50-99 100+0

1

2

3

4

5

6

7

8

9

10

0

10

20

30

40

50

60

70

80

90

100

1 1.44

3.73

8.87

Opioid dosage (MME/d)

Risk

(O

dds

Rati

o)

% P

atie

nt Y

ears

Pill Mills = High Dosage Prescribing


“Every three weeks he would give me 60 Xanax, 25 Trazapans, 300 thirties (30 mg) of Roxicodone, the little blue ones. He would give me 120 Percocets to go in between the blue ones, which makes no sense to me but I'm not going to fight it – plus another 120 wafers, which are the 40 milligram methadone. And then later on he added in Dilaudid, like 30 of those and the Oxy eighties. He put those in place of the Percocets, which made no sense but again whatever. Okay so now he's giving me eight times the amount, and that was every three weeks.”

--White male, 39, drug treatment enrollee

#3

doctor shopping

higher risk of overdose

People Prescribed CS II-IV, WV 2005-2007

Peirce LP, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 50(6): June 2012.

Doctor Shopping Pharmacy Shopping0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Control Group

People who Overdosed

7x more likely to doctor shop than control group

Peirce LP, Smith MJ, Abate MA, Halverson J. Doctor and pharmacy shopping for controlled substances. Med Care. 50(6): June 2012.

People who overdosed were…

and 13x more likely to pharmacy shop

Cepeda et al Characteristics of prescribers whose patients shop for opioid: results from a cohort study. J Opioid Manag. 2013.

Have 40% of all doctor shoppers among their

patients

The 5% of providers with the most opioid

patients...

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. 2012. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

Distribution of Patients and Overdoses by Risk Group

Patients Overdoses0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patients seeing one doctor, low dose Patients seeing one doctor, high dose

Florida & Pill Mills

Florida and the Epidemic 2003-2009 (CDC MMWR)

84% increase in prescription drug overdoses

264% increase in oxycodone overdoses

In 2009, 8 people died of overdoses every day

MMWR. Drug overdose deaths — Florida, 2003–2009. 869-72. 60(26). July 8 2011.

2010: 90 of the top 100 oxycodone purchasing physicians in

US were in Florida 900+ pain clinics

2011: Revised pill mill law enacted

2007 2008 2009 2010 20110

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

Grams dispensed of hydrocodone and oxycodone; National (without Florida) and Florida, ARCOS 2007-

2011

Hy-drocodone

Oxycodone

Gra

ms

Dis

pens

ed

Drug-caused deaths by drug type,Florida, 2007-2011

Source: Florida Medical Examiners Commission Annual Reports

2007 2008 2009 2010 20110

200

400

600

800

1000

1200

1400

1600

OxycodoneAlprazolamMethadoneHydrocodoneFentanyl

Num

ber

of d

eath

s


“They knew it was being abused, but nothing is ever spoken. I weighed about 90 pounds. I was so sick, and my blood pressure was so low it was bottoming out. I was having seizures. My physical health just deteriorated. I mean, it’s obvious if you walk in, you can tell if someone is an active crack head or actively abusing pills.”

--Hispanic female, 41, drug treatment enrollee

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.

National Center for Injury Prevention and ControlDivision of Unintentional Injury Prevention

epidemiologic basis for pain clinic laws

Documents